Irrespective of age, I am often referred challenging cases, replete with multiple and varying medication and behavioral dynamics. Here’s an example:
Connor, age 10, has bouts of intense aggression alternating with periods where he expresses wanting to die. He experiences severe moods swings, sleeps poorly, and is routinely irritable and irascible. School officials claim to be at their wits end with his behavior, as he is often in trouble, reacts inappropriately with peers and adults, and acts in defiance of school rules. He’s been spoken to multiple times, suspended from school, and has seen several different therapists over the past year. A similar scenario plays out at home. Connor has been treated with antidepressants and stimulants with minimal to poor results, and everyone interacting with him is exhausted and very concerned. Connor does have a family history of bipolar disorder, with other family members having responded to lithium in the past.
Complicated and challenging client circumstances such as what I described above, all but demand that we remain composed, while zeroing in on the identified problem list, as well as staying receptive to family frustration.
Effectiveness in Children
Lithium is FDA approved for bipolar disorder treatment in adults and children. It remains far and away the best pharmacological treatment going for acute and maintenance management of mania in adults, and it’s effectiveness for mania in children ages 7-17 is also robust. Studies related to how it helps with suicidal adults dating back to the early 1970s, indicate 15-25 percent reductions in suicide rates in adults. And although there is minimal data on the reduction of suicide attempts or completed suicides in youth, the general consensus – extrapolated mostly from adult data – is to consider lithium for children and adolescents in similar circumstances.
Preliminary Considerations; Initial Dosing
Lithium is typically not considered a first-line option in kids, but is instead employed after trials of Depakote, Tegretol, and Lamictal have not yielded results. Before beginning lithium, it’s generally wise to discontinue antidepressants because of their propensity for causing rapid cycling and possible switches to mania. It’s also prudent to stop stimulants in youth with sleep disturbance. Once these changes are made, obtaining a complete blood count (CBC), a metabolic profile, thyroid studies, and an EKG are recommended. If all tests check out well, lithium can then be initiated gradually. In young children, a reasonable starting dose is 150mg nightly with a target blood level range of 0.8-1.2mEq/L. (Lithium, of course requires blood level monitoring). For children 13 and older, the starting dose doubles to 300mg with the same blood levels in mind.
Discussing with Parents
This is the dicey part when it comes to considering lithium as part of the treatment regimen. Full disclosure: I’m a big fan of lithium, particularly in treatment-resistant instances and in otherwise difficult cases and I’ve found that some prescribers will go out of their way to avoid its use because of parental resistance or side effects and overall management issues. And my merely mentioning lithium as a drug parents may wish to consider, engenders looks of panic as to why I would even consider such a powerful drug that is reserved for the “insane.” This is sometimes followed by questions such as “do you really believe my son is some sort of two-headed monster,” or “so far gone that we have to go to this extreme?” When I hear this, I’m careful to respond with empathy and not move too quickly, risking the loss of trust, while knowing that the notion of using lithium takes time to absorb. If you find yourself in a similar situation, consider the following when talking to parents or guardians.
Side effects. Yes, there are many: hypothyroidism, renal effects, increases in thirst and urination, acne, and signs of toxicity such as ataxia, slurred speech and dizziness. At the same time, assure concerned parents that with consistent clinical and laboratory monitoring, most side effects are quite manageable.
Hydration. Children taking lithium should remain hydrated, particularly in hot weather. Because lithium is a salt, dehydration causes lithium levels to rise, which could lead to toxicity.
Sugary foods and beverages. Both can contribute to significant weight gain.
Thyroid changes. Hypothyroidism is a potential risk factor, although supplemental thyroid supplementation can often be utilized, particularly if lithium is proving beneficial to the child’s symptoms.
Drug use consideration, at its most basic, is dominated by a single question: Do the overall potential therapeutic benefits outweigh the potential risks? Lithium is controversial in this sense, but unless the perfect drug scenario of “all benefit, no risk” comes along, we’ll have to choose. In spite of its drawbacks, lithium’s effectiveness in managing mood instability and suicidality is sound.
The “perfect drug” is not coming soon.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.