Many patients and their families regard lithium as a wonder drug and have great expectations for its curative value. . . . These patients are educated in the concept that lithium is a perpetual preventive much like insulin. - Ronald Fieve, Moodswing (1989)Although it is often possible to help depressed people through caring, enthusiastic psychotherapy (see chapters 6 and 16), biopsychiatrists typically reject psychological approaches and instead make extraordinary claims for the efficacy of drugs.
Probably because of toxicity problems, lithium is rarely prescribed by nonpsychiatric physicians and is therefore not among the most widely used psychotherapeutic agents. It accounts for considerably less than 3 percent of total prescriptions for psychotherapeutic drugs by all physicians.
Among psychiatrists, less than 10 percent of drug consultations concern lithium.
The commonly prescribed brand names contain "lith," as in Eskalith, Lithane, Lithobid, Lithonate, and Cibalith-S. Although some preparations are longer-acting, they are interchangeable in regard to their basic effects. Lithium carbonate is the usual form in which it is administered.
A Magic Bullet? Or Russian Roulette?
The promotional campaign for lithium began in 1970, the year the FDA approved it for psychiatric uses. The opening salvo was fired by NIMH in a booklet aimed at the media and the general public. Entitled Lithium in the Treatment of Mood Disorders, it called lithium "the first specific chemical treatment for a mental illness" and claimed that "it rarely produces any undesirable effects on emotional and intellectual functioning."
The NIMH booklet took a potshot at the neuroleptics, claiming that lithium, unlike the neuroleptics, does not produce a "pharmacological straightjacket" or "suppress the frantic emotional lability and hyperactivity of mania by wrapping the patient's entire mind in a cocoon of stupefaction." Never mind that other authorities at NIMH were denying those neuroleptic effects. This group wanted to promote the contrasting image of lithium as a magic bullet: "Only the symptoms are leached out while the rest of the personality remains unaffected."
In 1973, three years after the NIMH booklet, psychiatrist Ronald Fieve started a promotional blitz for
lithium by making the media and medical conference rounds with his famous patient, Joshua Logan, by his
side. Fieve, a well-known biological psychiatrist, was the director of research for the New York State
Psychiatric Institute. Logan, sixty-four years old at the time, had been a producer and director of such
Broadway hits as South Pacific, Annie Get Your Gun, and Mr. Roberts. Now he was offering himself as a
demonstration of the efficacy of lithium in controlling his manic-depressive disorder. In earlier years he
had done the talk show circuit in support of electroshock therapy.
In an article by Harry Nelson in the June 25, 1973, Los Angeles Times, and elsewhere, Fieve estimated
that fifty thousand Americans already were receiving the drug. Fieve's goal was to put six million on the
drug. Other lithium advocates had a still more grandiose and shocking vision - putting everyone in the
United States on the drug.
Just Like Fluoride
Although the original research had been published in 1970 by Earl Dawson and others in Diseases of the Nervous System, the proposal for lithium in drinking water hit the press a few years later during the Fieve-Logan media tour. The researchers led by psychiatrist Dawson claimed to have found higher lithium levels in the drinking water of El Paso compared to Dallas. In El Paso, based on state mental hospital records, Dawson informed the press, "there are almost no mental illness admissions." Admissions to state hospitals were seven times higher where the lithium level was lowest in the water supply. Dawson's amazing conclusion is quoted in the July 7, 1973, National Observer by Diane Shah: "The lithium calms people in El Paso, makes them more cheerful, and gives them a more tranquil attitude toward life."
An October 15, 1971, Medical World News report picked up on the story and quoted Dawson as admitting, "Most of my reprint requests come from Poland, Czechoslovakia, Hungary and other Iron Curtain countries."
