Making sense of lithium

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What should I know before taking these drugs?
Why is lithium prescribed?
What is bipolar disorder (manic depression)?
In what way is taking lithium dangerous?
What sort of tests will I have to have?
What is lithium made from?
What dose should I be on?
Why do I need regular blood tests?
What about drug interactions?
What are the other dos and don'ts?
How long does lithium take to work?
What are the side effects?
How long will I have to be on lithium for?
What's the best way to withdraw?
How else can I treat bipolar disorder (manic depression)?
References
Useful organisations
Further reading

This booklet is aimed at people who are taking lithium, and anyone interested in learning more about it. It explains what the drug is, its drawbacks and benefits, and how it can best be used 'safely and effectively' for the treatment of bipolar disorder (manic depression) and recurrent depression. It also looks at ways to withdraw from it successfully.

What should I know before taking these drugs?

The law says that you have the right to make an informed decision about which treatment to have, and whether or not to accept the treatment a doctor suggests. To consent properly, you need to have enough information to understand the nature, likely effects and risks of the treatment, including its chance of success, and any alternatives to it.

Generally, you can only receive treatment that you have specifically agreed to. Once you have given your consent, it isn't final and you can always change your mind. This consent to treatment is fundamental, and treatment given without it can amount to assault and negligence. To find out more about when treatment can be given without consent, see Mind Rights Guide 3: consent to medical treatment.

Patient Information Leaflets
People who are prescribed medication as outpatients, or from their GP, should find with it an information sheet called a patient information leaflet (PIL), in accordance with a European Union directive. Inpatients may have to ask for it, specifically. The EU directive sets out what information should be included in the leaflet, and in what order. It starts with the precise ingredients of the medicine, including the active ingredient, the drug, and the extra contents that hold it together as a tablet or capsule, such as maize starch, gelatine, cellulose and colourings.

This information is important because some people may be allergic to one of the ingredients, such as lactose. The leaflet gives the name of the pharmaceutical company that made the drug. It explains what the drug is prescribed for, any conditions which mean you should avoid it, and anything else you should know before taking it. The leaflet states whether the drug is dangerous with other medicines, and, if so, which types. There are details about how to take it: by mouth or other means, at what time of day, when to take it in relation to meals (if necessary), the usual dose levels, and what to do if you take too much or forget to take it. Next, comes the list of possible side effects, and then the storage instructions.

The final item on the leaflet tells you that it contains only the most important information you need to know about the medicine, and that if you need to know more, you should ask your doctor or your pharmacist. Pharmacists are drug specialists, and may be more knowledgeable about your drugs than the doctor who prescribes them. They may be more aware of possible side effects, and also possible interactions with other drugs. This is when a drug changes the effect of other drugs you are taking, makes them less effective, or causes additional side effects. Pharmacists are usually very willing to discuss drugs with patients, and some high-street chemists have space set aside where you can talk privately.

This is a lot of information to include in the PIL, so it's often printed in very small type, on a piece of paper that is folded many times, which may get thrown away with the packaging, by mistake. If you do not receive this information with your medicine, you should ask for it from the person who makes up your prescription.

Many people would like to have all this information in advance and not after they have obtained the drugs. The following are questions you might like to raise with your doctor when she or he gives you a prescription for a drug:

• What is the name of the drug, and what is it for?
• How often do I have to take it?
• If I am taking any other drugs, will it be all right to take them together?
• Will I still be able to drive?
• What are the most likely side effects, and what should I do if I get them?
• Do I have to take it at any particular time of day? For example, if it is likely to make me sleepy, can I take it at night rather than in the morning? If it is likely to make me feel sick, can I take it with or after food?

When I want to stop taking it, am I likely to have any problems with withdrawal?

You may well think of other questions you wish to ask.

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Why is lithium prescribed?

Lithium has been widely used for many mental health problems, but its strength lies in its role as a mood stabiliser treating mania. Its main purpose has been to prevent relapse in cases of bipolar disorder (manic depression), and in recurring depression (unipolar depression). It's also licensed for schizoaffective disorder, managing aggression and self-harm. It was found to help people with mania, almost by chance, when it was given, experimentally, to a group of people in a psychiatric hospital, in 1949. Later studies confirmed that it worked well as a mood stabiliser, and tended to reduce the number of manic and depressive episodes people were having, or even to suppress them altogether. Lithium is not prescribed for children.

