Lithium on suicide prevention

[thelastpsych]

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What are your thoughts on the use of Lithium for suicide prevention in general? There are some studies that show good results for every suicidal patient and others that show no improvement, especially for patients who are not bipolar.

Do you use lithium outside of bipolar disorders, for this specific result? What are your experiences?

 

[annoyedpsychiatrist]

for bipolar 1 its a great medication. For bipolar 2, I think SGAs are taking over, though lithium has its role. For unipolar depression, i would personally rather augment with an SGA or another medication before lithium, but wouldnt be opposed to it if they had failed other medications. compliance has always been an issue with lithium for many of my patients, many people dont like the way it makes them feel. Though its slightly different for me, i see a higher number of geri compared to average psychiatrist many of which have signicant CKD with polypharm, so theyre less appropriate lithium candidates. I mean its a good drug at the end of the day, but ultimately compliance is what matters the most, and they have to take it/tolerate it.

 

[Stagg737]

The search function is your friend.

very low lithium dosing for suicide prevention

Currently going through a psychopharm book by Ghaemi, who has a section about lithium with some discussion of the lithium in the drinking water studies most of us have read before. In the book, he seems to be inferring that its a good idea to prescribe very lose doses of lithium (~30mg of...

forums.studentdoctor.net

That said, imo the order of operations is treat underlying illness, if still having actual chronic SI independent of primary diagnosis or just perseverative SI CBT+ACT for management of thoughts. I find many of my patients with chronic SI find it far less distressing when it's normalized or they understand that the thoughts aren't "wrong" but just thoughts.

If still having significantly distressing SI or if they're actually acting on SI then lithium is a decent option. I've always a love/hate relationship with this as I've seen plenty of lithium toxicity cases even when patient is taking it appropriately.

 

[Sushirolls]

I recommend to patients lithium adjunct for MDD very often. 150mg-600mg typically does the trick.
Lithium before SGA, majority of presentations.
Majority of times I've prescribed, people tolerate lithium. They want off in future due to blood draws.

 

[thelastpsych]

The search function is your friend.

very low lithium dosing for suicide prevention

Currently going through a psychopharm book by Ghaemi, who has a section about lithium with some discussion of the lithium in the drinking water studies most of us have read before. In the book, he seems to be inferring that its a good idea to prescribe very lose doses of lithium (~30mg of...

forums.studentdoctor.net

That said, imo the order of operations is treat underlying illness, if still having actual chronic SI independent of primary diagnosis or just perseverative SI CBT+ACT for management of thoughts. I find many of my patients with chronic SI find it far less distressing when it's normalized or they understand that the thoughts aren't "wrong" but just thoughts.

If still having significantly distressing SI or if they're actually acting on SI then lithium is a decent option. I've always a love/hate relationship with this as I've seen plenty of lithium toxicity cases even when patient is taking it appropriately.

Yes Ive seen this thread but since its 3+ years old and a bunch of studies came out, some in favor, some not, I thought it was valid to bring this up. Thanks for the input anyway!

 

[comp1]

I've seen too many patients OD. Sometimes it's intentional, sometimes not, but regardless, it creates a lot of headaches for me and danger for patients. I'll stick with SGAs. Even a 7 day supply of therapeutic lithium dosing swallowed all at once right in an emergency room is likely to need dialysis and a brief ICU stay.

 

[Merovinge]

I use it a lot in adolescents with MDD, but admittedly have a very biased population with severe SI being a large concern for many of them. I think it is a heavily underutilized drug and witness it having far more profound impacts in unipolar depression than classic antidepressants or SGAs. I can count on one hand the number of patient's for whom Abilify has completely changed their depression but I have dozens for whom lithium has.

 

[Stagg737]

I use it a lot in adolescents with MDD, but admittedly have a very biased population with severe SI being a large concern for many of them. I think it is a heavily underutilized drug and witness it having far more profound impacts in unipolar depression than classic antidepressants or SGAs. I can count on one hand the number of patient's for whom Abilify has completely changed their depression but I have dozens for whom lithium has.

