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Lithium carbonate is still tops for treating bipolar disorders, and for many people it is indeed a miracle pill.


Mannitol,...found in olives, beets, and celery...counteracts lithium....


Some people find that they must avoid eating sweets (including fruit) until a couple hours have passed after taking lithium.






Lithium


The following excerpt is taken from Chapter 4 of Bipolar Disorders: A Guide to Helping Children and Adolescents by Mitzi Walsh, copyright 2000 by O'Reilly & Associates, Inc. For book orders/information, call (800) 998-9938. Permission is granted to print and distribute this excerpt for noncommercial use as long as the above source is included. The information in this article is meant to educate and should not be used as an alternative for professional medical care.

Lithium carbonate is still tops for treating bipolar disorders, and for many people it is indeed a miracle pill. More than likely it will be the first medication that a doctor prescribes for your child.

Lithium

Generic name: lithium (lithium carbonate, lithium citrate)

Also known as: Eskalith, Lithane, Lithobid, Lithonate, Lithotabs

Use: Bipolar disorders, mood regulation, manic psychosis, PMS, eating disorders, thyroid problems, aggression.

Action, if known: Regulates circuits within the brain, possibly by having an effect on the enzyme inositol monophosphatase. Phosphoinositide signals are believed to important for controlling the body's circadian rhythms.

Side effects: Hand tremor, excessive thirst and urination, nausea (this should pass), diarrhea, blurred vision. Any of these side effects occurring over a long period of time can be a sign of toxicity. Call your doctor if it persists.

Known interaction hazards: Potentiates neuroleptics, danger of encephalopathic syndrome. Counteracted by acetazolamide and by theophylline drugs, such as those used for allergy or asthma.

Tips: Before starting lithium, have kidney function, thyroid, blood salts, and blood cell counts checked. Lithium users must have heart function, kidney function, thyroid function, and therapeutic level monitored regularly. Lithium can be toxic in doses that are not much higher than the therapeutic dose. If you are allergic to tartrazine dyes, ask your pharmacist if these are used in your lithium product. If side effects are a problem, the slow-release Lithobid version may be more tolerable. People who have diabetes or a family history of diabetes should be very careful with lithium, which may affect the pancreas.

There are many good things that can be said about lithium. It's a naturally occurring salt, and has been in use for thousands--that's right, thousands--of years. Native Americans were well aware of the beneficial effect of drinking water from lithium springs, and sent their own mentally ill to take the cure at these bodies of water. You can spot several place names on a US map, such as Lithia Springs in Oregon, indicating that European settlers also quickly grasped the curative value of this water. Despite this long history of casual use as a remedy for emotional distress, lithium was not discovered by modern medicine until 1949. An Australian doctor was the first to figure out its usefulness for patients with manic depression. It was approved by the US Food and Drug Administration in 1969.

Now lithium is available in tablets, with carefully measured doses of pure lithium carbonate at various strengths. A time-release version is also available. Unlike drinking or soaking in lithium-rich water, this method of dosing is much more convenient, and more reliable. Because lithium has been in medical use for almost 40 years, there's plenty of information available about side effects. Most of these are minor. For a few patients, however, lithium can have dangerous effects on the body. This is the case for almost every medication used to treat the symptoms of bipolar disorders.

Things about lithium even your doctor may not know

Lithium and other mood stabilizers tend to take longer to begin working for adolescents than for adults. It may be several months before you see positive results.

Stopping lithium suddenly can bring on a manic episode in some patients, and it may not work again when you restart the medication after stopping. Always taper off your dose under a doctor's supervision, and don't expect to stop and start lithium more than once.

Lithium may have some antiviral effects, including the ability to suppress the herpes simplex virus (and possibly other herpatiform viruses). 1

Calcium channel blockers can lower your lithium level.

Sodium bicarbonate (baking soda) counteracts lithium. People taking lithium probably don't need to worry about the minuscule amount of baking soda found in typical baked goods. Many common antacids are based on sodium bicarbonate, however, including Alka-Seltzer and Bromo Seltzer.

