Maintenance treatment in bipolar disorder: a reassessment of lithium as the first choice

In consideration of the declining use of lithium over the past several decades, this review focuses on three topics to argue for lithium's status as first choice as the maintenance treatment of bipolar disorder.

This review (i) describes success rates for patients assigned to lithium and those assigned to placebo in early (1973-1976) and recent (2000-2003) trials, as well as those assigned to alternative mood stabilizers versus placebo; (ii) summarizes the results of studies that compared lithium to alternative mood stabilizers by the degree of weight gain during maintenance therapy; and (iii) reviews evidence that lithium exhibits unique antisuicidal properties.

Differing success rates in early and more recent maintenance trials strongly suggest a cohort effect in which the lithium responders are relatively unavailable for recent maintenance trials. Moreover, among mood stabilizers studied in randomized trials, lithium appears least likely to cause substantial weight gain, and a considerable literature has developed to suggest that lithium has antisuicidal effects that extend beyond its benefits in relapse prevention.

The evidence reviewed here strongly supports the consideration of lithium when prophylactic treatment is first begun for a bipolar patient.