Psycholeptics. Lithium
Brand names: Cibalith-S, Lithobid, Eskalith, Lithonate, Lithotabs
Updated · Methodology
First line
For acute mania, lithium is effective as monotherapy or combined with antipsychotics. 2019 Cochrane review (McKnight) confirmed efficacy with NNT approximately 6 for clinical response. Onset is 5–7 days, so combination with a rapid-acting antipsychotic or benzodiazepine is common in the acute phase.
Sources
ICD-10: F30 · ICD-11: 6A60.0
First line
Lithium is the first-line maintenance therapy for bipolar disorder type I and II. CG185 2023 and RANZCP 2022 list lithium as the drug of choice for long-term mood stabilization in adults. Reduces manic episodes by 60–70% and depressive episodes by 30–40%. For acute mania, comparable to valproate and atypical antipsychotics. Lithium is unique in reducing suicide risk in bipolar disorder (Cipriani 2013 meta-analysis demonstrated all-cause mortality reduction).
Narrow therapeutic range: 0.6–1.2 mmol/L. Regular monitoring of plasma level, renal function, and thyroid is mandatory.
Sources
ICD-10: F31 · ICD-11: 6A60
Adjunct
Lithium is used as augmentation in patients with treatment-resistant unipolar depression. and recommend adding lithium to an antidepressant when adequate monotherapy fails. Meta-analyses show NNT approximately 5 for remission. Target blood level 0.4–0.8 mmol/L (lower than for bipolar disorder).
In Russia, the treatment-resistant depression indication is not registered directly in GRLS; use is off-label per clinical guidelines.
Sources
ICD-10: F33 · ICD-11: 6A72
The drug is promoted for these uses outside international guidelines. Each entry below is analyzed against AEMPS, FDA, EMA, Cochrane and major RCTs.
Not recommended
Lithium use without therapeutic drug monitoring is unacceptable. Narrow therapeutic range (0.6–1.2 mmol/L) and toxicity at levels above 1.5 mmol/L require regular monitoring every 3–6 months and with any change in dose, diet, or comedications. Without TDM the drug is not prescribed.
Sources
ICD-10: F02.8 · ICD-11: 6D86.Z
Exact mechanism unclear; affects second messengers (inositol triphosphate, GSK-3β), modulates serotonergic and dopaminergic transmission. First-line for bipolar disorder, reduces suicide risk. Narrow therapeutic window 0.6–1.2 mmol/L; overdose causes neurotoxicity and nephrotoxicity.
Boxed warning
FDA boxed warning: lithium toxicity is closely related to serum concentration and can occur at levels close to therapeutic. Regular plasma monitoring is mandatory. Use without TDM capability is not permitted. Administer with caution in patients at risk of dehydration, renal impairment, hyponatremia.
AEMPS summary of product characteristics (section 4.6): lithium should not be given during pregnancy, especially in the first trimester, because of possible teratogenicity. Lithium crosses the placenta; cases of increased neonatal goitre and congenital cardiovascular malformations such as Ebstein's anomaly have been reported, and animal studies have shown reproductive toxicity. Women taking lithium should use appropriate contraception, and stopping lithium is recommended when a pregnancy is planned. If continuing lithium is considered essential, serum lithium levels are monitored closely and the dose is adjusted, as renal function changes gradually during pregnancy and suddenly at delivery; lithium is stopped shortly before delivery and restarted a few days after. Newborns may show signs of lithium toxicity, including flaccid muscles or hypotonia, so exposed newborns are observed closely and their lithium levels may need to be checked.
Passes into breast milk at 40–50% of maternal plasma level. LactMed lists lithium as generally incompatible with breastfeeding: accumulation risk in infant with toxicity (lethargy, hypotonia, cyanosis). If breastfeeding is necessary, monitor infant lithium level.
Reference information, not a clinical decision. Discuss feeding pauses or changes with your physician or an IBCLC.
Lithium and sodium compete for reabsorption in proximal renal tubules. Reduced plasma sodium (salt-restricted diet, fluid loss, diuretics) increases lithium reabsorption and plasma concentration, precipitating toxicity. Patients are advised to maintain stable salt intake (about 4–6 g/day) and dietary sodium, increase fluid intake in heat or exertion. With acute diarrhea, vomiting, or fever, temporarily withhold and check level.