Mannitol, a sweet alcohol, is found in olives, beets, and celery, and is manufactured commercially from corn sugar and hydrogen. It counteracts lithium, although the amount found naturally in unprocessed foods may not cause problems. It is found in many sugarfree products, including gums, candies, powdered drink mixes, and manufactured sugarless foods. It may also be found in other powdered food products, chewable medicines and vitamins, and cereals. Mannitol is the main active ingredient of a few powdered laxatives. These laxatives are also commonly used by drug dealers to cut their product. Mannitol is believed to reduce pressure in the brain cavity, which may have something to do with its effects.

Some people find that they must avoid eating sweets (including fruit) until a couple hours have passed after taking lithium.

Urea counteracts lithium. Urea is a normal product of the body's ongoing internal detoxification efforts--this is an essential process, and there's no need to worry about the effect of this urea on lithium. Some very few people may be especially sensitive to urea from other sources, including animal milk and blood, urea-based fertilizers, and "outgassing" from products containing formaldehyde or other substances mixed with urea.

Inositol, a sugar present in organ meats, whole grains, vegetables, nuts, and beans, is also available in supplement form and in the health food staple lecithin. Inositol is also produced within the human body. People with bipolar disorders appear to better regulate this internal inositol level when taking lithium. So, taking inositol supplements might not be such a good idea when taking lithium--even though some small clinical studies have shown that inositol supplements taken alone can help stabilize some people with affective disorders, including bipolar disorders.

Ibuprofen (Advil, Motrin, Midol-IB, etc.) will raise the level of lithium in the blood.

Lithium causes the natural level of sodium (salt) in the body to decrease, which may cause cravings for salt or salty snacks.

Eating large quantities of salty foods (such as a big serving of potato chips) can raise the level of lithium in the blood.

Patient tips

Troy, a 30-year-old diagnosed with bipolar I disorder at age 17, has taken lithium successfully for almost 13 years. Here are his tips for young people:

When I was an adolescent the main side effect that upset me was acne. I was taking a generic brand of lithium. I was eventually informed that the difference in capsule brands has to do with the filler (not lithium carbonate) that they put in them. Since more than 80 percent of the capsule is filler, this is important. I switched to Eskalith ("the Ferrari of lithium"), and most of my acne disappeared, along with my stomachaches. This wasn't a tough decision, since Eskalith cost me about four cents per capsule, rather than two.

You should trust your body to know what the right dosage of lithium is for you. During the first few months I was taking lithium, my psychiatrist felt it was best to increase my dosage to 1200 mgs a day. On the second day of doing this I felt spaced out, so I went back to the 900 mg dose and soon felt "normal" again. I called up my psychiatrist and told him the situation, and that I was not going to take that extra 300 mgs.

Once you discover the right dosage for you, if you take the lithium on a regular basis and drink the right amount of water, it isn't too difficult to stay in a good range (.5 to 1.5). I take 900 mgs a day and drink about a gallon of bottled water a day. I drink most of the water in the afternoons and evenings after taking the lithium.

Without fail if my lithium level gets too high I get toxic and then I get diarrhea. This happened to me often when I was first taking lithium, but it rarely happens now. It would most commonly occur when I wasn't drinking enough water. I've become aware of my thirst enough to know now when that is happening so I can head it off by drinking more water to flush the lithium out of my body. I am most at risk for this when I go on a trip. There are times when travelling where I don't have access to enough water, or I don't want to drink a lot of water since a bathroom may not be available. I usually head this off by decreasing my lithium dosage during the trip. If you have a stable lithium level, small dosage changes over a couple of days won't really change anything.

When you take lithium for a long time, it becomes so habitual that you can actually take a capsule without remembering that you did so. A trick that's worked for me is to have my three capsules in a little container that I refill every day. Then when I'm not sure if I've taken it I just check the container.

One side effect lithium has given me is psoriasis of the scalp. I've been able to treat this with shampoo, so for me this is a very small price to pay for the mood balance I've been able to maintain.

When I first started taking lithium I had to have a blood draw every month to check my lithium level. For the past ten years, however, I've only had to see a psychiatrist twice a year for half an hour, and have a blood draw once a year to check my lithium level, and check on my kidneys and thyroid gland.

Other mood stabilizers

Many of these medications are also used to control seizure disorders. If you already take a seizure medication, your doctor will probably need to adjust your dosage of both drugs carefully. These drugs tend to have more side effects than lithium, but they are a better fit for some patients.