Litihum is a great med, but I think my experience has been the opposite. I've seen it work really well for a small handful of patients with legit TRD and do fine for other unipolar depression but not that much better than other antidepressants. Even as an augmenting agent I see it more take patients with depression at a 6/10 down to a 3/10, but not really resolve it.

I've seen Abilify work better more frequently as an augmenting agent. Also doesn't usually resolve the depression, but I see a lot of patients do really well with it. A caveat, I'm not afraid to go above 5 mg of Abilify to augment for depression. I see a lot of patients where 7.5 mg or even 10 mg is needed to really knock the depression down. Side effect profile of Lithium vs SGAs is often a wash imo and just depends on the patients.

I also don't really treat kids though, so could be part of the difference in experience there as I did see kids struggle with side effects of Abilify a lot more than adults.

 

[Merovinge]

Litihum is a great med, but I think my experience has been the opposite. I've seen it work really well for a small handful of patients with legit TRD and do fine for other unipolar depression but not that much better than other antidepressants. Even as an augmenting agent I see it more take patients with depression at a 6/10 down to a 3/10, but not really resolve it.

I've seen Abilify work better more frequently as an augmenting agent. Also doesn't usually resolve the depression, but I see a lot of patients do really well with it. A caveat, I'm not afraid to go above 5 mg of Abilify to augment for depression. I see a lot of patients where 7.5 mg or even 10 mg is needed to really knock the depression down. Side effect profile of Lithium vs SGAs is often a wash imo and just depends on the patients.

I also don't really treat kids though, so could be part of the difference in experience there as I did see kids struggle with side effects of Abilify a lot more than adults.

To be clear, I am not only using in the "traditional" TRD. If I have a patient that has been on Prozac, augmented with Wellbutrin or Abilify and expressing ongoing SI s/p 1+ hospitalizations or 1+ attempts, I will always offer Lithium. I consider success as resolution of active SI/suicide attempts. Most of the time depressive sx also improve, but I am most worried about my patient's not dying/not having sequele from failed attempts/not missing life due to being IP/RTC/therapeutic boarding/etc.

 

[TheRightMedication]

If I have a suicidal patient, I almost always mention lithium. To my mind, all reasonable means of risk reduction should be considered. Taking a pill is pretty dang reasonable.

Likewise if a patient with schizophrenia patient is suicidal, I will mention clozaril.

 

[Liquid8]

Occasionally use it for TRD as an augmentation strategy. I think it does help, but like with anything, I think you have to careful selection of patients is paramount. It may not be the best for those with a history of impulsive behaviour or attempts.

The topic of lithium use was trending a bit on social media last week, which was probably due to Nassir Ghaemi taking a shot at a study by the usual anti-medication Critical psychiatry suspects (Moncrieff, Ploederl) The pseudoscience of lithium and suicide: Reanalysis of a misleading meta-analysis - PubMed

 

[annoyedpsychiatrist]

Ive had a lot of patients do well on SGAs for depression augmentation and found them to be pretty effective and generally well tolerated, besides occasional akithesia. However there was one major exception. Another person treated an older female patient at my clinic with abilify, she had a positive response at 5mg, but after going off it she had a rebound dyskinesia and eventually developed persistent tardive dyskinesia. Very unfortunate. Most have been ok on it though.

With lithium i often have patients telling me it makes them have cognitive issues/emotional blunting/etc. I also somewhat worry about long term risk of CKD, tbh. And the OD potential is very real, as well as becoming toxic. I live in an area where temperature gets very high, very easy to get dehydrated if not drinking enough water. Especially in the geris here.

 

[Merovinge]

Ive had a lot of patients do well on SGAs for depression augmentation and found them to be pretty effective and generally well tolerated, besides occasional akithesia. However there was one major exception. Another person treated an older female patient at my clinic with abilify, she had a positive response at 5mg, but after going off it she had a rebound dyskinesia and eventually developed persistent tardive dyskinesia. Very unfortunate. Most have been ok on it though.