Source: FDA: Lithobid (lithium carbonate) prescribing information (2021)
12 pairs found. Sorted from critical to minor.
Mechanism
NSAIDs (including selective COX-2 inhibitors like celecoxib) reduce renal lithium clearance. Lithium plasma levels rise.
Symptoms
Tremor, muscle twitching, nausea, vomiting, diarrhoea, poor coordination and confusion; severe cases progress to seizures and coma. Toxicity is expected at serum lithium concentrations of about 1.5 mmol/L and above, but some patients develop it at lower levels, including within the therapeutic range.
Management
The UK National Institute for Health and Care Excellence () advises avoiding non-steroidal anti-inflammatory drugs (NSAIDs) in people on lithium if possible and warning them not to take over-the-counter NSAIDs (NICE CG185). If celecoxib is needed, prescribe it for regular use rather than as needed, and check lithium levels monthly until stable, then every 3 months (NICE CG185). When celecoxib is started or stopped, monitor the patient carefully (celecoxib SmPC), measure lithium more often, moving to weekly checks (lithium SmPC), and reduce the lithium dose according to levels and clinical response if needed (lithium SmPC; US lithium label, ). Take the lithium sample 12 hours after the last dose (lithium SmPC). Warn the patient about signs of lithium toxicity: diarrhoea, vomiting, coarse tremor, poor coordination, confusion and seizures (NICE NG222).
Sources
Mechanism
Lithium enhances serotonergic transmission, and its SmPC names SSRIs among the drugs that can bring on serotonin syndrome. The second layer is cardiac: the same label advises avoiding lithium in patients already taking QT-prolonging drugs, while the citalopram label files such combinations under contraindications.
Symptoms
Serotonin syndrome: agitation, confusion, tremor, myoclonus, hyperreflexia, sweating, diarrhoea, tachycardia, and in severe cases hyperthermia and rigidity. Symptoms usually appear within a day of adding the second drug or raising the dose. In patients with cardiac risk factors QTc is tracked separately.
Management
Lithium is added to an antidepressant on purpose in treatment-resistant depression, and the guideline includes this strategy. So the combination is not forbidden, but it needs monitoring. Before lithium is started, renal, cardiac and thyroid function are assessed (lithium label), and potassium and magnesium are corrected before citalopram is started (citalopram label). Lithium levels are checked 1–2 times a week at the start of treatment until they are stable, then every 1–2 months (lithium label). An extra level is taken after vomiting, diarrhoea, dehydration or an infection, and after starting a diuretic, an ACE inhibitor, an angiotensin receptor blocker or an NSAID. In people with cardiovascular disease or high cardiovascular risk, NICE advises considering ECG monitoring. If signs of arrhythmia appear, such as palpitations, skipped beats or fainting, citalopram is stopped and an ECG is done (citalopram label).
Sources
Mechanism
Similar to naproxen + lithium. NSAIDs reduce renal lithium clearance via prostaglandin blockade.
Symptoms
Tremor, muscle twitching, nausea, diarrhoea, confusion, ataxia. Symptoms emerge when serum lithium exceeds 1.2 mmol/L.
Management
Avoid prolonged combination. If diclofenac is needed for a short course, reduce lithium by 25–30% and check level at 5–7 days. For chronic analgesia: paracetamol.
Sources
Mechanism
Enalapril and other ACE inhibitors reduce renal blood flow and glomerular filtration, decreasing lithium excretion. Lithium plasma concentration rises 25–40% with risk of neurotoxicity and renal injury. Effect is greatest in the elderly and with dehydration.
Symptoms
Tremor, confusion, nausea, diarrhea within 2–4 weeks of enalapril start. Lab: lithium above 1.2 mmol/L.
Management
Check lithium before enalapril, then on days 7 and 14 and at 4 weeks. Reduce lithium by 25–50% if level rises above target. Warn the patient about toxicity signs and the need for adequate water intake.
Sources
Mechanism
Furosemide (loop diuretic) lowers circulating volume and, via subclinical volume depletion, increases lithium reabsorption in the proximal tubules. Serum lithium rises by 25–40%.
Symptoms
Tremor, muscle twitching, nausea, diarrhoea, confusion, ataxia. Severe cases include seizures, coma, and nephrogenic diabetes insipidus with dehydration. Symptoms emerge when serum lithium exceeds 1.2 mmol/L.
