Lithium and Age: Talk to your doctor. He/she needs to know.

Older people cannot tolerate as much lithium. This is a fact that some doctors and psychiatrists seem to have forgotten. Lithium is killing people.

Lithium continues to be prescribed as sedative and many people continue to take lithium for decades. This is bad because lithium gradually damages every part of our bodies and the more we consume the more damage is done.

If you are taking lithium then you need a plan for taking less as you get older. Even if you feel you benefit from taking lithium you need to be aware that it does cause damage and there is no such thing as a safe level.

Recently I accompanied a friend to see a doctor who went on at length about how my friend’s kidneys were fine and how he was thinking about reducing the lithium dose anyway. After a bit more questioning, it became clear that my friend, who is over 60, should have had his lithium dose reduced much sooner in the light of deteriorating kidney function.

We left with an agreement that his dose could be reduced from 800 to 600mg/day, something which I had agreed, for me, with my doctor when I was just 42. There is a mistaken belief that high doses of lithium are more effective than low doses. The research does not bear this out. It takes very little lithium to have a sedating effect.

Having established that less lithium was needed and my friend would most likely live longer with a less toxic level in his blood, the psychiatrist initially said my friend would feel ‘no difference at all’. It seems he had not thought through the logic of this. For 10 years my friend had been on a high level of lithium with blood tests showing that damage was being done all because the high dose was supposed to make him feel better in some way. Now he was being told that in taking less he would feel no different!

The reality is that an instant 25% reduction will cause feelings and energy levels to change. If you imagine 800mg/day as being like having a foot pushed down on a car brake pedal then 600mg/day is going to be like easing off that pressure and so with the accelerator still in the same place (the accelerator being having a busy life and simply just the energy from eating) then the car is going to speed up somewhat. The psychiatrist’s response was, “If you are going to look for problems then you will have problems.” Was he now agreeing my friend’s troubles were not of a physical/genetic origin and his energy levels were more to do with life events and lifestyle?

This psychiatrist, most likely, has no personal experience of what it feels like to be coming off a sedative drug after a decade or more of taking it every day. If you have not been through this kind of withdrawal, maybe think about someone smoking 40 cigarettes a day and then being told, “From now on you can only have 30 cigarettes a day”. It would be amazing if there were no changes in mood at all, and if there were no changes at all then why was that person feeling the need for those extra 10 toxic cigarettes?

The psychiatrist suggested waiting until my friend had used all his existing tablets before making any reduction.

What I recommended was changing from 800 to 700mg/day by cutting one 400mg tablet in half and then a half into quarters. Then 1¾ tablets = 700mg. This is a 12.5% reduction. Slightly more than the 10% recommended by most experts in this field but at least not the drastic 25% from going straight from 800 to 600. The next step 700 to 600 can now be when the new prescription comes through, giving about two weeks to adjust after the first small step and going down to 600 no later than the psychiatrist suggested.

WARNING: Before moving on to why my friend so urgently needs less lithium, I need to stress that coming off lithium altogether after taking it for years is a dangerous process. Lithium is like having brakes on and stopping it suddenly will cause a huge change in speed/mood for anyone regardless of any troubles they had before first taking it.

How lithium came back into fashion

Lithium carbonate is a naturally occurring mineral that was used for all sorts of illnesses until it was proved to be too toxic. Lithium is toxic to all parts of the body. The toxic effects have been proved to be cumulative, that is, the dose level times the number of doses determines the risk of damage.

There was a period when lithium was not used at all and the stocks of lithium in pharmacies around the world just stayed where they were. It was considered too dangerous to use. Then it was proposed as a way of slowing people down, which of course almost any toxin would do. Perhaps not surprisingly there were deaths from toxicity very early on (ref 1+2). It was however accepted that some people had too much energy for their own good and the risks were worth it. Certainly relatives found it easier than living with people who did not sleep or could not stop talking.