In his book Fieve concedes that lithium "probably" should never be added to the national water supply, and then he adds, "Nonetheless, the fascinating possibilities exist" (p. 220). Actually, the research was preposterous. The areas in Texas with high lithium concentrations in the water were also very rural, where state hospital admission rates are always lowest.(1) Furthermore, in psychiatry lithium is used at toxic or near-toxic levels, while the concentrations in the water were minute, much too small to influence the brain or mind.(2)
A Harmless Natural Substance?
Today patients and the public frequently are told that lithium carbonate is a harmless metallic salt found "naturally" in the body and that its function in manic-depressive disorder is similar to the function of insulin in diabetes.
None of this is true, except that it is a metallic salt found in nature. So is lead. Like lead, it is a toxic metal with no known function in the body. Like lead, it appears in traces in the body simply because it's in the environment. Before the lithium PR campaign, the 1960 standard textbook Goodman and Gilman's The Pharmacological Basis of Therapeutics observed that lithium has "no biological function" and "the only pharmacological interest in lithium arises in the fact that [it] is toxic." While insulin actually functions to help the metabolism of sugar in the body, lithium does nothing so positive. Instead it interferes with nerve transmission in general, slowing down the responses of the brain.
While admitting that the mechanism of action of lithium is unknown, the Comprehensive Textbook of Psychiatry seems to approve of the misleading practice of telling patients that it corrects a biochemical imbalance:
"Theories abound, but the explanation for lithium's effectiveness remains unknown. Patients are often told it corrects a biochemical imbalance, and, for many, this explanation suffices. There is no evidence that bipolar mood disorder is a lithium deficiency state or that lithium works by correcting such a deficiency" (p. 1656).Lithium in Psychiatry
Within standard psychiatric practice, lithium has two generally approved applications: to help abort manic episodes and to help prevent their recurrence. Its other uses, such as the prevention of recurrent depression, are controversial even among avid biopsychiatrists and thus will not be addressed here.
In actual clinical practice lithium is not even the drug of choice for aborting manic attacks. While both the NIMH booklet and psychiatrist Fieve remark on how the neuroleptics create a chemical straitjacket and "zonk" the patient, the neuroleptics nonetheless remain the more commonly used agent for actually stopping a manic attack. Lithium doesn't work fast enough, sometimes taking several days or weeks to slow down the patient. Also, the toxic doses required to stop a manic attack are too dangerous.
Lithium's most established role in psychiatry is in long-term administration for prophylaxis when the patient is between manic episodes.
Even so, other drugs - such as the neuroleptics or the anticonvulsant Tegretol - are used for prophylaxis when lithium proves inadequate or too toxic. Any lobotomizing or sedating agent is likely to be found useful. None of this fits the "magic bullet" scenario, and the story of how lithium was discovered demolishes that image.
From Guinea Pigs to Hospital Patients
John Cade accidentally discovered the effect of lithium while injecting it into guinea pigs in his laboratory in Australia. Serendipitously he noticed that the guinea pigs became sedated and even flaccid. As he explained in the 1949 Medical Journal of Australia, "A noteworthy result was that after a latent period of about two hours the animals, although fully conscious, became extremely lethargic and nonresponsive to stimuli for one to two hours before once again becoming normally active and timid."
Notice that the animals became "extremely lethargic and unresponsive to stimuli." Does this sound like the discovery of a treatment specific for "biochemical imbalance" in manic patients? It is, in fact, the now-familiar brain-disabling effect we first saw described in regard to the lobotomizing impact of the neuroleptics. Because this is so disillusioning, the typical textbook of psychiatry makes no mention of the many studies of lithium effects on animals, and the average psychiatrist knows little or nothing about it.
After this unexpected finding in guinea pigs, did Cade then set up a series of scientifically controlled studies in animals? No need for that, when he had ready access to human guinea pigs in the local state mental hospital. He quickly discovered that he could subdue hospital inmates as easily as he did the guinea pigs, making them into more docile inmates. He himself admitted in his pioneering report that the drug produced a nonspecific leveling effect:
An important feature was that, although there was no fundamental improvement in any of them, three who were usually restless, noisy and shouting nonsensical abuse ... lost their excitement and restlessness and became quiet and amenable for the first time in years. (italics added)Yet Cade would later call lithium a "magic wand" for mania.