With lithium i often have patients telling me it makes them have cognitive issues/emotional blunting/etc. I also somewhat worry about long term risk of CKD, tbh. And the OD potential is very real, as well as becoming toxic. I live in an area where temperature gets very high, very easy to get dehydrated if not drinking enough water. Especially in the geris here.

I see that very rarely in depression range dosages (technically 0.5-0.7 serum levels, although I find response at 0.4 not uncommonly) and much more commonly when used in bipolar disorder patient's (although often the benefits still dramatically outweigh the risks).

I am the ultimate in water enforcement and discuss fluid intake at every appointment for patient's on lithium. I do agree that patients' out in the heat can have issues even on lower dosages for MDD. I have intentionally avoided anything resembling taking care of older adults so I can certainly imagine more complications in that age range, although that is true for virtually all of our medication. I remember a simple SSRI tanking someone in their 80s due to hyponatremia to the point of almost death *shudders*.

 

[mistafab]

The pseudoscience of lithium and suicide: Reanalysis of a misleading meta-analysis - PubMed

This paper is spot on. The antisuicidal effects of lithium, irrespective of primary diagnosis, are clearly evidenced by decades of good research.

Lithium has antisuicidal properties independent of its effect on the primary diagnosis. Not a debate. It is fact. People who don't believe that are known as "wrong." This is not dogma. This is data.

 

[comp1]

Joanna Moncrieff is so extraordinarily biased, she actually makes pharma companies look fair and balanced. She's really undercutting her own message and goals with the blatancy of it at all.

 

[Stagg737]

To be clear, I am not only using in the "traditional" TRD. If I have a patient that has been on Prozac, augmented with Wellbutrin or Abilify and expressing ongoing SI s/p 1+ hospitalizations or 1+ attempts, I will always offer Lithium. I consider success as resolution of active SI/suicide attempts. Most of the time depressive sx also improve, but I am most worried about my patient's not dying/not having sequele from failed attempts/not missing life due to being IP/RTC/therapeutic boarding/etc.

Well yea. If this is chronic SI that is distressing or actually dangerous separate from a primary Axis I issue, then I typically discuss lithium too. Realistically many patients have "SI" that isn't severe or even serious though and contextualization and therapy to help with perspective is often enough to ensure they're safe. It's a great med, but it's also dangerous and has a lot of potential side effects. It's on the list of meds I love that I try to avoid using unless necessary.

With lithium i often have patients telling me it makes them have cognitive issues/emotional blunting/etc. I also somewhat worry about long term risk of CKD, tbh. And the OD potential is very real, as well as becoming toxic. I live in an area where temperature gets very high, very easy to get dehydrated if not drinking enough water. Especially in the geris here.

Eh, CKD risk is pretty overblown. Evidence that lithium itself causes CKD isn't great, even less so at lower serum levels. Toxic levels or AKIs are more likely to be risk factors for development of CKD, and lithium certain can cause AKI even at therapeutic levels. I worry more about long-term effects on thyroid and parathyroid with lithium as it's not really great to use lithium to treat depression only to cause hypothyroidism which can...worsen depression...

 

[Merovinge]

I would add that single dosages of IR lithium QHS have the lowest risk associated with CKD and is certainly better for adherence vs BID. If tolerability is poor (nocturia issues etc.) I would switch to ER lithium QHS.

 

[clausewitz2]

I would add that single dosages of IR lithium QHS have the lowest risk associated with CKD and is certainly better for adherence vs BID. If tolerability is poor (nocturia issues etc.) I would switch to ER lithium QHS.

All I want to add is that if you are the person in may area who keeps prescribing ER lithium BID, please don't.

 

[Stagg737]

All I want to add is that if you are the person in may area who keeps prescribing ER lithium BID, please don't.

