Lithium: Approved Uses, Off-Label Depression Use and Toxicity Warning

What lithium is

The label calls lithium a mood-stabilizing agent, and MedlinePlus calls it an antimanic agent. It comes as lithium carbonate tablets and capsules, an extended-release tablet (one current brand is Lithobid) and a liquid.

This page sums up the current FDA labels, MedlinePlus and a VA/DoD guideline. It is general information, not advice about your own treatment. See others on our list of medicines.

What it is approved for, and off-label use with depression

The current FDA label for lithium carbonate tablets and capsules says it is approved as a single medicine for bipolar I disorder: treating acute manic and mixed episodes, and maintenance treatment, in patients 7 years and older. Our psychiatrist's care described on this site is for anxiety, depression and trauma, so please ask us about anything else.

Using lithium for depression is off-label. MedlinePlus says lithium is also sometimes used to treat depression, and tells readers to talk with a doctor about the risks of using it for their condition.

One off-label use is adding lithium to an antidepressant when that antidepressant has not helped enough. The 2022 VA/DoD guideline on major depressive disorder reviewed this. One research review it cites found less depression with lithium added, while another found no difference from placebo. The guideline places lithium among medicines with insufficient evidence for or against this use, and notes that lithium requires blood level and thyroid monitoring.

How it is thought to work

The label says plainly that the way lithium works as a mood stabilizer is unknown. MedlinePlus describes it as decreasing abnormal activity in the brain.

What taking it can be like

Lithium is a medicine that depends on blood tests. Before treatment, the label calls for checking kidney function, vital signs, electrolytes, thyroid function and other medicines, and considering pregnancy status. During treatment, lithium blood levels are checked regularly, and again after changes in dose or certain other medicines.

Fluids and salt matter. MedlinePlus says to follow a proper diet with the right amounts of fluid and salt, and to talk with your doctor about caffeine. The label warns that dehydration from long periods of sweating, diarrhea or fever raises the risk of low sodium and lithium toxicity. Call your prescriber if you are sick and losing fluids.

MedlinePlus says to continue lithium even if you feel well and not to stop it without talking to your doctor, and to keep all appointments with your doctor and the laboratory.

Boxed warning and who should not take it

The boxed warning is about lithium toxicity. It says toxicity is closely related to the level of lithium in the blood and can occur at doses close to treatment levels, so facilities for prompt and accurate blood testing should be available before treatment begins. It applies to everyone taking lithium. Toxic symptoms can also be delayed, because the label says lithium may take up to 24 hours to reach brain tissue.

Signs in the label range from fine tremor, lightheadedness and weakness to drowsiness, muscle twitching, blurred vision, ringing in the ears and slurred speech, and on to confusion, seizures, coma and death. MedlinePlus, the National Library of Medicine's drug guide, gives an instruction that applies only to specific toxicity symptoms: drowsiness, shaking you cannot control, muscle weakness, stiffness, twitching or tightness, loss of coordination, diarrhea, vomiting, slurred speech, giddiness, ringing in the ears or blurred vision. For those symptoms, in its words, "stop taking lithium and call your doctor immediately." Outside that situation, MedlinePlus says not to stop lithium without talking to your doctor. For an overdose, it says to call 911 if the person has collapsed, had a seizure, has trouble breathing or cannot be woken.

If you are in crisis or thinking about harming yourself, call or text 988, or call 911. Locascio Wellness does not provide emergency services. You can also see our crisis resources.

The label's listed contraindication is a known allergy to an inactive ingredient in the product. It also says lithium is not recommended with severe kidney impairment, and should be avoided in people with Brugada syndrome, or suspected to have it.

Side effects and other warnings

The most common side effects in adults, per the label, are fine hand tremor, passing more urine, mild thirst, nausea and general discomfort early in treatment.

Tell your prescriber about every other medicine you take. The label says diuretics, NSAIDs, renin-angiotensin system blockers and metronidazole may raise lithium levels. Serotonin medicines, including many antidepressants, raise the risk of serotonin syndrome, and antipsychotics have been linked to serious neurologic reactions. Tell your prescriber if you are pregnant, plan to become pregnant or are breastfeeding.

Long-term warnings in the label include:

• Kidney effects, including reduced concentrating ability and chronic kidney disease.
• Thyroid changes, usually underactive thyroid, and high calcium with overactive parathyroid glands.
• Pressure in the skull (pseudotumor cerebri), which can threaten vision if undetected.
• Unmasking of Brugada syndrome, a heart rhythm condition, so tell your prescriber about any unexplained fainting, or a family history of Brugada syndrome or sudden unexplained death.

Can it be managed online in Pennsylvania and New York

Partly. A secure video visit can cover how you are doing, your side effects and your other medicines. Blood tests cannot be done over video, so anyone taking lithium needs a local lab and a clear plan for results.

A licensed psychiatrist on our team, a Doctor of Osteopathic Medicine (DO), treats depression by secure video for people physically located in Pennsylvania or New York during each visit. Whether it is an option for you is a decision for you and your prescriber. Ask us whether our psychiatrist can help. See online depression treatment, psychiatry in Pennsylvania or send us a medication question.

Our therapists do not prescribe. Their depression therapy is by video in Pennsylvania, West Virginia, Arizona, Colorado and Florida, not New York, so New York readers can get psychiatry here but not therapy here. If you have not felt better yet, it is reasonable to keep asking about options.