For a miracle treatment lithium was slow in being accepted and promoted. There were two reasons. First, the drug companies couldn't patent an elementary metallic salt, so they did not see megabucks in promoting their own brands in a competitive market. Equally discouraging, perhaps, in 1949, the very year that Cade was first plugging lithium for mental patients, a small epidemic of lithium toxicity in humans was breaking out. A 1949 Journal of the American Medical Association report by A. C. Corcoran and others, entitled "Lithium Poisoning from the Use of Salt Substitutes," described how a few too many shakes of lithium chloride was causing dangerous and even fatal central nervous system toxicity.
Lithium's Effect on Normal Volunteers
From the start, drug experts promoted lithium as having no effect on normal volunteers. This position has been key to the claim that lithium cures a disease instead of intoxicating the normal brain. This theme is usually bolstered by references to a 1968 foreign journal report by Mogens Schou, perhaps the world's best-known lithium researcher.
I was surprised to discover that the oft-cited Schou report was published in such an esoteric foreign journal that it was not even available in the stacks of the National Library of Medicine. Fortunately, Schou was kind enough to send me a copy of his article, which I have quoted from extensively in Psychiatric Drugs: Hazards to the Brain.
Schou and his two coauthors administered lithium to volunteers, but for too short a period of time to determine its effects. They then gave themselves lithium in doses within the therapeutic range for relatively short periods of one to three weeks.(3) Even though committed to the notion that lithium has no significant effect on "normal volunteers," their self-reports tell a dramatically different story. All three men were markedly emotionally flattened, especially when seen through the eyes of their families. In one case the family considered the blunting effect an improvement in Dad:
On other occasions responsiveness to the environmental stimuli was diminished; this was in one of the cases welcomed by the family ("Dad is much easier and nicer than usual"), while the families of the two other subjects complained about their being so dull.
The subjective experience was primarily one of indifference and slight general malaise. This led to a certain passivity. The subjects often had a feeling of being at a distance from their environment, as if separated from it by a glass wall.... Intellectual initiative was diminished, and there was a feeling of lowered ability to concentrate and memorize.... The assessment of time was often impaired; it was difficult to decide whether an event had taken place recently or some time ago. (Pp. 715-16)(4)Despite these published observations, Schou himself would declare in a review article in the March 25, 1988, Journal of the American Medical Association that lithium counteracts abnormal moods but "interferes to a remarkably low extent with normal mood level and emotional reactivity."
The most in-depth research on the effect of lithium on normal volunteers was led by Lewis Judd, the recent director of NIMH, and reported in the Archives of General Psychiatry in 1977-79. A July 20, 1979, study showed a:
"general dulling and blunting of various personality functions" and overall slowing of cognitive processes.The normal volunteers were observed by trained mental health professionals as well as by a "significant other" in the volunteers' lives, such as a girlfriend or roommate. The significant others recognized lithium's dulling and alienating impact on their companions, including "increased levels of drowsiness and lowered ability to work hard and to think clearly." The trained mental health professionals - what did they observe? They were "unable to detect any behavioral changes in the subjects induced by lithium."
Mental health professionals are trained - but trained to what end? They conveniently are taught not to notice the damaging impact of their treatments. This is true whether we are talking about lobotomy, electroshock, or drugs.
Normal volunteers or patients taking lithium won't necessarily realize how impaired they have become. One reason why lithium serum levels must be taken periodically is that the drugged patients lose their judgment about their impaired state.(5) Frequently they don't notice or report symptoms, such as an obvious tremor or a skin rash. This inattention to harmful drug effects reflects the psychological indifference or apathy produced by the medication, a reaction that worsens with larger and more dangerous doses. Hardly the anticipated magic bullet!