BuT i'M a RaPiD mEtAbOliZeR!?! /s

 

[aim-agm]

BuT i'M a RaPiD mEtAbOliZeR!?! /s

"The bad news is that if you are metabolizing lithium you would be making beryllium, which is toxic to humans. The good news is that if you are metabolizing lithium you are a brown dwarf star, so you'll be fine for the next 7 billion years or so."

 

[Crayola227]

No one has brought up DI? Any thoughts?

 

[Crayola227]

Yes, I know how ****ty it is to Google and then use AI answers.

My only point being, my understanding was that if someone takes Li long enough, most WILL experience a kidney issue, often irreversible, although not all kidney damage ends up having a lot of clinical significance even when permanent.

DI *can* be reversible, but not all. I'm not sure of total patients treated short and long term how many get irreversible DI.

People think of DI sometimes as NBD, like just have to drink more water. But my understanding is that for some folks the need for drinking water at the volumes needed and the need for urination/access to bathroom can actually greatly impact life, almost to a point of being crippled by it or certainly QOL and daily living.

Of course this thread seems to be talking more about patients who either have an acute need or likely will not need Li long term. But since we are discussing Li and kidneys...

Obviously staying alive arguably is important enough to tolerate a lot of side effects and even crap out the kidneys, but it seems worth discussing.

Eta: from Mayo site
Symptoms of diabetes insipidus in adults include:

Being very thirsty, often with a preference for cold water.
Making large amounts of pale urine.
Getting up to urinate and drink water often during the night.
Adults typically urinate an average of 1 to 3 quarts (about 1 to 3 liters) a day. People who have diabetes insipidus and who drink a lot of fluids may make as much as 20 quarts (about 19 liters) of urine a day.

Yikes. Waking all night... 20 liters vs 3??? Also low salt and low protein diet needed.

 

[Cath Up]

I think of lithium and clozapine similarly. They are both magical- we don’t know exactly how they work, they have significant side effects in those who don’t tolerate well (many do), and for the correct indication they are absolutely life-altering and -prolonging DESPITE the side effects. That’s pretty cool, they’re so effective they have positive outcomes even with their tolerability concerns.

As I understand it the average pt on lithium will drink/urinate 20% more- notable but pretty tolerable. I’d also wonder how the kidney disease risk is impacted (reduced) by the above mentioned IR qhs dosing which I doubt is the regimen studied with kidney risk.

 

[Mad Jack]

I would add that single dosages of IR lithium QHS have the lowest risk associated with CKD and is certainly better for adherence vs BID. If tolerability is poor (nocturia issues etc.) I would switch to ER lithium QHS.

What drives me crazy is the pharmacists in my hospital balk when I prescribe IR lithium once daily and I have to fight them every time I do it.

When does everyone get their troughs in once daily dosing btw? Most people seem to do 12h, which isn't really a trough, per se, but waiting 24h would likely lead to relatively high levels for much of the day if you're shooting for trough numbers we would typically view as therapeutic, which is against the whole theory behind once-daily dosing (high peak, low trough). Sorry to get ever so slightly off topic, but knowing when other people are doing their troughs and what numbers they're going for and why would really help me clarify all of this when I'm dealing with pharmacists and lab techs that are upset that lithium isn't being administered and monitored like it is 1960.

 

[Jules A]

What drives me crazy is the pharmacists in my hospital balk when I prescribe IR lithium once daily and I have to fight them every time I do it.

When does everyone get their troughs in once daily dosing btw? Most people seem to do 12h, which isn't really a trough, per se, but waiting 24h would likely lead to relatively high levels for much of the day if you're shooting for trough numbers we would typically view as therapeutic, which is against the whole theory behind once-daily dosing (high peak, low trough). Sorry to get ever so slightly off topic, but knowing when other people are doing their troughs and what numbers they're going for and why would really help me clarify all of this when I'm dealing with pharmacists and lab techs that are upset that lithium isn't being administered and monitored like it is 1960.