Why less lithium is needed as we age

The research into this has focused on deterioration of kidney function which theoretically will happen quicker in anyone taking lithium supplements. A lot of research has been carried out and it has all found the same thing. Yes, those people on lithium are losing kidney function, while damaged kidneys become less able to remove all toxins and that includes lithium.

As we get older our kidneys increasingly struggle to eliminate lithium and blood concentrations become more toxic.

In this example, greater attention to annual monitoring could have allowed this man’s lithium dosage to be reduced a year earlier as his lithium in blood result went above 0.8mmol/l and his kidney function as estimated by GFR dropped below 70.

My opinion

A diet/lifestyle that causes someone to seem ‘manic’, and have to see doctors about not sleeping, etc, requires help other than lithium tablets.

Most people will experience a lot of sedation from just 400mg/day lithium and I know people who are very satisfied taking just 100mg/day. This is said to be below the ‘therapeutic limit’, but they find it therapeutic, while avoiding the risks of complete withdrawal.

If you are supporting someone prescribed lithium, please help them with thinking about how and when they will be able to reduce the dosage. Even if they like the idea of taking lithium a sensible target could be to be on half the dose within a decade.

Summing up

Talking about lithium tends to cause controversy as so many people believe lithium helps. In some ways it does, but overall I am sure the world would be a better place if ‘lithium therapy’ could once again be banned.

Those who read this blog regularly will know there is plenty of evidence that people who have extremes of mood need more help other than tablets, especially help with getting their diet right, to cope with stress. Effective help/support is far better than labelling and drugging.

For those on psychiatric drugs regular reviews and help with reduce drug dependence are essential to avoid lives being shortened by drug effects.

Roger Smith – www.rethinkingbipolar.com – article updated 15th August 2014

References:

  1. Robert Whitaker, 2011, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, Broadway Books

Page 183, “…in 1949, the FDA banned it [lithium] after it was found to cause cardiovascular problems.”, “John Cade fed it [lithium] to guinea pigs and found it made them docile.”,

  1. Dr Joanna Moncrieff, 2009, The Myth of the Chemical Cure: A Critique of Psychiatric Drug Treatment

Page 181 “However after looking at Cade’s [1949] clinical notes on this experiment, Johnson suggests that the results were more ambiguous. Toxic effects and ‘side-effects’ were more frequent and severe than the impression conveyed in the published paper. The notes record that one patient  died, two others had to discontinue lithium because of severe toxicity and one patient refused to take it, none of which was reported in the published article.”

Bibliography:

Year A few research papers I feel are relevant
1977 Age as a factor affecting lithium therapy

D S HewickP NewburyS HopwoodG Naylor, and J Moody

Br J Clin Pharmacol. Apr 1977; 4(2): 201–205.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1429021/

1993 Kidney damage in long-term lithium patients: A cross-sectional study of patients with 15 years or more on lithium

Bendz, M. Aurell, J. Balldin, A. A. Mathé, I. Sjödin

Author Affiliations

1Department of Psychiatry, University of Lund Lund

2Nephrology, University of Göteborg Göteborg

3Psychiatry and Neurochemistry, University of Göteborg Göteborg

4Department of Psychiatry, Karolinska Institute Stockholm

5Department of Psychiatry, University of Linköping Linköping, Sweden

Correspondence and offprint requests to:Dr M. Aurell, Njurkliniken Göteborg liniversitet, Sahlgrenska Sjukhuset, 41345 Goteborg, Sweden

http://ndt.oxfordjournals.org/content/9/9/1250.short

2000 Differential pharmacokinetics of lithium in elderly patients

Drugs Aging. 2000 Mar;16(3):165-77.

Sproule BA1Hardy BGShulman KI.

