Why is not lithium prescribed more often? Here are the reasons

One of the current conundrums in the psychopharmacology of bipolar disorder is usually phrased as: Why isn’t lithium prescribed more often, especially as a maintenance treatment? After all: 1) It is our oldest and most well established agent; its efficacy has been established in many studies and verified in a recent meta-analysis (1); 2) multiple Practice Guidelines from a variety of countries and regions have consistently deemed lithium as the first line, “gold standard” of mood stabilizers; 3) befitting a gold standard treatment, it is frequently utilized as an active comparator when testing new mood stabilizers (2-4); 4) since it has been prescribed for over 50 years, there is little worry that new long term toxicities or side effects will emerge; 5) equally, there is an astonishing amount of clinical experience with lithium’s use (including mine, having prescribed lithium for 40 years, during over 30 years of which I have directed an academic Mood Disorders Clinic). Despite these compelling reasons to prescribe lithium, evidence from multiple studies in both bipolar disorder and when it is used as an adjunctive antidepressant treatment demonstrate declining and/ or lower prescribing rates of lithium than would be anticipated (5-7). Frequently, this issue is reviewed with the conclusion that we should prescribe lithium more often (as in Professor Nolen’s (8) thoughtful and wise review in this Journal recently). Yet, when a phenomenon-the decreased use of lithium-is repeatedly observed, it may be wise to consider the reasons for the observation instead of simply exhorting our colleagues to act differently. In this article, despite my gratitude for the availability of, experience with, and academic interest in lithium (9), I will present the counter argument, suggesting answers to the question of why lithium is not prescribed more often.