I check at 12 hours and anticipate 20-30% higher than previous when changing from bid to qhs dosing. I also wonder if some of the later in life renal issues could be secondary to the high rate of metabolic syndrome in people in the US but gets blamed on Li.

 

[Crayola227]

I check at 12 hours and anticipate 20-30% higher than previous when changing from bid to qhs dosing. I also wonder if some of the later in life renal issues could be secondary to the high rate of metabolic syndrome in people in the US but gets blamed on Li.

But is metabolic syndrome really a big culprit for kidney issues? The only link I could see there is metabolic syndrome leading to coronary disease and heart failure. You would hope the latter outcomes would be controlled for in studies linking kidney damage and Li, but admittedly I haven't dug into the data.

 

[Mad Jack]

I check at 12 hours and anticipate 20-30% higher than previous when changing from bid to qhs dosing. I also wonder if some of the later in life renal issues could be secondary to the high rate of metabolic syndrome in people in the US but gets blamed on Li.

That's what I do, based on the study that inferred the same. The labs hate when I do it, the pharmacists hate when I do it, and I have to TigerText my sources every time to make them leave me alone. It annoys the hell out of me

 

[thelastpsych]

This paper is spot on. The antisuicidal effects of lithium, irrespective of primary diagnosis, are clearly evidenced by decades of good research.

Lithium has antisuicidal properties independent of its effect on the primary diagnosis. Not a debate. It is fact. People who don't believe that are known as "wrong." This is not dogma. This is data.

I think its a bit more nuanced than that - even if you included the pre-2000s studies, you'll have an N of reported suicide deaths of only 9. Ghaemi included the pre-2000s studies and found a CI 0.08 - 1.08 and a p=0.07 which is not a positive result. He then adds two questionable suicides from these studies and finds a significant result.

Now, I'm not saying that Lithium does not prevent suicides, I just think we need more evidence, since this is such a rare event. Its all the more pressing when you compare with the very real risk of intoxication and nephrogenic problems/diabetes insipidus.

I would argue that Lithium is the Gold standard for bipolar disorder, and a valid augmentation for unipolar depression. Outside of that, the evidence doesn't seem all that conclusive (again, not saying it doesnt work), although I might be wrong.

 

[clausewitz2]

Paging Dr. Claude:

"You know, when I really think about it, I've noticed some interesting patterns in how different patients respond to lithium for suicidality. It's not clear-cut, of course, but there are certain types that stand out in my mind.


There are those young adults, often with trauma histories or attention issues, who seem to act on suicidal thoughts almost as soon as they have them. Lithium sometimes seems to dampen that impulsivity, giving them a bit more breathing room.


Then there are the patients, usually older, who get stuck in these relentless cycles of suicidal thinking. It's not that they're impulsive, but they just can't shake these thoughts. For some of them, lithium appears to interrupt that pattern, almost like it's loosening a mental gridlock.


I've also seen interesting responses in patients who have these predictable ups and downs, often tied to hormonal cycles or seasons. They're not bipolar, but there's a clear rhythm to their mood and suicidal thoughts. Lithium sometimes seems to smooth out those peaks and valleys.


There's another group that comes to mind - those anxious, agitated patients who are constantly anticipating disaster. They're wound so tight, and that tension seems to fuel their suicidal ideation. Lithium occasionally takes the edge off that anxiety, which in turn seems to reduce suicidal thoughts.


I've had some surprising results with patients who have borderline personality traits. They often describe their suicidal feelings as this intense, almost physical sensation. Lithium sometimes seems to cool that internal fire.


Then there are those patients who talk about this persistent emptiness, this lack of meaning. It's curious, but some of them report feeling more "solid" or "grounded" on lithium.


Lastly, I've noticed some patients who don't quite meet the criteria for bipolar disorder, but have these periods of agitated depression that look a lot like mixed states. Lithium can be surprisingly helpful in these cases.


Of course, this is all anecdotal. I could be seeing patterns that aren't really there, or attributing improvements to lithium when other factors are at play. But these are the types of patients where I'm more likely to consider giving lithium a try if other approaches haven't panned out."

