Irrational Behavior & Lithium Toxicity?
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Q:  Irrational Behavior & Lithium Toxicity?

Hello Sir.
My brother & I have been diagnosed, my question is for him. I have a question which carries great importance, I would appreciate it immensely if after consideration you can afford me an answer. He was diagnosed 6-7 yrs ago at his 45 yrs of age as being bipolar hypermanic. Due to hepatitis and liver concerns it is decided that lithium is the best route to go, it is established that 900 mg per day is what's needed to put him at a theraputic level & for over 5 yrs 900 mg is perscribed & consumed per day. One day he goes to pick up a Rx refill for the lithium, he knows the pill sizes vary & relies on the Rx'd dos. on the label. the Rx refill states take 2 tablets am &  pm. he does so for some 6 wks until he is arrested for an incredibly senseless crime. At that point he learns that the Rx refill label was INCORRECT & should have been take "1" am & "1" pm. For 6 wks he was accidentally subjected to  1800 mg of lith. per day. This was during April/May/June of 20  08 in Fla's hot sun. He works outside in construction. 2 wks into this accidental overdose he undergoes knee surgery & is Rx'd oxycodone, 60 tabs. Lith. mandates you  stay hydrated/oxycodone dehydrates. hot weather/sun makes it worse.He is 6' 2" tall & 175 lbs w/ little body fat if not zero. 

What are the odds that he could suffer from psychosis due to the toxic level of lith. that he consumed for 6 wks? Could he  suffer from a "black out spell" & do things out of the normal and context & exhibit irrational behaviour? Dr.  Phelps, any input would honestly be greatly appreciated. Thank you for your time.


Dear K--
Lithium can cause confusion when the blood level is too high; this is well known.  Generally at that point the person will also be quite physically ill, with nausea, sometimes vomiting, and often difficulty with balance.  

Could too high a lithium level cause someone to commit an "incredibly senseless crime"?  Well, I suppose there are some crimes one could commit from confusion.  "Irrational behavior", that could certainly fit; and "black out spell", and that is quite possible, due to lithium toxicity.  On the other hand, it would be a little surprising to actually go six weeks with lithium toxicity, although I suppose as healthy guy he might have been able to tolerat it except for some hot days with too little fluid.  The role of his knee surgery and the pain medication thereafter is be difficult to factor in (you are right, in the middle of some lithium toxicity he was just barely handling, adding another medication that can cause confusion could have been a tipping point of some kind).  One would hope that someone might actually have checked the lithium level at that point, but I can imagine how that would be passed over (e.g. outpatient day surgery). 

At minimum, I hope readers will conclude from this that if their regular prescription suddenly changes, without new instructions from their physician, it would be wise to call and say "is there really supposed to be a change in my dose?" 

I hope things get straightened out soon.  It is kind of you to try to help your brother with your investigations.  Good luck with that -- 

Dr. Phelps


 Published February, 2010


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