Management
Reduce lithium dose by 25–30% when starting or escalating furosemide; check serum lithium at 1 week, then monthly. Maintain normal sodium and fluid balance: deficits worsen lithium toxicity.
Sources
Mechanism
Hydrochlorothiazide increases sodium and lithium reabsorption in the distal tubule. Lithium plasma concentration rises 25–40% (up to 100% in some patients). Lithium toxicity develops within 1–2 weeks.
Symptoms
Tremor, nausea, diarrhea, confusion; in severe cases seizures and coma.
Management
For hypertension in a lithium patient, choose another class: calcium channel blocker (amlodipine) or a potassium-sparing diuretic with caution. If thiazide is required, halve lithium and check level on days 5–7 and at 2 weeks.
Sources
Mechanism
Ibuprofen reduces lithium renal clearance by inhibiting prostaglandin synthesis in the proximal tubule. Lithium plasma concentration rises 25–60%, leading to intoxication. Lithium has a narrow therapeutic index (target 0.6–1.0 mmol/L, toxic above 1.5).
Symptoms
Within 5–10 days: nausea, vomiting, diarrhea, tremor, confusion, drowsiness. Severe toxicity: seizures, coma, renal injury, arrhythmia.
Management
In bipolar disorder, paracetamol is the first-line analgesic. If an NSAID is needed, use a short course (up to 5 days); check lithium level 4–7 days after NSAID start and 4–7 days after stop. Reduce lithium by 50% and titrate to level.
Sources
Mechanism
Indapamide is a thiazide-like diuretic. The lithium-raising mechanism is the same as hydrochlorothiazide: enhanced lithium reabsorption in the proximal tubules via subclinical volume depletion. Serum lithium rises.
Symptoms
Tremor, muscle twitching, nausea, diarrhoea, confusion, ataxia. Severe cases include seizures, coma, and nephrogenic diabetes insipidus with dehydration. Symptoms emerge when serum lithium exceeds 1.2 mmol/L.
Management
Reduce lithium dose by 25–30% when starting indapamide; check serum lithium at 1 week, then monthly. Alternatives: amlodipine or a beta-blocker without lithium effects.
Sources
Mechanism
Drugs that block the renin-angiotensin system increase steady-state serum lithium concentrations (US lithium label, ). Reversible rises in lithium levels and lithium toxicity have been reported with angiotensin-converting enzyme inhibitors and, very rarely, with angiotensin II receptor blockers such as losartan (losartan SmPC). Lithium has a narrow therapeutic range: toxic concentrations are close to therapeutic ones (US lithium label).
Symptoms
Tremor, muscle twitching, nausea, vomiting, diarrhoea, poor coordination and confusion; severe cases progress to seizures and coma. Toxicity is expected at serum lithium concentrations of about 1.5 mmol/L and above, but some patients develop it at lower levels, including within the therapeutic range.
Management
The Spanish losartan SmPC advises combining it with lithium with caution and only if the combination is essential; in that case, monitor lithium levels throughout co-administration (losartan SmPC). When losartan is started, stopped or its dose is changed, measure lithium more often, moving to weekly checks (lithium SmPC), and reduce the lithium dose according to levels and clinical response if needed (US lithium label, ). Take the lithium sample 12 hours after the last dose (lithium SmPC). The UK National Institute for Health and Care Excellence () advises taking any start or change of an angiotensin II receptor blocker into account when reviewing lithium levels and seeking specialist advice if in doubt (NICE NG222). Warn the patient about signs of lithium toxicity: diarrhoea, vomiting, coarse tremor, poor coordination, confusion and seizures (NICE NG222).
Sources
Mechanism
NSAIDs reduce renal lithium clearance via prostaglandin-dependent renal blood flow blockade. Lithium plasma levels rise 1.5- to 2-fold with toxicity risk.
Symptoms
Tremor, muscle twitching, nausea, diarrhoea, confusion, ataxia. Symptoms emerge when serum lithium exceeds 1.2 mmol/L.
Management
Avoid prolonged combination. If naproxen is needed for a short course, reduce lithium by 25–30% and check lithium level at 5–7 days. For chronic analgesia: paracetamol or celecoxib (with lithium monitoring).