EDIT: Claude is an AI, specifically Sonnet 3.5 for posterity's sake.

 

[clausewitz2]

But Dr. Claude, when would you avoid lithium?

"
One group that stands out is patients with primary anxiety disorders. These folks might have suicidal thoughts, but they're often more tied to overwhelming worry or panic rather than mood instability. I've rarely seen lithium make a significant dent in their suicidal ideation.


Then there are the patients with chronic pain and associated depression. Their suicidal thoughts often seem directly linked to their physical suffering, and lithium doesn't address that underlying issue. These patients usually need a more comprehensive pain management approach.


I've also been underwhelmed by lithium's effects in patients with severe personality disorders, particularly those with strong narcissistic or antisocial traits. Their suicidal threats often seem more manipulative or impulsive, and lithium doesn't appear to shift that dynamic much.


Another group where I've seen little benefit is in patients with primary substance use disorders. When their suicidal thoughts are closely tied to intoxication or withdrawal states, lithium doesn't seem to offer much protection.


I've also found lithium to be less helpful in older adults with vascular depression. Their mood symptoms and suicidal thoughts often seem more directly tied to cerebrovascular changes, and lithium doesn't appear to address that underlying pathology.


Patients with eating disorders and associated suicidality are another group where I've seen minimal benefit from lithium. The complex interplay of body image issues, control, and mood dysregulation in these cases doesn't seem to respond well to lithium alone.


Lastly, I've been disappointed with lithium's effects in patients whose suicidality is closely tied to external circumstances - like chronic unemployment, legal troubles, or ongoing abuse situations. It feels almost naive to expect a medication to significantly impact suicidal thoughts that are so contextualized in real-world problems."

EDIT: EDIT: Claude is an AI, specifically Sonnet 3.5 for posterity's sake. Seems to have been a point of confusion.

 

[Merovinge]

But Dr. Claude, when would you avoid lithium?

"
One group that stands out is patients with primary anxiety disorders. These folks might have suicidal thoughts, but they're often more tied to overwhelming worry or panic rather than mood instability. I've rarely seen lithium make a significant dent in their suicidal ideation.


Then there are the patients with chronic pain and associated depression. Their suicidal thoughts often seem directly linked to their physical suffering, and lithium doesn't address that underlying issue. These patients usually need a more comprehensive pain management approach.


I've also been underwhelmed by lithium's effects in patients with severe personality disorders, particularly those with strong narcissistic or antisocial traits. Their suicidal threats often seem more manipulative or impulsive, and lithium doesn't appear to shift that dynamic much.


Another group where I've seen little benefit is in patients with primary substance use disorders. When their suicidal thoughts are closely tied to intoxication or withdrawal states, lithium doesn't seem to offer much protection.


I've also found lithium to be less helpful in older adults with vascular depression. Their mood symptoms and suicidal thoughts often seem more directly tied to cerebrovascular changes, and lithium doesn't appear to address that underlying pathology.


Patients with eating disorders and associated suicidality are another group where I've seen minimal benefit from lithium. The complex interplay of body image issues, control, and mood dysregulation in these cases doesn't seem to respond well to lithium alone.


Lastly, I've been disappointed with lithium's effects in patients whose suicidality is closely tied to external circumstances - like chronic unemployment, legal troubles, or ongoing abuse situations. It feels almost naive to expect a medication to significantly impact suicidal thoughts that are so contextualized in real-world problems."

Definitely agree with your two above posts generally.

I will say on very rare occassion I have had patient's with comorbid restrictive ED that are making significant progress in physical (and maybe cognitive) recovery that are still plagued by SI that in turn limits motivation around ongoing recovery. I have had more success with adjunctive Remeron in these cases but have had a few respond very well to lithium. As most reading this know, eating disorders are a significant risk factor for SI and account for a very sizable chunk of the mortality in Anorexia. If someone is not making progress with their ED, certainly lithium alone is not going to fix it, but as part of a RTC/PHP/IOP type setting with someone who is making progress, I would not hesitate to consider Li.