Turning Down the Dial of Life
Studies of the impact of lithium on mental patients show the same mentally suppressive result found in volunteers. An October 1968 article by William Dyson and Myer Mendelson in the American Journal of Psychiatry captures the lithium effect in graphic terms. Describing lithium's action upon patients who are high or hypomanic, they wrote:
It is as if their "intensity of living" dial had been turned down a few notches. Things do not seem so very important or imperative; there is a greater acceptance of everyday life as it is rather than as one might want it to be; and their spouses report a much more peaceful existence.Turning down the dial of life! Getting people to accept life "as it is rather than as one might want it to be." Providing spouses a more peaceful existence. Many people would question these goals and the values inherent in them.
A recent report on noncompliance asks why a large proportion of patients, 43 percent in this study, stop taking their lithium. Michael Gitlin and his colleagues report in the April 1989 Journal of Clinical Psychiatry that patients most frequently stopped because of weight gain and mental impairment, with symptoms of "poor concentration," "mental confusion," "mental slowness," and "memory problems."
Consistent with its toxic effects on the nervous system, lithium causes a tremor in 30 to 50 percent of patients. Tremors can be a warning sign of impending serious toxicity of the brain, especially if it occurs along with other danger signals, such as memory dysfunction, reduced concentration, slowed thinking, confusion, disorientation, difficulty walking, slurred speech, blurred vision, ringing in the ears, nausea, vomiting, and headache. Muscle aches and twitches, weakness, lethargy, and thirst are other common signs of lithium toxicity. In the late stages of toxicity, the patient may become delirious and succumb to seizures and coma. EEG studies indicate an abnormal slowing of brain waves in a significant portion of patients routinely treated with lithium; the condition worsens with toxicity.(6)
Newborn and Nursing Infants
If there was any doubt about the basic subduing effect of lithium, its impact on newborn and nursing infants should have put them to rest. In mothers receiving routine doses of lithium, it reaches the baby through the milk and makes them flaccid and apathetic. In pregnant mothers it crosses the placenta, impacting on the fetus and producing a newborn who is neurologically sluggish.
Are There Permanent Mental and Neurological Effects?
The first indicator of generalized brain damage from any cause is often the subjective feeling of memory dysfunction. This awareness often develops far ahead of objective findings on neuropsychological or neurological tests. I initially expressed concern about memory impairment from lithium in my 1983 book on drugs. Three years later, concern about memory difficulties among lithium patients had become sufficiently widespread for the December 5, 1986, Psychiatric News to highlight research on the subject, in an article headlined LITHIUM AND MEMORY LOSS. Researchers were reporting "a major concern with respect to memory functioning." Patients on long-term lithium did more poorly on recalling numbers and on an information subtest of the Wechsler Memory Scale. Duration of exposure to lithium correlated with negative performance on a number of other memory measures. In addition, an unspecified but apparently significant number of patients reported memory difficulties.
The danger to memory sometimes goes unmentioned in textbooks, or it is dismissed. The Comprehensive Textbook of Psychiatry (1989) observes, "Patients may express concern about the effects of lithium carbonate on their learning, memory, spontaneity, or creativity. Although some impairment can be objectively delineated in detailed neuropsychological testing, most patients either do not experience this effect or do not find it unduly impairing" (p. 927). Yet as we've seen, many patients are so disturbed by these side effects that they stop taking lithium. Indeed, in a different section of the textbook it is stated, "Complaints of dysphoria, intellectual inefficiency, slowed reaction time, and lack of spontaneity are common, especially early in the course of treatment" (p. 1660). Meanwhile, others will be too blunted to complain.
One report raises the possibility of more severe mental deterioration on lithium. In 1985 in the French publication L' Encephale, M-P Marchand presents two cases of "progressive intellectual deterioration" from lithium treatment and relates it to the drug's known toxic impact on cerebral functioning. While no body of evidence has accumulated to confirm this finding, I am gravely concerned that someday we will find ourselves confronting mountainous documentation for dementia due to long-term lithium exposure, much as we must do now in regard to the neuroleptics (chapter 4).