2003 Risk factors for the development of lithium-induced polyuria

Br. J. Psychiatry (2003) 182 (4): 319-323

2008 Lithium-induced Nephrogenic Diabetes Insipidus: Renal Effects of Amiloride

Jennifer J. Bedford, Susan Weggery, Gaye Ellis, Fiona J. McDonald, Peter R. Joyce, John P. LeaderRobert J. Walker

Author Affiliations

Departments of *Medical and Surgical Sciences and Physiology, University of Otago, Dunedin, New Zealand; and Department of Psychological Medicine, University of Otago, Christchurch, New Zealand

Correspondence:

Robert J. Walker, Department of Medical & Surgical Sciences, University of Otago, PO Box 913, Dunedin, New Zealand. Phone: (643) 474 0999, 8045; Fax: (643) 474 7641; E-mail: rob.walker@stonebow.otago.ac.nz

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2518801/

2008 Monitoring of glomerular filtration rate in lithium-treated outpatients–an ambulatory laboratory database surveillance

Nephrol Dial Transplant (2008) 23 (2): 562-565

http://ndt.oxfordjournals.org/content/23/2/562.short

2012 The Effects of Lithium on Renal Function in Older Adults–A Systematic Review

J Geriatr Psychiatry Neurol (2012) 25 (1): 51-61

http://www.ncbi.nlm.nih.gov/pubmed/22467847

2012 SOLID RENAL TUMORS OF COLLECTING DUCT ORIGIN IN PATIENTS WITH CHRONIC LITHIUM NEPHROPATHY

Boer Walther, Goldschmeding Roel, Rookmaaker Maarten1

http://ndt.oxfordjournals.org/content/27/suppl_2/ii66.abstract  (scroll down to find article SUO018)

2013 Management of the renal adverse effects of lithium

Adv. Psychiatr. Treat. (2013) 19 (6): 457-466

http://apt.rcpsych.org/content/19/6/457.short

2014 Increased risk of solid renal tumors in lithium-treated patients – Clinical Investigation

Kidney International (2014) 86, 184–190; doi:10.1038/ki.2014.2; published online 22 January 2014

Mohamad Zaidan1,2,3, Fabien Stucker4, Bénédicte Stengel5,6, Viorel Vasiliu7, Aurélie Hummel1,2, Paul Landais, Jean-Jacques Boffa4,9, Pierre Ronco4,9, Jean-Pierre Grünfeld1,2 and Aude Servais1,2

1Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris Descartes University, Paris, France

2Paris Descartes University, Sorbonne Paris Cité, Paris, France

3INSERM U845, Centre de Recherche “Croissance et Signalisation”, Paris, France

4Department of Nephrology, Tenon Hospital, APHP, Paris, France

5INSERM U1018, Centre for Epidemiology and Population Health, Villejuif, France

6UMRS 1018, Univ Paris-Sud, Villejuif, France

7Department of Pathology, Necker Hospital, APHP, Paris Descartes University, Paris, France

8Department of Biostatistics, Necker Hospital, Paris, France

9UPMC Univ Paris 6, Paris, France

Correspondence: Aude Servais, Department of Nephrology-Transplantation, Necker Hospital, APHP, Paris Descartes University, 149 rue de Sèvres, Paris 75015, France. E-mail:aude.servais@nck.aphp.fr

Received 1 September 2013; Revised 14 November 2013; Accepted 12 December 2013
Advance online publication 22 January 2014

http://www.nature.com/ki/journal/v86/n1/full/ki20142a.html

 

About Roger A Smith
Helping you to think about bipolar disorder in different ways so that we can eliminate the disorder and eventually eliminate the need for this diagnosis.

One Response to Lithium and Age: Talk to your doctor. He/she needs to know.

  1. Margaret Taylor says:

    Hi Roger,
    Another excellent post. I believe the help you are offering your friend is sound. After the six-month period was over when I was mandated to take lithium, I gradually reduced the amount over the course of 12 weeks. I did it with the help of Truehope (and their vitamins EMPowerPlus and AminoPowerPlus). With their guidance, I reduced my dosage from 900 mg by 25% every three weeks (900 to 675 to 450 to 225), while taking their vitamins as instructed. I continued with the megavitamins for another nine months. Now, I just take B12, 1000 mg a day, and B complex a few days a week. I still have a prescription for Ativan, but I haven’t taken one for almost eight months. Also added a magnesium supplement last month and haven’t taken melatonin pretty much since then. All the best to you and your friend.

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