Medication Management for Mood
Lithium has been in clinical use for about seven decades now. It is, therefore, one of the oldest drugs in the pharmacopeia. However, its use has declined gradually owing to related risks and adverse clinical effects (Pérez de Mendiola et al., 2021). Lithium carbonate is available as capsules, tablets, and oral solutions.
Other lithium salts used the same way as lithium carbonate are lithium citrate, lithium sulfate, and lithium orotate (Pacholko & Bekar, 2021). The purpose of this paper is to describe the clinical uses of lithium carbonate, its mechanism of action, side effects, and monitoring, and the role of a psychiatric mental health nurse practitioner in patient management using lithium carbonate.
Clinical Uses of Lithium
Lithium was approved by the food and drug administration for clinical use in 1970, about 20 years after its first use in Australia. The FDA approved it for the management of acute mania and alter. In 1974, it was approved for use in the prevention of recurrences in bipolar illness. The FDA approved lithium specifically for treating manic episodes of Bipolar Disorder, Manic, as it was referred to in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) (American Psychiatric Association, 2013).
In bipolar disease (BD) treatment, lithium carbonate reduces the frequency of symptomatic occurrence and reduction in the intensity of the symptoms. When given during the active manic episode, lithium can take about 1 to 3 weeks to achieve normalization of symptoms (Food and Drug Administration, n.d.). Therefore, lithium is not only effective in the management of acute mania in bipolar disorder but also has mood-stabilizing properties in the long term.
According to Tondo et al. (2019), lithium is more effective in preventing bipolar mania than bipolar depression. Lithium provides better mood stabilizing and prophylactic outcomes for patients with a family history of BD and no co-occurring mental health disorders. Lithium carbonate has no off-label uses. However, lithium citrate, especially the reverse micelle formulation, has been used in the management of Huntington’s disease.
Additionally, all the aforementioned lithium salts have been shown to reduce suicidality in the general population (Pérez de Mendiola et al., 2021; Tondo et al., 2019). Among the elderly, lithium has shown evidence of a reduction in the rates of cognitive decline. Other studies have attributed lithium with antiviral and neuroprotective uses and effects (Pérez de Mendiola et al., 2021). Therefore, lithium has various advantages over other mood stabilizers.
Contraindications for the Use of Lithium
As seen with all other medications, lithium’s use is contraindicated in patients with documented hypersensitivity. Severe cardiac disease, pregnancy (especially first trimesters), severe debilitation, severe dehydration, severe hyponatremia, and renal failure are other situations where the use of lithium is contraindicated (Malhi et al., 2020). Some cardiovascular conditions where lithium use is contraindicated are acute myocardial infarction (MI) and Brugada syndrome, a sudden cardiac death associated with alteration in electrocardiogram levels and ventricular arrhythmia.
Lithium use has a risk of cardiac malformation during the embryogenesis period. However, its use should be resumed in the postpartum period when the administration was stopped because of pregnancy. Abrupt cessation of use is also discouraged due to the risk of relapse of mania. Lithium use is also cautioned in patients with thyroid disease, parathyroid disease, renal disease, and those receiving neuromuscular blocking agents due to toxicity risks.
This is because lithium increases thyrotropin-releasing hormone (TRH) or lowers thyroid hormone levels and can lead to hypothyroidism (Post, 2018). This contraindication is relative; thus use of lithium in patients with thyroid issues can be corrected through hormone supplementation
Lithium’s Mechanism of Action
The specific biochemical mechanism of action of lithium carbonate to improve mania symptoms is unclear from scientific and clinical literature items. Lithium causes the movement of sodium across cell membranes of neurons and muscles. Therefore, it promotes the metabolism of catecholamines in the central nervous system neurons (Food and Drug Administration, n.d.).
It is associated with an increase in the volumes in brain regions such as the hippocampus and the cortex. This mechanism supports the neuroprotective effects of lithium that were mentioned earlier. Decreasing neuronal apoptotic cell death, promoting neurogenesis, and promoting gliogenesis specific mechanism through which lithium improves neuroprotection among the elderly and prevents cognitive decline, as aforementioned.