One advantage that lithium has over other drugs is that it doesn't act as a sedative, even though it stabilises mood. On the whole, people cope very well with taking lithium in the long term. But users have complained that it makes them less able to express themselves and that it dampens down their imagination. It can also be dangerous under certain circumstances, and people need to be aware of this. (See below for more information.)

If lithium is recommended, ask for as much information as you feel you need about using it, and about any potential problems of the treatment. Lithium clinics are usually very good at providing guidelines and advice. Some doctors, however, are less open. (See Useful organisations and Further reading.)

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What is bipolar disorder (manic depression)?

Bipolar disorder (manic depression) is a severe mental health problem characterised by periods of deep depression and periods of mania. There may be stable times in between, which vary in length.

There is disagreement about the causes of bipolar disorder (manic depression), and a lot still to learn. Many psychiatrists believe that there is a family inclination towards developing it, which can be passed down in the genes. It's likely that experiences in early childhood, or later, have a part to play in someones ability to withstand stress, and this influences to what extent later experiences are seen or felt as stressful. Stressful events may act as triggers to set off the characteristic signs of bipolar disorder. (See Understanding bipolar disorder(manic depression).)

Symptoms of mania include:

• feeling elated
• being unable or unwilling to sleep
• having a constant flow of ideas
• a constant wish to talk
• loss of judgement
• impulsive, badly thought-out ideas
• being easily irritated or impatient
• expressing inappropriate sexual interest

Advanced symptoms include hallucinations and loss of contact with reality.

Symptoms of depression include:

• feeling low
• lacking self-esteem and self-confidence
• negative thoughts
• feeling numb and empty
• feeling guilty
• difficulty concentrating and making decisions
• irritability
• apathy and suicidal thoughts
• losing interest in food, or eating too much
• sleep problems
• loss of interest in sex
• taking no pleasure in things normally enjoyed
• seeing the world as drab or threatening.

Bipolar disorder can have a devastating impact on a person's family life and on those close to him or her. It can lead to broken marriages, loss of jobs and a greatly reduced social life. These social consequences can often prove more damaging and distressing than the more immediate effects of bipolar disorder.

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In what way is taking lithium dangerous?

When someone is diagnosed with bipolar disorder, one of the doctor's first considerations is likely to be, 'Is it appropriate to treat the condition with lithium? Is this treatment safe in this case?'. Lithium is a dangerous drug, which can cause brain damage or have fatal consequences if the dose is too high. In particular, people who have a history of heart disease or kidney disease, and women in early pregnancy, are advised not to take lithium.

Avoiding lithium in pregnancy
If possible, discuss the effects of lithium with your doctor before deciding to have a baby. During the first three months of pregnancy, there is a risk that lithium may interfere with the baby's development, although the risk appears to be low. It's important to inform your doctor if you think you may be pregnant. There doesn't seem to be any ill effect from taking lithium beforehand, as long as you stop taking it once you are pregnant. It doesn't appear to make any difference whether the father takes lithium.

What a doctor needs to know
Before prescribing lithium, your doctor will need to know your medical history, and will want to know whether you suffer from:

• heart disease
• thyroid disease
• kidney disease
• psoriasis (a skin problem)
• epilepsy

He or she will want to know of mental health problems in your family, especially mania or depression. Another check will be on any other medicines you are taking (whether bought on prescription, over-the-counter, or as an alternative remedy from a health food shop) to make sure that these drugs don't interact with each other.

Your doctor should ask how much alcohol you normally consume and whether, for instance, you drink large amounts of tea or coffee. He or she will check whether you are on a limited salt diet, and whether you are on, or planning, any special diet.

Sometimes, lithium impairs coordination, so your doctor may ask whether you are involved in performing delicate tasks with your hands, and whether you need to drive or operate machinery.

This is not a comprehensive list of the information your doctor may need. It's important that you mention anything you feel may be relevant, even if you are uncertain whether it matters.

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What sort of tests will I have to have?

