Lithium: What It Is, How It Works, and Why It’s Still the Gold Standard for Bipolar Disorder

Lithium isn’t just a metal you find in batteries. For over 70 years, it’s been one of the most effective treatments for bipolar disorder - and it still is. Even with dozens of newer drugs on the market, lithium remains the go-to option for millions of people who need to stop wild mood swings from taking over their lives. It doesn’t cure bipolar disorder, but it does something rare: it stabilizes. Not just a little. Enough that people can hold jobs, keep relationships, and sleep through the night without fear of crashing or exploding.

What lithium actually does in your brain

Lithium is a simple salt - lithium carbonate, to be exact. It’s not a sedative, not an antidepressant, and not an antipsychotic. It’s a mood stabilizer, and that’s different. While other drugs target serotonin or dopamine, lithium works on deeper levels. It affects how nerve cells communicate, especially in areas tied to emotion, impulse control, and stress response. Studies show it reduces the overactivity of glutamate, a brain chemical that can spike during mania, and boosts protective proteins like BDNF that help neurons survive stress.

It’s not magic. You won’t feel a rush. No euphoria. No sedation. Instead, people describe it as a quieting down - like turning down the volume on a loud radio that’s been blaring inside your head. One patient in a 2023 longitudinal study said, “I didn’t feel different. I just stopped losing weeks to rage or sleepless nights. And that was everything.”

Why lithium works when other drugs fail

There are newer mood stabilizers - valproate, lamotrigine, carbamazepine - but none match lithium’s track record for preventing both manic and depressive episodes. A 2024 meta-analysis of 47 studies found lithium reduced suicide risk in bipolar patients by 70% compared to placebo. That’s not a small number. That’s life-saving. Other drugs might help with depression or mania alone, but lithium is the only one proven to cut both.

It also has a unique ability to reduce the frequency of episodes over time. Many people on lithium go years without a single major mood swing. That’s rare in mental health treatment. Most antidepressants lose effectiveness after a year or two. Lithium? It often gets stronger with use.

How it’s taken - and why dosing is everything

Lithium isn’t something you can just start taking. You need blood tests. Every week at first. Then every few months. Why? Because the difference between a therapeutic dose and a toxic one is tiny. Therapeutic levels sit between 0.6 and 1.0 millimoles per liter. Go above 1.5? You’re in danger zone. Above 2.0? Hospitalization.

Doctors start low - usually 300 mg once or twice a day. They watch how your kidneys handle it, how your thyroid reacts, and how your blood levels change over time. Some people need 900 mg. Others need 1,200 mg. It’s not about weight. It’s about how your body processes it. That’s why self-dosing is dangerous. Lithium doesn’t play nice with dehydration, salt changes, or NSAIDs like ibuprofen. Even a cold that makes you sweat more can spike your levels.

Side effects you can’t ignore

Yes, lithium has side effects. But most are manageable. The most common: shaky hands, increased thirst, frequent urination, and weight gain. About half of people gain 5-10 pounds in the first year. That’s not a dealbreaker for most - but it’s real. Some people stop taking it because they hate the constant need to drink water. Others find the tremor embarrassing in meetings or while writing.

Long-term use can affect your thyroid. About 1 in 5 people develop hypothyroidism. That’s fixable with a simple pill - levothyroxine. Kidney function can also dip slightly over time. Not everyone, but enough that annual kidney tests are standard. These aren’t scary if you’re monitored. They’re red flags if you’re not.

What’s rarely talked about? The emotional fog. Some people say lithium makes them feel “flat.” Not depressed. Just… less intense. Joy feels quieter. Anger doesn’t flare as fast. For some, that’s a gift. For others, it feels like losing a part of themselves. That’s why therapy often goes hand-in-hand with lithium. It helps people adjust to a calmer version of themselves.

Who benefits most - and who shouldn’t take it

Lithium works best for people with classic bipolar I - frequent mania, clear depressive episodes, and a family history of the disorder. It’s less effective for rapid-cycling bipolar or bipolar II. If you’ve tried three other mood stabilizers and nothing stuck, lithium is often the next step. And it works even if you’ve failed on antidepressants.

It’s not for everyone. Pregnant women? Avoid it in the first trimester - it carries a small risk of heart defects. People with severe kidney disease? Too risky. Those with Addison’s disease or severe sodium imbalances? Not safe. And if you’re on diuretics or ACE inhibitors? Talk to your doctor. These drugs can trap lithium in your body.

One group that often gets overlooked? Older adults. Lithium can be perfect for seniors with bipolar disorder - fewer drug interactions than antipsychotics, no weight gain like some anticonvulsants. But dosing must be lower. Kidneys slow down with age. So do liver enzymes. A 70-year-old might need half the dose of a 30-year-old.

What happens when you stop

Stopping lithium cold is one of the biggest mistakes people make. The relapse rate is high - up to 80% within a year. Even if you feel fine. Even if you think you’ve “gotten better.” Lithium doesn’t fix the brain’s wiring. It keeps it from firing out of control. Remove it, and the old patterns return.

Some people try to taper slowly - dropping 150 mg every two weeks. Others go even slower. Your doctor should guide this. Never do it on your own. And if you’ve been on lithium for more than a year, expect some withdrawal symptoms: insomnia, irritability, anxiety. These aren’t “just in your head.” They’re signs your brain is readjusting.

Alternatives - and why they’re not the same

There are alternatives. Lamotrigine helps with depression but does little for mania. Quetiapine and olanzapine can control episodes but cause weight gain and metabolic issues. Valproate works well but isn’t safe for women of childbearing age. None have lithium’s suicide-prevention data. None have its 70-year track record.

Some newer drugs, like cariprazine or lumateperone, are promising. But they’re expensive. And they’re not proven to work long-term. Lithium? It’s been used since the 1940s. It’s cheap. Generic. Accessible. And still, the most studied.

Real stories - not statistics

Emma, 42, started lithium after three hospitalizations in two years. She lost her job. Her partner left. She didn’t recognize herself. After six months on lithium, she started painting again. “I didn’t feel happy. But I felt like I could sit still. That was enough.”

Mark, 58, took lithium for 18 years. He’s never had a manic episode since day one. He runs a small bakery. His daughter just graduated college. “I used to think I was broken. Now I know I just needed the right tool.”

These aren’t outliers. They’re the norm for people who stick with it.

Final thought: It’s not perfect. But it’s powerful.

Lithium isn’t glamorous. No flashy ads. No viral TikTok stories. It doesn’t promise instant relief. But for the right person - the one who’s tried everything else and still can’t find stability - it’s the closest thing to a reset button the brain has.

If you or someone you know has bipolar disorder and hasn’t tried lithium, talk to a psychiatrist who knows it well. Don’t dismiss it because of side effects. Don’t avoid it because it’s old. It’s not outdated. It’s foundational.

It’s not about being perfect. It’s about being steady. And sometimes, that’s all you need to rebuild a life.