Sources
Mechanism
Calcium carbonate as an antacid mildly reduces lithium intestinal absorption, but no clinically significant drop in blood concentration has been documented.
Symptoms
The combination usually causes no specific symptoms. Each drug's individual side effects remain.
Management
No dose adjustment needed. Check lithium levels on the usual schedule (every 3 months on stable dose). With significant clinical changes (return of manic or depressive symptoms), check off-schedule.
Sources
Mechanism
Magnesium theoretically antagonises lithium-driven neuronal excitability, but no clinical cases of efficacy loss at standard magnesium doses (up to 400 mg/day) have been described.
Symptoms
The combination usually causes no specific symptoms. Each drug's individual side effects remain.
Management
No dose adjustment needed. On stable lithium dose, monitor levels on the usual schedule. Higher magnesium doses (over 1 g/day) are discussed separately — hypermagnesaemia risk in chronic kidney disease.
Sources
Pair details →Magnesium (oral salts: citrate, glycinate, oxide, sulfate) →
Verbatim lines from the interaction sections, in the language of the label
«Agentes bloqueantes neuromusculares: el litio prolonga el tiempo de bloqueo neuromuscular inducido por la succinilcolina y el pancuronio. Se recomienda interrumpir temporalmente el tratamiento con…»AEMPS, section 4.5 · Open on CIMA
«Interacciones que aumentan los niveles de litio: Diuréticos (incluidos los preparados de hierbas) : la administración concomitante de diuréticos tiazídicos y litio ejerce un efecto antidiurético…»AEMPS, section 4.5 · Open on CIMA
«Interacciones que aumentan los niveles de litio: Diuréticos (incluidos los preparados de hierbas) : la administración concomitante de diuréticos tiazídicos y litio ejerce un efecto antidiurético…»AEMPS, section 4.5 · Open on CIMA
«Interacciones que aumentan los niveles de litio: Diuréticos (incluidos los preparados de hierbas) : la administración concomitante de diuréticos tiazídicos y litio ejerce un efecto antidiurético…»AEMPS, section 4.5 · Open on CIMA
«Fármacos que prolongan el intervalo QT: el litio puede provocar una prolongación del intervalo QT, particularmente con niveles sanguíneos altos. Por ello, se debería evitar el uso concomitante con…»AEMPS, section 4.5 · Open on CIMA
«Interacciones que aumentan los niveles de litio: Diuréticos (incluidos los preparados de hierbas) : la administración concomitante de diuréticos tiazídicos y litio ejerce un efecto antidiurético…»AEMPS, section 4.5 · Open on CIMA
«Interacciones que aumentan los niveles de litio: Antiinflamatorios no esteroideos (AINEs) incluidos los inhibidores selectivos de la ciclooxigenasa (COX) : la indometacina, el ácido mefenámico, la…»AEMPS, section 4.5 · Open on CIMA
«Interacciones que disminuyen los niveles de litio: Antipsicóticos típicos y atípicos : se han reportado casos de reacciones neurotóxicas en pacientes tratados tanto con litio como con un…»AEMPS, section 4.5 · Open on CIMA
«Interacciones que disminuyen los niveles de litio: acetazolamida, urea, xantinas (p.e. cafeína, teofilina), agentes alcalinizantes tales como inhibidores de la anhidrasa carbónica o productos con…»AEMPS, section 4.5 · Open on CIMA
«Interacciones que aumentan los niveles de litio: Fármacos que actúan sobre el sistema renina-angiotensina (IECAs, antagonistas del receptor de angiotensina II). Inhibidores de la enzima convertidora…»AEMPS, section 4.5 · Open on CIMA
«Drugs Having Clinically Important Interactions with Lithium: Intervention: Monitor patients closely for adverse reactions of methyldopa, phenytoin, and carbamazepine.»FDA, section 7 · Open on DailyMed
«Tratamiento concomitante con sales de litio (ver sección 4.5.).»AEMPS, section 4.3 · Open on CIMA
«Litio y digoxina: como muchos fármacos antiinflamatorios no esteroideos inhiben el aclaramiento renal del litio y la digoxina, aumentando las concentraciones séricas de ambos. Debe evitarse el…»AEMPS, section 4.5 · Open on CIMA
«Lit io : se ha demostrado que los AINEs disminuyen la excreción de litio, aumentando los niveles de litio en sangre, que pueden alcanzar valores tóxicos. No se recomienda el uso concomitante de litio…»AEMPS, section 4.5 · Open on CIMA
«DRUG INTERACTIONS: QT Prolonging Drugs class I and III antiarrhythmics, lithium, certain phenothiazines, tricyclic antidepressants, certain fluoroquinolone and macrolide antibiotics, azole…»FDA, section 7 · Open on DailyMed
