Here, as always, we give our closing thoughts on lithium and its underutilization in the field of psychiatry, especially in American psychiatry, followed by a song by a local Louisville artist, Jack Rabbit and the Dirty Hares, called "Lying on Sunday."
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Ethan: Dr. El-Mallakh, do you have any closing thoughts to wrap up our discussion?
Rif: It's important for clinicians to make decisions that are not emotionally based. And, what's happening, unfortunately, in psychiatry, if you look at general numbers, the use of lithium is actually declining. We know more about lithium, we know more about the amazing things that it does. We know that it's superior in every way that we could measure compared to alternatives. Lithium reduces the risk for suicide, [00:01:00] lithium actually reduces the likelihood of homicide. And we use it less and less frequently. And a lot of that is driven by fear, not understanding how to use lithium, driven by kidney issues, concerns about that. We talked a little bit about acute toxicity, concerns about that. But, that's really ultimately fear that's driving that. We make the decision to deprive our patients of actually perhaps one of the best drugs we have in psychiatry based on fear.
Patients in general don't like lithium because it has stigma associated with it and the stigma is to some degree because you can see lithium through the tremor, but really because of the public sort of view of lithium and its relationship to mental illness, whereas lithium is really, in a way, the least stigmatizing of [00:02:00] all of our drugs. You're on an antipsychotic, antidepressant, or on lithium, which is just an element for God's sake. It's really a perverse situation. As somebody interested in lithium, one of the things that's really disturbing is that my colleagues actually would prefer to use another drug that doesn't work as well and probably has more adverse effects associated with it just because they think it's safer. And yes, it might very well be safer in an overdose but lithium is quite safe in routine use when you educate your patient. And I think that it's unfortunate, as a field, reducing the use of a drug that if used correctly, is way better than the drugs that we're using as its replacement.
Ethan: Maybe if we can get enough people to listen to this, [00:03:00] a few years down the road, we'll start to see those lithium numbers rising again (Rif: Perhaps.) I really do hope in the age of widespread information, of the Internet and the expansion of where people get their information, that there are enough good outlets that are touting the benefits of medications like lithium, that people can sift through all this information and hopefully drive change and increase in use in the future.
Rif: Yeah, I hope so too. In science, I don't worry too much because truth will come out. But, misinformation can really take hold. If I'm scared, I'm gonna talk about what I'm talking about in a more forceful way. Again, people that speak out of fear might be more convincing than people that speak out of logic, so I guess I'm not as hopeful.
Ethan: I'd like to thank Dr. El-Mallakh for being on the podcast. I really respect [04:00] his opinions and respect his ability to have a very nuanced discussion, and admit things that are still under investigation or unknown, which, the amount of that information is astronomical, despite the way that it is presented a lot of times to us. Some of my closing thoughts: Lithium is a very important drug that is severely under-utilized in psychiatry, especially in American psychiatry. It has allowed so many bipolar disorder patients that previously destined for very tumultuous, difficult lives to function and even excel in our world today. It is one of the only medicines we have in psychiatry that actually fixes a known abnormality associated with the disease. It's under utilization is, in part, due to its historical origins in the United States and the lithium chloride [05:00] deaths of the night late 1940s, but the drastic reductions in use in the last few decades in the United States and now worldwide are at least in part related to a concerted effort by big industry or big pharma to push patients and providers away from lithium and toward more recently patented and therefore more profitable medications like Depakote or the anti-psychotics.
It does have potential side effects, some of which can be severe. Though, in comparison to its alternatives, is safer in so many ways, and much more effective. And patients actually prefer lithium, are more compliant with it, than the alternatives. It additionally has several potential benefits outside of just bipolar disorder, including low-dose lithium without the same side effect profile, lowering the risk of suicide and homicide in the general [06:00] population, reducing the incidence of viral infections and neurodegenerative conditions, and even in prolonging lifespan. The amount of positive data, and the amount of data in general is astounding compared to its alternatives. It's dirt cheap. And it absolutely should be used more often. The bottom line is that it is the best medicine in bipolar disorder. And hands down, every bipolar patient deserves a trial of lithium, prior to moving on to any of the alternatives.
I sincerely hope by broadcasting this series on lithium we pique a renewed interest in lithium prescribing by providers, as well as engage patients to have conversations with their providers about lithium and its potential benefits, and hopefully, we can [07:00] drive the numbers in terms of lithium's use, especially in the United States. Up and back towards where they belong. Thanks for listening. Stick around after the disclaimer/outro for a listen to a local Louisville artist, Jack Rabbit and the Dirty Hares, with their song, “Lying on Sunday.”