Question: In the CMHRC book on Bipolar Disorder it says that lithium levels needed for stabilization range from 1.0-1.2 mmol/L but my child’s psychiatrist says the best range is 0.6-0.8. Which is it?
Answer:
At CMHRC we take our lead on medication from three sources:
1. Published peer-reviewed journal articles
2. Collaboration with board certified expert psychiatrists
3. Information gathered from families with lived experience
0.6-1.2 mmol/L is considered the “normal” range on the blood serum level tests for lithium. Some providers interpret this range differently from others, but this is widely accepted as a safe therapeutic range.
Dr. Demitri Papolos is a child psychiatrist who specializes in juvenile onset bipolar disorder and is the Research Director for the Juvenile Bipolar Research Foundation. He talks in his book, The Bipolar Child, about therapeutic levels of lithium in children with bipolar disorder and the fact that they need to be in the upper range of what is considered therapeutic.
The information in the CMHRC book on bipolar is sourced from a forthcoming paper that Dr. Papolos wrote with Bob Post, MD (National Institute of Mental Health – NIMH), and Martin Teicher, MD (McLean Hospital Harvard Medical School) in which they lay out the guideline that 1.0-1.2 is the lithium blood level needed to address early onset bipolar disorder in children.
Dr. Papolos joined me last June for a clinical seminar presentation on the FOH phenotype of bipolar disorder. During that presentation he goes into detail about the medications that are recommended and the levels necessary to reach for therapeutic effect. It can be viewed on our YouTube channel, here.
From our perspective at CMHRC as parents, advocates, and mental health professional who work with countless families as they go through this journey, we have rarely seen lithium be effective in the 0.6-0.8 mmol/L range. While the goal is always to find the lowest medication dose required to alleviate symptoms, levels that fall within the range recommended by Dr. Papolos and others has, in our experience, almost always been necessary to cause relief from bipolar symptoms in youth.
Generally speaking, mono-therapy with bipolar disorder is uncommon. Lithium is often titrated up to a 1.0-1.2 range, very slowly (i.e. no more than 150 mg increases every 5-7 days, with blood work 5 days after each dose increase, and strict observation for side effects) while taking care to maintain proper hydration and electrolyte levels. Once reaching the desired therapeutic effect with lithium, it is sometimes necessary to add another mood stabilizer as an adjunctive pharmacological therapy. Most frequently, families report success from adding medications such as Lamictal or Trileptal.