 

[clausewitz2]

Definitely agree with your two above posts generally.

I will say on very rare occassion I have had patient's with comorbid restrictive ED that are making significant progress in physical (and maybe cognitive) recovery that are still plagued by SI that in turn limits motivation around ongoing recovery. I have had more success with adjunctive Remeron in these cases but have had a few respond very well to lithium. As most reading this know, eating disorders are a significant risk factor for SI and account for a very sizable chunk of the mortality in Anorexia. If someone is not making progress with their ED, certainly lithium alone is not going to fix it, but as part of a RTC/PHP/IOP type setting with someone who is making progress, I would not hesitate to consider Li.

Just to be clear, those were the AI's opinions. It is called Claude. I am not.

 

[Stagg737]

Just to be clear, those were the AI's opinions. It is called Claude. I am not.

Lol, wasn't going to comment but those responses seemed weirdly formulaic. Idk that I agree with all those points, but several of them aren't bad and the idea that certain groups seem to benefit while others don't seems pretty accurate.

 

[vanfanal]

many of the comments in this thread have me confused. It seems like many use Lithium to address any aspect of “suicidality”; whereas I always thought the reduction in suicide was from effective treatment of severe MDD or bipolar. Also, my framework for unipolar depression was that I Li is more effective in those with more discrete episodes and more severe neurovegetative symptoms.

 

[Crayola227]

Paging Dr. Claude:

"You know, when I really think about it, I've noticed some interesting patterns in how different patients respond to lithium for suicidality. It's not clear-cut, of course, but there are certain types that stand out in my mind.


There are those young adults, often with trauma histories or attention issues, who seem to act on suicidal thoughts almost as soon as they have them. Lithium sometimes seems to dampen that impulsivity, giving them a bit more breathing room.


Then there are the patients, usually older, who get stuck in these relentless cycles of suicidal thinking. It's not that they're impulsive, but they just can't shake these thoughts. For some of them, lithium appears to interrupt that pattern, almost like it's loosening a mental gridlock.


I've also seen interesting responses in patients who have these predictable ups and downs, often tied to hormonal cycles or seasons. They're not bipolar, but there's a clear rhythm to their mood and suicidal thoughts. Lithium sometimes seems to smooth out those peaks and valleys.


There's another group that comes to mind - those anxious, agitated patients who are constantly anticipating disaster. They're wound so tight, and that tension seems to fuel their suicidal ideation. Lithium occasionally takes the edge off that anxiety, which in turn seems to reduce suicidal thoughts.


I've had some surprising results with patients who have borderline personality traits. They often describe their suicidal feelings as this intense, almost physical sensation. Lithium sometimes seems to cool that internal fire.


Then there are those patients who talk about this persistent emptiness, this lack of meaning. It's curious, but some of them report feeling more "solid" or "grounded" on lithium.


Lastly, I've noticed some patients who don't quite meet the criteria for bipolar disorder, but have these periods of agitated depression that look a lot like mixed states. Lithium can be surprisingly helpful in these cases.


Of course, this is all anecdotal. I could be seeing patterns that aren't really there, or attributing improvements to lithium when other factors are at play. But these are the types of patients where I'm more likely to consider giving lithium a try if other approaches haven't panned out."

EDIT: Claude is an AI, specifically Sonnet 3.5 for posterity's sake.

Seriously AI generated this??? No wonder all the writers and whatnot are worried about being replaced.

 

[annoyedpsychiatrist]

I would add that single dosages of IR lithium QHS have the lowest risk associated with CKD and is certainly better for adherence vs BID. If tolerability is poor (nocturia issues etc.) I would switch to ER lithium QHS.

yes i tend to prefer consolidated dose of lithium nightly, IR format as well.

