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6.4 Mood Stabilizer – Lithium

Mood stabilizers are used primarily to treat bipolar disorder. They are also used to treat depression (usually in combination with an antidepressant), schizoaffective disorder, and disorders of impulse control. Lithium is an example of a medication historically used as a mood stabilizer. Other medications prescribed for mood stabilizers include anticonvulsants, antipsychotic, antianxiety, and antidepressant medications.[1] Read more about medications used to treat bipolar disorder in the “Treatments for Bipolar Disorder” section of the “Bipolar Disorders” chapter.

Lithium

The most commonly prescribed mood stabilizer is lithium. Lithium is primarily used to treat mania in bipolar disorder. Lithium reduces excitatory neurotransmission (dopamine and glutamate) and increases inhibitory neurotransmission (GABA). It also alters sodium transport in nerve and muscle cells and causes a shift in metabolism of catecholamines. When administered to a client experiencing a manic episode, lithium may reduce symptoms within 1 to 3 weeks. It also possesses unique antisuicidal properties that sets it apart from antidepressants. However, lithium toxicity can occur at doses close to therapeutic levels so lithium levels must be monitored regularly.[2],[3]

Side Effects

Lithium toxicity can occur at doses close to therapeutic levels, so lithium levels must be routinely monitored regularly. Signs of lithium toxicity must be promptly reported to the health care provider for dosage adjustment and treatment. Lithium blocks ADH, so symptoms of diabetes insipidus (i.e., excessive thirst and urination) should be monitored and promptly reported. Lithium’s mechanism of action, nursing considerations, and side effects are summarized in Table 6.4.

Table 6.4 Lithium

Medication Class Nursing Considerations Common Side Effects

(*Indicates medical emergency)
Lithium
  • Used as a first-line mood stabilizing agent to treat mania when symptoms are acute or as maintenance therapy
  • Improved tolerance with food and better drug absorption
  • Recommended water intake is 1.5 – 3 liters/day
  • Given in divided doses if gastrointestinal distress occurs
  • NSAIDs are not recommended because they increase lithium levels
  • Therapeutic blood levels are required. Blood levels are drawn 10-12 hours after the last dose taken. The therapeutic lithium serum level is 0.6-1.2 mEq/L
  • Treatments for toxicity:
    • Notify the health care provider regarding elevated lithium levels
    • Withhold the lithium
    • Encourage fluids; IV fluids may be required
    • Gastric lavage
    • May require urea, mannitol, aminophylline, or dialysis to hasten the excretion of the drug in severe cases
 Lithium blocks ADH, so monitor for symptoms of diabetes insipidus (i.e., excessive thirst and urination)

  • Long-term use increases risk for hypothyroidism, hyperparathyroidism, and impaired kidney functioning

*Lithium toxicity (notify the health care provider)

  • Early signs (<1.5 mEq/L): nausea, vomiting, diarrhea, thirst, polyuria, slurred speech, muscle weakness, or fine tremors
  • Moderate signs (1.6-1.9 mEq/L): coarse hand tremors, mental confusion, persistent GI complaints, muscle hyperirritability, EEG changes, or uncoordinated movements
  • Severe signs (>2.0  mEq/L): ataxia, blurred vision, large output of dilute urine, severe hypotension, clonic movements, overt confusion, cardiac dysrhythmias, proteinuria, or death secondary to pulmonary complications

*Lithium levels > 2.5 mEq/L constitute a medical emergency, even if the client is asymptomatic.

 

Client Education

Nurses teach clients that lithium must be taken as prescribed or serious side effects can occur. They reinforce the importance of adhering to regular blood tests to measure lithium levels and reporting symptoms of elevated levels of lithium, including diarrhea, vomiting, drowsiness, muscular weakness, lack of coordination, ringing in the ears (tinnitus), or large amounts of dilute urine. Driving or operating heavy machinery should be avoided when first starting lithium because it can impair mental alertness. Lithium should not be taken during pregnancy or while breastfeeding unless it is determined that the benefits to the mother outweigh the potential risks to the baby.

Read additional information about lithium in the “Antimanias” section of the “Central Nervous System” chapter of Open RN Nursing Pharmacology, 2e.

  1. National Institute of Mental Health. (2016, October). Mental health medications. U.S. Department of Health & Human Services. https://www.nimh.nih.gov/health/topics/mental-health-medications ↵
  2. This work is a derivative of DailyMed by U.S. National Library of Medicine and is available in the Public Domain ↵
  3. Malhi, G. S., Tanious, M., Das, P., Coulston, C. M., & Berk, M. (2013). Potential mechanisms of action of lithium in bipolar disorder. Current understanding. CNS Drugs, 27(2), 135–153. https://doi.org/10.1007/s40263-013-0039-0 ↵

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