You will have to undergo a number of tests before you start lithium, to make sure that the medication can be used safely and to provide an accurate picture of how your body systems are functioning. The tests will vary according to your medical condition and the doctor's judgement, but they should include the following:

• a heart function test
• a kidney test, because lithium is eliminated from your body in the urine and can cause changes in how the kidneys function
• a thyroid test, because an overactive or underactive thyroid gland may cause psychiatric symptoms that resemble mania or depression, and lithium may also interfere with thyroid function.

Once you are taking lithium, you should have a thyroid function test every year. It will also be necessary to have regular blood tests, variously called a lithium level, a serum lithium level or a plasma lithium level test.

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What is lithium made from?

Lithium is an element that occurs naturally in the environment. As early as the 2nd century AD, Soranus of Ephesus suggested that mania should be treated with the alkaline waters of the town, which, it turns out, contain very high levels of lithium salts. Lithium is often found in food and water, and therefore in your body in small amounts. However, this doesn't mean that it's a substance that everybody needs in order to function properly. Lithium is not prescribed because you have a deficiency of it.

Certain natural minerals have a high lithium content and are the source of the medication. Prescriptions are for lithium carbonate or lithium citrate, depending on which salt of lithium is used. The carbonate and citrate have no effect. Most drug companies sell the medicine under a trade name. In the UK, lithium carbonate comes in tablet form under the names Camcolit, Liskonum, Priadel, and Lithonate. Lithium citrate comes as a tablet, Litarex, or in liquid form as Li-liquid and Priadel. It makes no medical difference which one you take, but it's best to stick to one brand. If you do change brands, double check the amount of lithium in the tablets, as they do vary.

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What dose should I be on?

There can be no standard dose of lithium, because the amount of lithium in the blood depends on kidney function, which varies from person to person. Doses are adjusted to keep the blood level within a range of 0.4-1 millimole (mmol) of lithium per litre of blood serum, which is considered to be the appropriate therapeutic range. (The millimole is a unit of measurement used by biochemists.)

For most people, the appropriate range to maximise benefits and minimise side effects should be 0.5-0.8mmol lithium per litre of blood serum. Some doctors believe a higher level is acceptable, though adverse effects may increase. Serum levels over 1.5mmol lithium per litre of blood serum are toxic and may be fatal.

Manufacturers recommend a starting daily dose of 0.4-1.5g lithium carbonate, or 1-3g lithium citrate for treating acute mania. This dose will then have to be adjusted according to the results of blood tests (see opposite). For preventing relapse in mania or depression, they suggest a starting daily dose of 0.3-1.2g lithium carbonate or 1-3g lithium citrate. In practice, the starting dose used by specialists is commonly the equivalent of 0.4-0.8g lithium carbonate daily. If you have any questions about dosage instructions, check them with the pharmacist.

Because drugs are eliminated more slowly in elderly people, they are particularly susceptible to lithium toxicity. Lower doses are usually given, and the aim is for a lower serum level. Elderly patients usually have half the normal dose.

Some people take their lithium in divided doses, several times a day. Others take a modified-release formulation as a single dose, usually at night. All the tablets, except Camcolit 250mg, are marketed as modified-release formulations. One of the effects of taking lithium is to make people need the toilet more often, but this may happen less with the once-daily dose.

You may need to discuss with your doctor which type is best for you, depending on your symptoms, side effects and any other medicines you may be taking. It's important to see your doctor, regularly, to discuss any side effects and possible changes in dose. Don't change your prescribed dosage without consultation. Always contact your doctor, immediately, if you think your lithium level may be too high.

Missing a dose
Don't double up a dose of lithium if you forget a prescribed dose. If you have missed your regular time by three hours, or less, take your normal dose. If you have missed your normal dose by over three hours, skip the missed dose and resume your lithium medication at the next regularly scheduled time.

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Why do I need regular blood tests?

Blood tests are important because they enable your doctor to monitor the amount of lithium in the bloodstream, and therefore to ensure that your dosage is both effective and safe. You need to have blood tests more often in the early stages of treatment, or when your dosage is being adjusted. In these circumstances, you may need to have one every week. Once serum levels have steadied, you will need blood tests only once a month, and every three months later on. Lithium reaches a steady level in the blood about five days after starting a fixed daily dose. People aren't always given blood tests as often as they should be, and because of this, the medication doesn't always work as well as it might.