Though i wonder sometimes when these people come in on ER BID with CKD and no other clear risk factors for CKD is it coincidence or did lithium have a hand? no way of knowing. But I also dont like to gamble in vegas, so if there is a less potential for SE for depression im going to always try those first.

Its interesting some people don't seem too fond of SGAs for depression, ive had some pretty good results overall. I also find them helpful for irritability

 

[Stagg737]

Seriously AI generated this??? No wonder all the writers and whatnot are worried about being replaced.

Eh, not to derail thread but it reads like someone or something trying to imitate a psychiatrist. Definitely does not sound like Clausewitz, imo (WW skills activated, lol). Feels very formulaic and inorganic to me, but maybe not to others?

 

[clausewitz2]

Eh, not to derail thread but it reads like someone or something trying to imitate a psychiatrist. Definitely does not sound like Clausewitz, imo (WW skills activated, lol). Feels very formulaic and inorganic to me, but maybe not to others?

I mean, I did ask it to pretend to be a mid career academic psychiatrist who was answering a question from a colleague but "tell me how you really feel."

 

[Merovinge]

I mean, I did ask it to pretend to be a mid career academic psychiatrist who was answering a question from a colleague but "tell me how you really feel."

Less elegant than you normally write, but I figured you were just in a sassy mood and maybe taking the piss a bit. Especially since the answers seem awfully reasonable. I clearly need to spend more time with LLMs.

 

[Stagg737]

I mean, I did ask it to pretend to be a mid career academic psychiatrist who was answering a question from a colleague but "tell me how you really feel."

Less elegant than you normally write, but I figured you were just in a sassy mood and maybe taking the piss a bit. Especially since the answers seem awfully reasonable. I clearly need to spend more time with LLMs.

Idk, kind of had a Clint Eastwood talking to a chair feel, lol.

 

[thelastpsych]

I mean, I did ask it to pretend to be a mid career academic psychiatrist who was answering a question from a colleague but "tell me how you really feel."

Maybe we should create an account that only posts AI generated texts here and see how long it takes for someone to figure it out.

 

[clausewitz2]

Maybe we should create an account that only posts AI generated texts here and see how long it takes for someone to figure it out.

Speaking as a moderator, please don't.

 

[Crayola227]

Eh, not to derail thread but it reads like someone or something trying to imitate a psychiatrist. Definitely does not sound like Clausewitz, imo (WW skills activated, lol). Feels very formulaic and inorganic to me, but maybe not to others?

He said quoting Dr. Claude, so I didn't think it was him, but I did think it might be a real writer. The formulaic aspect I thought was maybe just how they were trying to organize their thesis for different groups.

I'm not saying AI can replace doctors, but you have various technical writers and such, and I could see how if your job was writing articles about healthcare topics for lay people with physician review for accuracy (a real job I saw listed for someone with a healthcare background) that AI could actually be a threat for certain writing jobs.

 

[vanfanal]

The latest VA/DoD guidelines (2024) on suicide have change their recommendation for lithium from weak for to neither for or against. They cite this study by Nabi 2022: Effects of lithium on suicide and suicidalbehaviour: a systematic review andmeta-analysis of randomised trials

 

[Merovinge]

The latest VA/DoD guidelines (2024) on suicide have change their recommendation for lithium from weak for to neither for or against. They cite this study by Nabi 2022: Effects of lithium on suicide and suicidalbehaviour: a systematic review andmeta-analysis of randomised trials

I mean that analysis found that data was underpowered but also showed an OR of suicide of 0.4 with recent data and then data from pre-2000 showing an OR of 0.33 (but also not statistically significant). It's extremely hard to get good data on long-term antisuicidality associated with randomized introduction of lithium for pretty obvious reasons, particularly with very low base rates of suicide. I would strongly support large cohort data analysis but this is far from some very damning finding. The authors seem to be pretty excited that these results challenge the previous metanalysis findings, whereas any other intervention that had a OR of death of 0.33-0.4 would be heralded as the next coming of a revolution with every effort made to increase sample size to sufficient power.