Other Lithium Side Effects
Many studies show that the vast majority of patients suffer from one or more side effects, the most common being thirst, dry mouth, metallic taste, excessive urination, weight gain, nausea and other gastrointestinal problems, sleep difficulties, fatigue or lethargy, poor coordination, tremor, and the various other neurological and mental effects already described.
Kidney problems associated with long-term lithium treatment have been the subject of much research and controversy. Lithium causes an increased excretion of water through the kidneys, and long-term use has resulted in pathological changes in the kidneys of some patients. Despite many studies, the relationship between lithium and kidney disease remains controversial and clouded, but the clouds are rather dark and ominous.
In a March 1989 review in the Journal of Clinical Psychiatry, James W. Jefferson of the Lithium Information Center at the University of Wisconsin responded to the question, "Does lithium cause kidney rot?" He answered:
Not exactly. While lithium is not a kidney-friendly drug, neither does it wreak the havoc on function and morphology [structure] that was suggested by studies in the late 1970s. It is well established that therapeutic amounts of lithium can impair renal concentrating ability, increase urine volume, and cause morphological abnormalities.... Patients can be told that while their kidneys may not win a beauty contest, they can expect them to function adequately for years. On the other hand, when long-term studies become very long-term, the result may not be as encouraging.Most patients would not find these "beauty contest" remarks encouraging, and they are rarely given such a glimpse of the potential menace to their kidneys.
Lithium suppresses thyroid function, causing hypothyroidism and goiter, in up to 10 percent of patients. Hypothyroid symptoms of sluggishness can mimic or elicit depression, and the physician can mistakenly interpret the problem as a recurrence of depression requiring more of the offending medication.
Much more rarely, lithium can produce hyperthyroidism, an overactivity of the thyroid gland. It also can produce an excessive output of hormone from the parathyroid gland, causing demineralization and weakening of the bones."
Lithium raises the white-blood-cell count, and there are reported cases of leukemia in association with lithium treatment. Whether lithium actually produces leukemia and the seriousness of other reported blood abnormalities remains uncertain. Unhappily, these dangers frequently go unmentioned in authoritative sources.
Skin rashes similar to psoriasis and acne frequently are caused by lithium; occasionally a rash persists long after removal from lithium. More than 10 percent of women may experience hair loss on lithium.
Perhaps as an aspect of its suppression of passion, lithium frequently reduces sexuality.
Twenty to 30 percent of patients taking lithium develop cardiac abnormalities as measured by electrocardiogram (EKG). Patients with arrhythmias should be cautious about taking lithium.
People Who Want Lithium
Patients should not take lithium under the mistaken impression that it is a specific cure for mania rather than a nonspecific brain-disabling agent. They should not be misled into believing that it is a natural substance in the body and that taking it is comparable to taking insulin for diabetes. Nor should they be led to believe it is harmless.
Earlier we saw that Joshua Logan traveled around the country promoting lithium with psychiatrist Ronald
Fieve. Was Logan informed about the potential negative effects of lithium? We don't know, but in a letter
to me Logan ridiculed the idea that the drug might harm his creativity. Yet his own doctor, Fieve, with
coauthor Polatin, had described cases of suppressed creativity as early as 1971 in the Journal of the
American Medical Association (JAMA).
Many patients with a history of becoming extremely high do want to take lithium. They certainly have the right to do so, and they will have little trouble finding a psychiatrist to provide it to them. But physicians and psychotherapists also should have the right to refuse to give toxic remedies, much as we reject giving alcohol or street drugs to patients who feel they cannot live without them.