In other pieces of literature evidence, lithium has been documented to increase telomere length and thus improve degenerative conditions such as dementia, seizures in the elderly, and amyotrophic lateral sclerosis. Because of these mechanisms of action, lithium is superior to other medications for bipolar disorder in terms of preventing co-occurring conditions.
Potential Side Effects
Potential side effects of lithium have been the key reasons for its declining use in the United States (Pérez de Mendiola et al., 2021). The conventional belief is that lithium has a narrow therapeutic window and the risk of side effects is minimal within this window. However, Post (2018) reported that lithium side effects are generally benign and tremors can occur even within the therapeutic levels.
Apart from this dose-dependent tremor, other potential side effects of lithium use include but are not limited to an increase in appetite, nausea, fatigue, polyuria, leukocytosis, thirst, headache, weakness, hyperreflexia, and muscle twitch. In long-term use, hypothyroidism, hyperparathyroidism, and hypercalcemia are also possible.
Monitoring and Follow-up
Due to the risk of toxicity and narrow therapeutic window, monitoring of lithium use can be achieved by measuring serum lithium levels. This can be done one week after the first week of first use and weekly on the first month, and thereafter, every three months. Other parameters to be monitored are serum creatinine, potassium, sodium, parathormone, thyroid hormone, and calcium levels (Food and Drug Administration, n.d.).
Role of Psychiatric Mental Health Nurse Practitioner
A PMHNP has the obligation as a nurse and patient advocate to ensure that lithium use is safe and effective in the patients. Therefore, offering patient education is key. Patient education should cover indications, potential adverse effects, need for adherence to the lithium regimen. They should also order tests to monitor lithium used to prevent toxicity and ensure that patient harm is avoided or prevented. Assessment of cardiovascular and disease risk before use is also a role that PMHNPs can fulfill
Lithium carbonate, one of the oldest psychopharmacotherapy modalities, is an FDA-approved medication for bipolar disorder in the manic phase. The exact mechanism of action is unclear, but transmembrane sodium movement is the proposed mechanism. Its use is absolutely contraindicated in severe cardiac disease, renal disease, and dehydration.
Critical adverse effects include tremors, headache, dehydration, nausea, fatigue, and leukocytosis. Therefore, PMHNPs should educate patients, monitor them, and follow them up to ensure patient safety and treatment effectiveness to fulfill their advocative, educative, and caring roles.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.
Food and Drug Administration. (n.d.). Lithium carbonate tablets USP, lithium carbonate capsules USP, lithium oral solution USP. https://www.accessdata.fda.gov/drugsatfda_docs/label/2011/017812s028,018421s027lbl.pdf
Malhi, G. S., Bell, E., Outhred, T., & Berk, M. (2020). Lithium therapy and its interactions. Australian Prescriber, 43(3), 91–93. https://doi.org/10.18773/austprescr.2020.024
Pacholko, A. G., & Bekar, L. K. (2021). Lithium orotate: A superior option for lithium therapy? Brain and Behavior, 11(8), e2262. https://doi.org/10.1002/brb3.2262
Pérez de Mendiola, X., Hidalgo-Mazzei, D., Vieta, E., & González-Pinto, A. (2021). Overview of lithium’s use: a nationwide survey. International Journal of Bipolar Disorders, 9(1), 10. https://doi.org/10.1186/s40345-020-00215-z
Post, R. M. (2018). The new news about lithium: An underutilized treatment in the United States. Neuropsychopharmacology: Official Publication of the American College of Neuropsychopharmacology, 43(5), 1174–1179. https://doi.org/10.1038/npp.2017.238
Tondo, L., Alda, M., Bauer, M., Bergink, V., Grof, P., Hajek, T., Lewitka, U., Licht, R. W., Manchia, M., Müller-Oerlinghausen, B., Nielsen, R. E., Selo, M., Simhandl, C., Baldessarini, R. J., & International Group for Studies of Lithium (IGSLi). (2019). Clinical use of lithium salts: a guide for users and prescribers. International Journal of Bipolar Disorders, 7(1), 16. https://doi.org/10.1186/s40345-019-0151-2