«Litio: Se han notificado casos de incrementos reversibles de las concentraciones de litio sérico y toxicidad del mismo durante el uso concurrente de litio e inhibidores de la enzima convertidora de…»AEMPS, section 4.5 · Open on CIMA
«Se han descrito aumentos reversibles de las concentraciones séricas de litio y su toxicidad durante la administración concomitante de litio con inhibidores de la ECA. Un efecto similar puede…»AEMPS, section 4.5 · Open on CIMA
«Bloqueo dual del sistema renina-angiotensina-aldosterona (SRAA): Litio: durante la administración concomitante de litio con inhibidores de la ECA se han detectado incrementos reversibles de los…»AEMPS, section 4.5 · Open on CIMA
«Litio: La administración concomitante de clortalidona y litio conduce a un aumento del efecto cardiotóxico y neurotóxico del litio debido a la reducción de la excreción de litio. Si a pesar de ello…»AEMPS, section 4.5 · Open on CIMA
«Litio (descrito con varios AINEs): los AINEs aumentan los niveles del litio en sangre, que pueden alcanzar valores tóxicos (disminución de la excreción renal del litio). Por tanto este parámetro…»AEMPS, section 4.5 · Open on CIMA
«Litio: Se han comunicado aumentos reversibles de las concentraciones séricas de litio y toxicidad durante la administración concomitante de litio con inhibidores de la ECA. El uso concomitante de…»AEMPS, section 4.5 · Open on CIMA
«Litio: No se han realizado estudios de interacción de eplerenona con litio. Sin embargo, se ha descrito toxicidad producida por litio en pacientes que tomaban litio de forma concomitante con…»AEMPS, section 4.5 · Open on CIMA
«Sales de litio: Furosemida disminuye la excreción de las sales de litio y puede incrementar los niveles séricos de litio, aumentando el riesgo de la toxicidad del litio, incluyendo aumento del riesgo…»AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: Lithium generally should not be given with diuretics because they reduce lithium's renal clearance and add a high risk of lithium toxicity.»FDA, section 7 · Open on DailyMed
«Litio: La administración concomitante de hidroclorotiazida y litio puede reducir la eliminación de litio y aumentar los efectos cardiotóxicos y neurotóxicos del litio. Por ello, la administración…»AEMPS, section 4.5 · Open on CIMA
«Lithium: generally should not be given with diuretics. Diuretic agents reduce the renal clearance of lithium and greatly increase the risk of lithium toxicity. Refer to the package insert for lithium…»FDA, section 7 · Open on DailyMed
«Litio : los AINEs pueden incrementar los niveles plasmáticos de litio, posiblemente por reducción de su aclaramiento renal. Deberá evitarse su administración conjunta, a menos que se monitoricen los…»AEMPS, section 4.5 · Open on CIMA
«Litio: Aumento de la concentración sanguínea de litio con signos de sobredosis, como en el caso de un régimen sin sodio (disminución de la excreción urinaria del litio). Sin embargo, en los casos en…»AEMPS, section 4.5 · Open on CIMA
«Litio : durante la administración concomitante de litio e inhibidores del enzima conversor de la angiotensina, se han descrito incrementos reversibles en las concentraciones séricas de litio y…»AEMPS, section 4.5 · Open on CIMA
«Litio (descrito con varios AINE): los AINEs aumentan los niveles del litio en sangre, que pueden alcanzar valores tóxicos (disminución de la excreción renal del litio). Por tanto este parámetro…»AEMPS, section 4.5 · Open on CIMA
«Litio: Durante la administración simultánea de litio e inhibidores de la ECA se han comunicado aumentos reversibles de las concentraciones séricas de litio y toxicidad. La utilización simultánea de…»AEMPS, section 4.5 · Open on CIMA
«Litio: Se ha descrito que los AINES incrementan los niveles de litio en sangre que pueden alcanzar valores tóxicos (mediante la disminución de la excreción renal del litio). No se recomienda el uso…»AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: When methyldopa is used with other antihypertensive drugs, potentiation of antihypertensive effect may occur. Patients should be followed carefully to detect side reactions or…»FDA, section 7 · Open on DailyMed
