Why Lithium Remains the First-Line Medication for Bipolar Disorder

Both doctors agree that sleep is one of the most crucial parts of bipolar disorder management, and the first step is to regulate sleep patterns. So before addressing medications for bipolar disorder, it’s essential to get sleep under control.

According to Dr. Fondriest, “Sleep is king”. When sleep is disrupted, it significantly increases the risk of manic episodes. Common disruptions like significant life changes, night shifts, or medications such as corticosteroids can trigger these episodes. Once sleep starts slipping below six hours, a person with bipolar disorder can quickly move toward a manic state within days, highlighting the urgency of addressing sleep issues promptly.

Sleep is king. Once sleep starts slipping below six hours, a person with bipolar disorder can quickly move toward a manic state within days, highlighting the urgency of addressing sleep issues promptly.

To quickly reestablish stable sleep patterns, Dr. Fondriest often begins treatment by choosing a strongly sedating mood stabilizer or antipsychotic medication, such as Olanzapine, Lithium, or Depakote. “Once you have sleep regulated, managing the rest becomes significantly easier. If patients consistently achieve six to eight hours of sleep at roughly the same time each night, the stability greatly improves.”

Dr. Herman agrees strongly, noting that disrupted sleep patterns serve as an unmistakable sign of bipolar disorder. He compares the brain’s rhythm to musical harmony: if one beat is missed, the entire performance is affected. This analogy emphasizes the importance of maintaining consistent circadian rhythms—daily sleep and wake cycles—to manage bipolar disorder effectively. Both psychiatrists stress that stabilizing sleep is foundational in preventing and managing bipolar episodes.

Lithium remains one of the best and most widely recommended medications for bipolar disorder. Dr. Herman emphasizes, “Many experts believe everyone with bipolar disorder deserves a trial of lithium due to its common effectiveness.” He highlights lithium’s significant role in preventing both manic and depressive episodes, and notably, its reputation for reducing suicide risk.

Dr. Fondriest also acknowledges lithium’s efficacy, stating, “Lithium has unparalleled power in stabilizing bipolar disorder,” but he remains cautious about potential long-term kidney and thyroid risks, especially in younger patients. Regular monitoring is essential to mitigate these and other potential side effects.

Additionally, emerging research indicates that low doses of Lithium may help prevent dementia, and low-dose lithium can act like a bridge between medications and integrative approaches, supporting well-being with limited adverse effects.

Lamotrigine, marketed as Lamictal, holds a distinctive role in bipolar disorder management, particularly praised for its common effectiveness in addressing depressive aspects of the condition. Dr. Herman highlights that lamotrigine is often especially beneficial in preventing depressive episodes, making it particularly suitable for bipolar II disorder or milder forms of bipolar disorder predominantly characterized by depressive episodes. He explains, “Lamotrigine does not reliably prevent mania but is generally very effective at keeping depressive episodes at bay.”

A clinical study comparing Lithium, Lamotrigine, and a placebo found Lamotrigine significantly effective in reducing depressive relapses over extended periods. Lamotrigine often complements Lithium well in treatment regimens, combining their respective strengths in managing both mania and depression. This approach, often referred to by professionals as “belt and suspenders,” leverages the strengths of both medications in an effort to achieve more robust mood stabilization.

Beyond medications, the importance of maintaining regular rhythms and structured routines through therapies like interpersonal and social rhythm therapy (IPSRT) is paramount. This approach educates patients about managing their daily routines to support stable moods.

Dr. Herman suggests several valuable resources for patients:

• International Society for Bipolar Disorders
• Depression and Bipolar Support Alliance (DBSA)
• National Alliance on Mental Illness (NAMI)