Q:  Lithium Toxicity & Long Term Effects

My sister in law, who is 33 years old, was recently diagnosed with Bipolar disorder. For the last 3 years, she has suffered from clinical depression episodes as well shorter periods of brief mania.  Yet, she has also had numerous medical problems including migraine headaches, kidney malfunctions along with possible diagnosis of lupus.  She has also had thyroid abnormalities.  Currently, she is in ICU with lithium levels as high as 4.0.  Her doctor is unsure of long term effects but has reported concerns of long term memory loss and confusion along with kidney damage. My question is what are the common long term effects of lithium toxicity?  Also, could her numerous medical problems be causing what is going on her bipolar symptoms and how should her doctors treat her bipolar diagnosis with her medical problems?  Thanks in advance for your time.
 

Dear Tina -- 
Ouch, that's a high level.  Some doc's say after that experience not to use lithium again.  Some just turn to other agents for a while.  The issue is both the brain effect and the kidney effect, as you've learned.  Hunting around for some references on just why we might best avoid lithium after an episode of toxicity, I've not really come up with anything; it may just be "clinical lore".  When she comes out of this if her balance and her speech are all right, she may well not show any signs of this having happened. 

Could her numerous medical problems be causing her bipolar symptoms?  Well, thyroid may very well be related but probably not "the" cause; there are lots of suspicious connections between the two conditions but none that suggest you can "fix" the bipolar just by getting thyroid levels back to normal (well above normal, yes; there are some data about that approach, summarized under Thyroid and Bipolar on my site).  

How about lupus?  It is possible to have mania from lupus^{(e.g. Khan, Moorhead )} but it is certainly possible to have both conditions as well, even though under those combined circumstances one can certainly wonder about how the two might be related.  Can you treat the "bipolar" by treating lupus?  Well, that's tricky:  steroids can make apparent mania in lupus better; but steroids can make psychosis that looks very bipolar-like emerge in about 5% of patients to whom they're given.^Lewis  

How should she be treated now?  Unfortunately, not all that differently than before except:  less reliance on lithium and more vigilance, if it's used, to avoid this happening again, if said vigilance is realistically possible -- and if not, probably look beyond lithium; and secondly, watching kidney function closely to make sure it does not affect subsequent lithium levels or other medications that are largely excreted by the kidney.  While that "watching" is going on, thyroid can also be monitored closely (things may change significantly there if lithium goes out of the picture). 

Dr. Phelps

Published July, 2003