My husband was diagnosed with bipolar disorder one and a half years ago and was hospitalized. A doctor on a public radio program stated that most mentally ill people are over-medicated and there are other alternatives. Since I wasn’t with him, I didn’t hear this. Later he informed me that because of the damage lithium can do to his kidney and the fact that he hates being on lithium, he has been off of it for over a month. I am sure you can imagine how I reacted. What is his chance of having another manic episode, now that he’s off his medication?
Staying on drugs chronically and indefinitely is a drag. It’s a nuisance, an expense, a stigma, and often produces side effects and health concerns. People generally don’t like it, whether the drug is insulin for diabetes or lithium for bipolar disorder. But they do it when persuaded that a relapse or worsening of a serious condition can be prevented. Some people, of course, are not persuaded (especially when the condition being treated has faded to a memory and seems to present no active threat) and go off the drugs. They feel encouraged and vindicated when nothing terrible happens. People who go off antihypertensives, for example, can have years of apparent good health before the day of reckoning, with the onset of heart failure or a sudden stroke.
Let’s take a look at what we know about bipolar disorder: It’s a condition that usually starts in early adulthood, consists of episodes of depression and mania in varying combinations. Episodes are recurrent. It’s estimated that patients not on preventive treatment will experience an average of nine to ten episodes in their lifetime. Episodes last an average of one-and-a-half to four months; some are ill for years at a time.
Although psychological stress is prominent in early episodes, later ones tend to have a life of their own, less linked to stress. Episodes tend to get more frequent with age. Current thinking favors the notion that episodes actually cause changes in the brain that prepare the way for later episodes and progressive intensity of illness. Mania and depression, it should be remembered, are disruptive events. Jobs are lost, marriages severely tried, social relations undermined. Drug and alcohol abuse often complicate things. Some 10 percent of patients eventually commit suicide.
The mainstay of bipolar treatment — both of acute episodes and long-term maintenance (prophylaxis) to prevent or lessen future episodes — is lithium, usually in the form of lithium carbonate pills. Many people take lithium without any trouble, but it’s common to pay a price: hand tremors, copious urination and water intake, skin problems, and mild mental impairments (feeling dulled or slowed.) There is a small risk of some degree of kidney impairment. Hypothyroidism can occur. Since the therapeutic level of lithium is not far below its toxic level, blood has to be drawn frequently for lithium levels, especially early in treatment.
Is it worth taking this drug? How effective is it at treating bipolar disorder?
Studies with a one-year follow-up show that people on lithium prophylaxis get only half the recurrent episodes of people on placebo. A similar protective value extends over the years. Many individuals are wonderfully helped by lithium, with complete cessation of episodes. By contrast, half the people who discontinue lithium have relapsed by six months.
Not all patients are helped by lithium. In those who are nonresponsive or poorly responsive, other drugs are used, often in combination with lithium. Sometimes formerly lithium-responsive individuals who discontinue lithium and have another episode are no longer lithium-responsive.
Some people have milder diseases than average. About 7 percent of bipolar patients do not have recurring episodes. Withdrawing lithium or other drugs might be considered in some individuals who have been stable for years, but your husband, who had an episode severe enough to result in hospitalization so recently, would do well to remain on treatment. An alternative — if his objection is to lithium specifically — would be to talk with his doctor about other drugs, like valproate and carbamazapine, which, although having lesser scientific credentials than lithium, are also widely used in bipolar prophylaxis.
Lithium is a wonderful drug to be free of, if you just look at some of the side effects; the alternative drugs are no picnic either. But it must be remembered that bipolar disorder is a very serious and destructive disease, and an effective treatment, though flawed, is still worth its weight in gold.
One final word for your husband: Treatment is not just taking a drug. Education, guidance, discussion, and psychotherapy are still important, even in the era of pills and managed care.