«Litio: Se debe tener precaución cuando se administre metronidazol simultáneamente con sales de litio, ya que durante el tratamiento con metronidazol se han observado concentraciones plasmáticas de…»AEMPS, section 4.5 · Open on CIMA
«Litio : Se ha descrito aumento reversible de la concentración sérica de litio y casos de toxicidad durante la administración concomitante de litio con inhibidores de la enzima conversora de…»AEMPS, section 4.5 · Open on CIMA
«Fármacos serotoninérgicos: Se aconseja precaución y un estrecho control del paciente cuando se combinan fármacos con actividad serotoninérgica (incluyendo L-triptófano, triptanes, tramadol…»AEMPS, section 4.5 · Open on CIMA
«Litio: Se han notificado aumentos reversibles de las concentraciones séricas de litio y de la toxicidad durante la administración concomitante de litio con inhibidores de la enzima convertidora de…»AEMPS, section 4.5 · Open on CIMA
«Drug Interactions: Based on the mechanism of action of SNRIs and SSRIs, including venlafaxine hydrochloride, and the potential for serotonin syndrome, caution is advised when venlafaxine is…»FDA, section 7 · Open on DailyMed
«Sales de litio: La administración conjunta de amisulprida con sales de litio puede dar lugar a la aparición de síntomas extrapiramidales.»AEMPS, section 4.5 · Open on CIMA
«Lithium: Increases in serum lithium concentrations and toxicity have been reported during concomitant administration of lithium with angiotensin II receptor antagonists, including candesartan…»FDA, section 7 · Open on DailyMed
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Lithium is evaluated for the following indications with varying evidence strength: Bipolar disorder (evidence tier A), Acute mania (evidence tier A), Treatment-resistant depression (evidence tier B). See the full indication matrix with dosing and citations above on this page.
Common side effects of Lithium (≥ 1 in 100): Fine hand tremor, Polyuria and polydipsia (nephrogenic diabetes insipidus), Nausea, diarrhea at initiation, Weight gain, Subclinical hypothyroidism, Metallic taste. See the Safety section for uncommon and serious reactions.
AEMPS summary of product characteristics (section 4.6): lithium should not be given during pregnancy, especially in the first trimester, because of possible teratogenicity. Lithium crosses the placenta; cases of increased neonatal goitre and congenital cardiovascular malformations such as Ebstein's anomaly have been reported, and animal studies have shown reproductive toxicity. Women taking lithium should use appropriate contraception, and stopping lithium is recommended when a pregnancy is planned. If continuing lithium is considered essential, serum lithium levels are monitored closely and the dose is adjusted, as renal function changes gradually during pregnancy and suddenly at delivery; lithium is stopped shortly before delivery and restarted a few days after. Newborns may show signs of lithium toxicity, including flaccid muscles or hypotonia, so exposed newborns are observed closely and their lithium levels may need to be checked.
Passes into breast milk at 40–50% of maternal plasma level. LactMed lists lithium as generally incompatible with breastfeeding: accumulation risk in infant with toxicity (lethargy, hypotonia, cyanosis). If breastfeeding is necessary, monitor infant lithium level.
Lithium is contraindicated in: Hypersensitivity to lithium; Severe renal impairment (eGFR < 30 mL/min); Severe cardiovascular disease; Addison disease; Severe dehydration. Full list in the Safety section.
FDA boxed warning: lithium toxicity is closely related to serum concentration and can occur at levels close to therapeutic. Regular plasma monitoring is mandatory. Use without TDM capability is not permitted. Administer with caution in patients at risk of dehydration, renal impairment, hyponatremia.
second half is true: with regular TDM, renal and thyroid monitoring, lithium is safe and effective. There really is no need to fear it. But without monitoring, the risk of irreversible toxicity is high.
in most patients, renal function changes are minimal with proper use. Chronic kidney disease develops in some patients after over 15–20 years of therapy, offset by reduced suicide risk and bipolar relapse.
NICE 2023 and RANZCP 2022 retain lithium as first-line maintenance therapy in BD. The unique suicide-reducing effect has not been replicated by other agents.
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