Lithium
This is general information to help you ask better questions. It is not medical advice. Your prescriber knows your full picture. Never stop or adjust an antipsychotic without medical guidance - abrupt discontinuation can be dangerous.
Lithium is one of the oldest psychiatric medications still in use, and despite many newer drugs, it remains in many ways the most effective. Its primary use is bipolar disorder, but it shows up in psychosis recovery for a few specific reasons.
Why you may be on this
If your psychotic episode had significant mood features - if it looked like, or turned out to be, bipolar disorder with psychotic features, lithium may be the foundation of long-term treatment, with or without an antipsychotic.
If post-psychotic depression has been hard to treat with antidepressants alone, lithium is sometimes added as an augmenting agent. It has solid evidence for this use.
If suicidal thoughts or behavior have been a concern - lithium is unusual among psychiatric medications in having direct evidence for reducing suicide risk, separate from its effect on mood.
If your prescriber is considering schizoaffective disorder or another diagnosis where mood symptoms are central, lithium may be part of the long-term plan.
An honest note about limits
Lithium requires blood draws, careful hydration, and a different relationship with your body than most medications ask for. In exchange, it does things that few other medications can do, particularly in stabilizing mood across years, and in protecting against suicide.
What to expect early on
Lithium has a distinctive set of effects, and the early period is when most of them appear.
i. Increased thirst and urination. Most people on lithium drink more water and pee more, sometimes significantly. This is partly the medication's effect on the kidneys' handling of water, and partly because staying well-hydrated is genuinely necessary on lithium. Plan to carry water with you.
ii. Mild tremor in the hands. Often a fine tremor, most noticeable when holding something steady or trying to write. For most people it eases over weeks; for some it persists at a manageable level. If it interferes with daily life, there are options, like a different timing of doses, a different formulation, or sometimes a beta blocker.
iii. Nausea or stomach discomfort. Common in the first weeks. Often resolves with taking lithium with food, or switching to an extended-release formulation if you're on immediate-release.
iv. Mental dulling that's hard to describe. Some people experience what they call brain fog or a sense that the edges of thinking are softer. This is one of the most-reported and most-divisive side effects. Some people barely notice it, others find it significant. If it's affecting you, name it specifically to your prescriber. Dose adjustments often help.
v. Weight gain. Common but variable. Often modest; sometimes more significant. Worth tracking honestly so it can be addressed early if it becomes an issue.
vi. Acne or skin changes. An under-mentioned side effect. Lithium can worsen acne or cause skin changes in some people. Standard treatments work; worth mentioning if it's bothering you.
The blood tests, and why they matter
Lithium is unusual among psychiatric medications in requiring regular blood tests. The reason is simple: the difference between an effective dose and a toxic dose is small, and the only way to know where you are is to measure it.
Standard monitoring includes lithium level (drawn 12 hours after your last dose), kidney function, thyroid function, and calcium levels. The first few months involve more frequent draws, typically every one to two weeks until you're stable, then every few months once you are.
If you are ever told a blood draw isn't necessary, push back politely. This isn't a difficult-patient thing; it's the standard of care, and your prescriber should be doing it.
What can throw off your level
Dehydration from heat, exercise, illness, or just forgetting to drink water. Lithium levels rise when you're dehydrated. This is the most common cause of accidental toxicity.
Salt intake changes - a sudden low-salt diet can raise lithium levels. Significant increases in salt can lower them. Consistency matters more than the absolute amount.
Vomiting or diarrhea - fluid loss can quickly raise levels. If you're sick for more than a day, contact your prescriber.
NSAIDs (ibuprofen, naproxen) can significantly raise lithium levels. Acetaminophen is safer for casual use.
Some blood pressure medications (ACE inhibitors, certain diuretics) interact strongly with lithium. Make sure every prescriber knows you're on it.
Signs of lithium toxicity
Lithium toxicity is one of the clearest medical emergencies in psychiatric care. Catching it early matters.
DON'T WAIT THROUGH THESE: Worsening tremor (coarse, not fine). Nausea and vomiting that doesn't stop. Diarrhea. Slurred speech. Unsteadiness or difficulty walking. Confusion or feeling sluggish in a way that's different from your baseline. Twitching or muscle jerks. These can signal lithium toxicity and warrant immediate medical attention - go to the ER. If you're not sure, err on the side of going.
Lithium toxicity is treatable when caught early and can be life-threatening when ignored.
Long-term considerations
Lithium can affect a few systems over years, which is why the monitoring continues even when you're stable.
Kidneys: Long-term lithium use can affect kidney function in some people. This is monitored through regular blood tests. Most people on lithium for years have normal kidney function; a subset develop changes that may require dose adjustment or switching.
Thyroid: Lithium can cause the thyroid to slow down (hypothyroidism) in a meaningful minority of people. This is easy to detect with the thyroid blood tests your prescriber should already be doing, and easy to treat by adding a thyroid medication.
Pregnancy: Lithium has historically been considered higher-risk in pregnancy because of an association with a specific heart defect in the developing baby. More recent research suggests the risk is real but smaller than previously thought. The full picture is more nuanced than the older guidance suggested, and there are situations where staying on lithium during pregnancy may be safer than stopping it, particularly for someone with a history of severe mood episodes. If pregnancy is a possibility, this is a conversation to have early with both your psychiatrist and an obstetrician familiar with psychiatric medications.
Things that interact
NSAIDs (ibuprofen, naproxen, aspirin at higher doses) raise lithium levels, sometimes substantially. Acetaminophen is safer for casual pain relief.
ACE inhibitors and ARBs (some blood pressure medications) raise lithium levels.
Thiazide diuretics raise lithium levels significantly.
Caffeine lowers lithium levels somewhat. Major changes in caffeine intake can affect your blood level.
Alcohol interacts unpredictably; can worsen tremor and affect hydration.
High-sodium energy drinks or significant salt changes can shift levels. Consistency in diet matters more on lithium than on most psychiatric medications.
Worth asking at your next appointment
"When is my next lithium level check?"
"What was my last level, and what range are you aiming for?"
"Are we checking kidney and thyroid function regularly?"
"What should I do if I get sick or have diarrhea for a few days?"
"Is there anything about my other medications that I should worry about with lithium?"
This is general information. Your prescriber knows your full picture - use this to ask better questions, not to make changes on your own. Lithium in particular requires careful monitoring and should never be adjusted without medical guidance.