Like lithium, the other mood stabilizers may be part of a complex drug cocktail. This can increase the risk of side effects.

Depakote caused tremors, mainly in Lisa's hands, which the doctor was able to control with Propronolol. But Depakote also caused her to be hungry all the time and she could never get enough to eat. She put on about 150 pounds in one year. She was becoming so depressed because of her weight gain that we decided it was better to decrease the Depakote to help with that.

In trying to help Lisa with her weight gain, the doctor first tried taking her off Risperdal. In one day's time that sent her into such terrible panic attacks that she temporarily lost her vision. The doctor put her back on it and doubled the dose to help her immediately.

Since taking her off the Risperdal didn't work, the doctor started to gradually decrease her dosage of Depakote. She was on 2500 mg initially, then it was slowly decreased until last April she was taken off completely. Since then she has lost about 35 pounds, and is still working on it. --Donna, mother of 16-year-old Lisa (diagnosed bipolar II disorder, post-traumatic stress disorder, and anxiety disorder)

Depakene

Generic name: valproic acid

Use: Seizure disorders, bipolar disorders, migraine, panic disorder, rages/aggression.

Action, if known: Antispasmodic--increases the levels of gamma-aminobutyric acid (GABA) in the brain, and increases its absorption. Also stabilizes brain membranes.

Side effects: Nausea, sedation, depression, psychosis, aggression, hyperactivity, changes in blood platelet function.

Known interaction hazards: Do not take with milk, and do not use charcoal tablets when taking Depakene. Be careful with alcohol, and with any medication that has a tranquilizing or depressant effect. Side effects may increase if you use anticoagulants (including aspirin), non-steroidal anti-inflammatory drugs, erythromycin, chlorpromazine, cimetidine, or felbamate.

Tips: Watch out for increased bruising or bleeding, an indicator of blood platelet problems. Regular liver tests are a must. Do not crush or chew tablets. Starting with a very small dose and titrating it up slowly can often help patients avoid even the common side effects. Depakene has recently been linked to polycystic ovaries in female patients. The symptoms of this problem include irregular periods and unexplained weight gain.

Depakote

Generic name: divalproex sodium (valproic acid plus sodium valproate)

Also known as: Depakote Sprinkles

Use: Seizure disorders, bipolar disorders, migraine, panic disorder, rages/aggression.

Action, if known: Antispasmodic--increases the levels of gamma-aminobutyric acid (GABA) in the brain, and increases its absorption. Also stabilizes brain membranes.

Side effects: Nausea, sedation (this usually passes after a few days), depression, psychosis, aggression, hyperactivity, changes in blood platelet function, hair loss.

Known interaction hazards: Do not take with milk, and do not use charcoal tablets when taking Depakote. Be careful with alcohol, and with any medication that has a tranquilizing or depressant effect. Side effects may increase if you use anticoagulants (including aspirin), non-steroidal anti-inflammatory drugs, erythromycin, chlorpromazine, cimetidine, or felbamate.

Tips: Watch out for increased bruising or bleeding, an indicator of blood platelet problems. Regular liver tests are a must. Therapeutic level tests can be misleading with Depakote: actual therapeutic levels may be higher (or perhaps lower) than published charts indicate. Do not crush or chew tablets. Starting with a very small dose and titrating it up slowly can often help patients avoid even the common side effects. Hair loss can be avoided by taking 50 mg of zinc daily; some patients also take .025 mg of selenium to boost zinc's effect.

Gabitril

Generic name: tiagibine HCL

Use: Seizure disorders, including partial seizure disorders.

Action, if known: Antispasmodic--enhances the activity of gamma-aminobutrytic acid (GABA), a chemical substance that inhibits electrical activity in the brain. May have other as yet unknown effects.

Side effects: Stomach problems, severe rash, weakness, possible eye effects. Can lower white blood cell and blood platelet count.

Known interaction hazards: Antacids. May interact with other anti-epileptic drugs, so monitor doses carefully.

Tips: This new medication has been approved for use in adolescents, but not for children under 12 years of age. Watch dosage increases closely to avoid toxic reactions.

Lamictal

Generic name: lamotrigine

Use: Seizure disorders, bipolar disorders, Lennox-Gastaut syndrome in children.

Action, if known: Binds to the hormone melanin. Stabilizes electrical currents in the brain and blocks the release of seizure-stimulating neurotransmitters.

