Lithium The Good The Bad The Ugly
Element 3: Better for Batteries or Brains…or Beverages???
Think back to chemistry class, when you studied the periodic table of the elements. You may remember it as being just a confusing jumble of letters and numbers. But our daily lives would be very different without element number 3. It’s a key component in the batteries that power our smartphones, laptops, and even fancy-schmancy Teslas. But that same element also happens to be one of the most effective treatments ever discovered for bipolar disorder and mania, as well as other mental illnesses like depression, schizophrenia, and eating disorders. It is especially effective for treating suicidal ideation. Through the years it’s also been used to treat anemia, headaches, alcoholism, epilepsy, and diabetes. But it’s very scary, because it has some serious and potentially lethal short and long term side effects, and there is a very narrow window between the dose where it’s effective and the dose where it’s deadly. It’s so scary that I literally have only one patient out of my entire practice on it. The element I’m talking about is lithium. Let’s consider the good, the bad, and the ugly of lithium.
The good: it’s effective as all get out. I would call it one of the most effective drugs in the treatment of mania. It treats the high of the manic episode, the irritability, the agitation, disorganization, hallucinations, delusions, rapid speech, insomnia, racing thoughts, grandiosity, and impulsivity of mania. It prevents the mood cycling of bipolar, and it also treats the suicidality associated with mania and depression.
The bad: it has a nasty side effect profile. It causes a host of issues. Sedation is a big one. It makes people tired and causes obvious mental slowing. I say obvious because it becomes obvious to everyone. The person appears dull and medicated. It slows the mind down. Thoughts don’t process at normal speed, and speech and reactions are slow. It also affects kidney function, causing frequent urination, as well as nausea and diarrhea. It also can be very disabling because lithium commonly causes fine tremor. When all of the side effects are looked at together, they can easily be mistaken for alcoholism or drug abuse, so it can affect people’s opinions at work and have other huge social and personal consequences. It can cause a great deal of weight gain, as well as disfiguring acne on the face and back, as well as psoriasis, red scaly patches of skin on the body. On top of all of that, it can also affect the heart, potentially causing sick sinus syndrome, which is an arrhythmia where the heart’s natrual pacemeker, the sinus node, doesn’t work properly.
As for the ugly; let’s just say that lithium wouldn’t be winning any molecular beauty pageants… it is uuuu-uuu-gly! Lithium can cause nephrogenic diabetes insipidus and interstitial nephritis. Those are big words that simply mean it shuts the kidneys down. Like dunzo down. Patients on long term lithium therapy regularly have chronic renal failure. One of my patients that used to be on lithium is currently on a kidney transplant list. Another ugly component of lithium is that it shuts down the thyroid. You kind of need your thyroid to maintain metabolic processes in your body. It’s pretty important…without it, you become ill with all sorts of terrible issues and you must take another drug to kick it back into gear.
There are other issues with taking lithium. There are some commonly used medications that don’t play well with it. You cannot take diuretics, and you can’t take NSAIDs ibuprofen or naproxen for pain, because these can cause dangerously high levels. Lithium is unusual in that it has that small window of operation I mentioned. You have to have levels checked to make sure they’re between 0.6 and 1.2 mEq/L. If you get toxic by taking thiazide diuretics or NSAIDs or by getting dehydrated, lithium can cause permanent brain damage, nausea, vomiting, diarrhea, and death. So, it is extremely problematic in that it has that narrow window between efficacy and death. In addition, certain drugs lower lithium levels. A big one is caffeine; people have to be very careful with caffeine intake. Even drinking too much water can lower lithium levels, because you can literally dilute it in your system.
All things considered, I say lithium is a last line drug. Yes, it works, but it’s like using a sledgehammer to nail a one penny nail into the wall…there’s going to be collateral damage to the structure of the wall. As good as the good is, the bad is too bad and the ugly too ugly. There are so many other drugs now to try first. Lamotrigine, oxcarbazepine, valproic acid, lurasidone, aripiprazole, and quetiapine to name some. Some psychiatrists would argue with me because these other choices may not be as effective, but they won’t cause the mental slowing, acne, tremor, frquent urination, kidney failure, and hypothyroidism. I treat a patient as a whole, I don’t treat just the mental illness. If my treatment of the mental illness damages or destroys other parts of a patient’s life, is that proper treatment? I say no, but some physicians say yes. It’s a philosophical issue, a quality of life issue, that won’t be solved until somebody develops a drug that works as well but without the terrible side effects. As I mentioned above, I have only one patient in my entire practice on lithium, and I’m currently trying to get him off of it. Why? Well, he’s experiencing sedation, cognitive slowing, frequent urination, tremor, nausea, acne, and weight gain; surprise, surprise…it is making his life miserable. So we’ll continue to try other drugs and hopefully find some success elsewhere.
We’ve talked about the use of lithium in batteries and in brains, but in beverages? Believe it or not, it’s true.
Lithium was once a key ingredient in 7 Up soda. This is a 7 Up ad in a 1948 issue of Ladies’ Home Journal magazine. Look how happy everybody is, and notice all the open bottles of liquid lithium everywhere. The father is like “These crazy kids, drinking all this 7 Up. They’re going to drive me to the poor house!” And the son is like “It’s okay, dad! Have another sip of your 7 Up!” And the daughter is like “Wheeee! I LOVE 7 Up!” And the mom is like “I hope I have enough 7 Up to keep me from murdering my entire family.” And the tagline just kills me… “You like it- it likes you!”
7 Up debuted in 1929, and before 7 Up became it’s name, it was called “Bib-Label Lithiated Lemon-Lime Soda,” (really catchy name) and its original ingredients included a “healthy dose” of lithium citrate. Apparently there were more than 500 lemon-lime soft drinks on the market at the time, which is yet another fact that blows my mind. Anyway, to make their product stand out, Cadbury Beverages North America touted in their ads the “positive health effects” of the lithium in the soda, which interestingly was released just a few months before the 1929 stock market crash and the onset of the Great Depression….things that make you go hmmm….Apparently the recipe had some appeal, because in the 1940s, 7 Up was the third best-selling soft drink in the world. But alas, somebody got wise, and lithium was removed from the recipe in 1950. Just a little fun fact: there is a precedent for the addition of “pharmacologically active” ingredients in soft drinks. Coca Cola added a lot of coca leaves (from which cocaine is derived) to it’s original 1886 formulation, giving it it’s name. Another fun fact: the guy that formulated it was an alcoholic and opium addict who was looking for a cure for his affliction. Evidently it contained a great deal of the cocaine molecule, a fact that undoubtedly led to it’s popularity in those olden days. I’m sure lots of folks were bummed out when it was removed from the formulation in 1903. Didn’t matter to the formulator/owner, because he’d been found dead long before on his office floor with an opium stick in his hand.
For more interesting stories on psychiatric conditions and the medications that treat them, check out my book, Tales from the Couch, available in my office or on Amazon.