Most psychiatrists don't have a needed perspective on the degrees of extremes.
If you work in a long-term facility, expect to have patients where nothing, I mean nothing works. Clozapine? No. ECT? No.
In situations like this, you see lithium as needed because it's one of the best meds out there for bipolar disorder and it's highly augmenting for antipsychotics.
Most residents will never see this level of severity outside a long-term facility.
On the flip-side, most residents don't know how good Lamictal is as a med for weaker bipolar disorder because they don't have enough experience seeing patients with weaker bipolar II disorder or cyclothymia. No weight gain, cheap, and patients that are very compliant-this happens actually quite a bit in private practice.
The problem here is residencies tend to be in hospitals with majority Medicaid/Medicare because they're the people who finance residency salaries. This limits most residents into the community or university hospital in the middle of a downtown with Medicare/Medicaid only patients.
Several psychiatrists I see only prescribe one of a few of the possible meds out there and based on very limited reasoning. I've seen some even say "I like the color of the pill" or "it's my favorite medication, I give it to everyone." I wish I were joking.
I've worked in community mental health, private practice, long term and short term facilities, uber-expensive private institutions for the rich, academia, forensic, geriatric, an all-women facility, an all male facility, jails, state hospitals, community hospitals, university hospitals....
I still have the perspective that I am learning. Some people I know do one job and stick with it. They have blinders on from that one perspective, and they aren't even that good in that one specific setting. This can be dangerous not just clinically-because of the intellectual limitations and incest, but because you could be paid and treated like crap and not know it because had to just worked 10 minutes away you would've known what the other side was like.
I think one of the only settings off-hand that I haven't worked in is a child-psych facility, prison and the other being a pill-mill, but I don't want to do the latter. (Hmm, maybe right before I retire, so that way if they take my license it won't matter anyway---yes I am joking). That and wherever you can get sex-surrogates. Hey they're mentioned in textbooks for the treatment of non-physiological psychological erectile dysfunction, but hey, if they're supposed to be the treatment for that disorder why is it that no one ever seems to be able to refer anyone to them?
Point is-there's a proper place for every single medication given the level of severity and treatment resistance, that is unless you got a patient where none of them will work.
Lithium is a very good medication for several specific situations. I wouldn't put every single bipolar disordered person on it, but it's a great tool for treatment for worse cases and cases where you can't tell if it's a cluster-b vs a mood disorder vs ADHD vs GAD (that looks like bipolar disorder) because it being so efficacious, if the person has no side effects and no benefit whatsoever, it greatly pushes my opinion in crossing off bipolar disorder off the differential. If the patient is in good health, follows up for labwork, and is not at high risk for kidney damage, it also helps them as being a better candidate.