Side effects: Headache, dizziness, nausea, general flu-like feeling, light sensitivity. If you develop a rash, call your doctor immediately as it may be a warning of a serious, even life-threatening, side effect. May make seizures worse in some people.

Known interaction hazards: Interacts with Depakote/Depakene, carbamazepine, and phenytoin--your doctor will have to monitor doses carefully. Potentiated by antifolate drugs. Phenobarbital and primidone may lessen its effects.

Tips: Not normally recommended for use by children. If you have heart, kidney, or liver disease, use only under careful supervision. Lamictal may act as an antidepressant when added to another mood stabilizer.

Neurontin

Generic name: gabapentin

Use: Seizure disorders, especially those that do not respond to other drugs, anxiety, panic, bipolar disorders, rage/aggression.

Action, if known: Antispasmodic--appears to act by binding a specific protein found only on neurons in the central nervous system. May increase the GABA content of some brain regions.

Side effects: Blurred vision, dizziness, clumsiness, drowsiness, swaying, eye-rolling.

Known interaction hazards: Alcohol and all other central nervous system depressants, including tranquilizers, over-the-counter medications for colds and allergies, over-the-counter sleep aids, anesthetics, and narcotics. Antacids may counteract the effects of Neurontin.

Tips: Titrate dose very slowly to avoid side effects. People with kidney disease should be carefully monitored while taking Neurontin. Corn is used as a filler in the usual formulation of this drug, causing allergic reactions in some people. Recent parent reports indicate that Neurontin can cause mania in some patients, especially younger patients. This can be offset by adding another medication, or by changing the dose of Neurontin or other medications used with it. Others report that Neurontin made their psoriasis worse. A new drug under development called Pregabolin is based on Neurontin, but with fewer side effects.

Tegretol

Generic name: carmazepine

Use: Seizure disorders, nerve pain, bipolar disorders, rage/aggression, aid to drug withdrawal, restless leg syndrome, Sydenham's chorea and similar disorders in children.

Action, if known: Antispasmodic--appears to work by reducing polysynaptic responses, and has other as yet unknown effects.

Side effects: Sleepiness, dizziness, nausea, unusual moods or behavior, headache, retention of water. May cause low white blood cell count. Call your doctor right away if you have flu-like symptoms or other unusual reactions while taking this drug.

Known interaction hazards: Never take with an MAOI (MAO or monoamineoxidase inhibitor). Tegretol is often used in combination with other antispasmodics or lithium, but the dose of Tegretol and drugs used with it must be very carefully adjusted. Tegretol is potentiated by numerous prescription and over-the-counter medications, including many antibiotics, antidepressants, and cimetadine. It also counteracts or changes the effect of many drugs, including Haldol, theophyllin, and acetaminophen. Because these interactions can be very serious, discuss all medications you take--including all over-the-counter remedies--with your doctor before beginning to use Tegretol.

Tips: You should have a white blood cell count done before taking Tegretol, and be monitored thereafter. Do not take if you have a history of bone marrow depression. Tegretol can be fatal at fairly low doses, so all patients taking this drug should be carefully monitored, particularly since it interacts with so many other medications.

Topamax

Generic name: topiramate

Use: Seizure disorders, including as an adjunctive therapy for partial seizure disorders.

Action, if known: Antispasmodic--enhances the activity of gamma-aminobutrytic acid, a substance that inhibits electrical activity in the brain. Also acts as a calcium-channel blocker, and blocks the excitatory neurotransmitter glutamate. May have other, as yet unknown, effects.

Side effects: Sleepiness, dizziness, loss of coordination, slowed thinking and speech.

Known interaction hazards: Dosage must be adjusted carefully when used with other antispasmodics or any central nervous system depressant drug.

Tips: Topamax was recently approved for use in children with epilepsy, and is available in a "sprinkle" formulation that can be combined with soft food, such as applesauce or ice cream. Because of the side effects that can happen with this drug, it is recommended that patients start very low and titrate the dose upward very slowly.


Notes:

  1. Jay D. Amsterdam, MD, et al., "A Possible Anti-Viral Action of Lithium Carbonate in Herpes Simplex Virus Infections," Biological Psychiatry 27 (1990): 447-453.

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