We must ask ourselves whether drugs actually help people understand and take better control over their inner mental lives and their conduct, and we must ask ourselves whether the potential moral downside isn't too great. Taking psychoactive drugs on a regular basis readily becomes a symbolic gesture that interferes with personal growth and even fosters personal failure. The associated brain dysfunction also increases the individual's helplessness. Beyond that, we must be concerned about the long-lasting and permanent damage, known and unknown, that can result from these agents.
I don't doubt that some manic-depressive people have fewer mood swings as a result of taking lithium on a regular basis. But even greater numbers of people have fewer bouts of extreme emotion as a result of drinking alcohol, smoking cigarettes or marijuana, or overeating. Recently a patient consulted me after becoming manic when he stopped abusing alcohol, but I didn't encourage him to resume drinking beer. Instead I urged him to deal with himself and his problems, and he has transformed his life for the better without resorting to alcohol or lithium.
Nonetheless, many persons feel so committed to "self-medicating" with alcohol that they will pursue it even when it becomes life-threatening. I don't believe that the desire to handle life through a psychiatric drug is essentially different from the desire to do it with alcohol, and I don't believe that physicians should look upon it more favorably.
To cast the problem of psychiatric drug use into the realm of drug use in general is more honest and realistic and should enable each person to make a more informed choice. In the meantime, drugs are being pushed by psychiatry and by the media.
In the world of modern psychiatry, claims can become truth, hopes can become achievements, and propaganda is taken as science. Nowhere is this more obvious than in psychiatric pretensions concerning the genetics, biology, and physical treatment of depression and mania. As we also found in regard to neuroleptics and so-called schizophrenia, biopsychiatric research is based too often on distortions, incomplete information, and sometimes outright fraud - at the expense of reason and science.
1. State hospital admissions are largely proportional to urban poverty and homelessness, and to the willingness of hospitals to admit these people involuntarily (see chapter 3).
2. Hardly anyone believes that lithium is such a panacea that its wide-scale use, even in clinically effective doses, could substantially reduce psychiatric admissions to hospitals. Nonetheless, the lithium-in-your-drinking-water proposal illustrates an extreme of biopsychiatric thinking that can only be restrained, like threats to liberty itself, by eternal vigilance. It was widely covered in the press, and other psychiatrists supported it.
3. It is extremely unusual for psychiatrists to administer drugs to themselves as part of their research.
4. The description is very similar to that of lobotomy, with its classic impact of reduced initiative and interest.
5. Because of this drug-induced indifference, even to signs of toxicity, and because of the drug's negative impact on the brain, patients taking lithium must have their blood levels checked regularly in order to prevent potentially lethal reactions.
6. People who already have brain damage, as from electroshock or neuroleptic treatment, tend to become toxic more easily when taking lithium, probably because their brains have less functional reserve. Many sources recommend against combining lithium and electroshock. There are reports of life-threatening neurotoxic reactions when lithium is combined with neuroleptics, especially Haldol.
Peter Breggin's Home Site - Peter R. Breggin, M.D. founded The International Center for the Study of Psychiatry and Psychology (ICSPP) as a nonprofit research and educational network concerned with the impact of mental health theory and practices upon individual well-being, personal freedom, and family and community values. For 25 years ICSPP has been informing the professions, media and the public about the potential dangers of drugs, electroshock, psychosurgery, and the biological theories of psychiatry.
Suggested Reading:Brain-Disabling Treatments in Psychiatry : Drugs, Electroshock, and the Role of the FDA Today! by Peter R. Breggin, M.D.
The Manufacture of Madness : A Comparative Study of the Inquisition and the Mental Health Movements by Thomas S. Szasz, M.D., Professor
Law, Liberty, and Psychiatry : An Inquiry into the Social Uses of Mental Health Practices by Thomas S. Szasz, M.D., Professor
The Limits of Biological Treatments for Psychological Distress by Seymour Fisher and Roger P. Greenberg
Psychiatric Drugs: Hazards to the Brain by Peter R. Breggin, M.D.
Say NO To Psychiatry!
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