Your doctor may also ask for a blood level check if there are signs that the bipolar disorder is returning (suggesting that the lithium level may be too low) or if there is an increase in adverse side effects (a sign that the lithium level may be too high).

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What about drug interactions?

Before prescribing lithium or any medication, your doctor should be aware of all the medicines you are currently taking, so that any possible drug interactions can be avoided. If you are admitted to hospital for any reason, you should tell the medical staff that you are taking lithium. Make sure you are given a lithium treatment card and remember to carry this with you.

Prescription medication
Lithium has potentially serious interactions with a number of different prescribed drugs, including steroids (treating asthma, for example) and drugs for high blood pressure and for water retention.

Antipsychotic drugs (major tranquillisers) may increase side effects, such as muscular disorders, if you take them while on lithium. This particularly applies to phenothiazines, such as chlorpromazine (Largactil), and butyrophenones, such as haloperidol (Haldol, Dozic or Serenace). There's also a risk that the two together may have a poisonous effect on the nervous system (neurotoxicity). Lithium and haloperidol are often given together during a manic phase, because lithium can be slow to take effect. In this case, the antipsychotic is normally started at a lower dose than usual.

SSRI antidepressants (the Prozac group) can also affect the central nervous system, if combined with lithium. It can also increase the risk of serotonin syndrome, which causes hyperthermia (high temperature), tremors and convulsions (fits). (See below for more information.)

Over-the-counter drugs
If you buy medicines over the counter, without a doctor's prescription, you should let the pharmacist know about any other medicines that you are taking, so that he or she can tell you of any potential problem with drug combinations. Drugs like Neurofen, Proflex, Inoven, Hedex, and other similar preparations, contain ibuprofen, which can reduce lithium excretion, especially at high doses, and therefore raise serum lithium levels.

Lithium may also interact with herbal and other complementary medicines. Take advice from a qualified professional before taking any of these with lithium.

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What are the other dos and don'ts?

Your salt and water intake affects the way that lithium is removed from your body, so you need to maintain a sufficient and steady supply of both. Reducing either may allow lithium to build up to dangerous levels, but you also need to keep levels high enough to be effective.

The important thing is not to drink too much or too little fluid. You should drink about the same amount of water every day (the usual range is 4-6 pints) and avoid any dramatic changes in your fluid intake. If you usually drink less than 4-6 pints of fluid per day, and blood tests show that your lithium level is stable, there's no need to drink more water. But don't ignore any feelings of thirst. Have a drink when you feel you need to. Avoid too much coffee, tea, colas or other drinks containing caffeine. Caffeine causes water loss and can interfere with lithium treatment. Although it's safe to drink alcohol, in moderation, in most cases, it's best to check this with your doctor.

In the same way, keep to your normal, daily amount of salt. Inform your doctor before you begin any new diets, especially low-salt diets, and don't fast while taking lithium. People sometimes gain weight on lithium. This may be due to your body retaining water. You may have to adjust your diet to compensate, for example by reducing the amount of sugary fluids you drink.

Try not to get into situations where you are likely to sweat heavily. Take care not to overdo things in hot weather, and avoid sauna baths, for example. If you are running a temperature, sweating heavily, vomiting, or having diarrhoea, tell your doctor. It may be necessary, temporarily, to stop taking lithium until you're better. Avoid sudden bursts of heavy exercise. It's safe and beneficial to exercise regularly, provided that you ensure you take in sufficient fluids and salt. It's also advisable to time your lithium dose so that you are not taking it immediately before vigorous exercise.

Lithium can impair coordination, so you need to take particular care when driving or operating dangerous machinery. Be prepared to stop if it's clear that you can't do it safely any more.

Don't keep lithium in direct sunlight or near other sources of heat, and never leave drugs within reach of children.

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How long does lithium take to work?

Although some people feel better as soon as they begin taking lithium, most improve more gradually. It can take anything from a few days to several weeks for a noticeable improvement.

Some people don't respond to lithium therapy at all, or can't tolerate it. Some may respond only partially, and may have fewer or less severe episodes of depression or mania. It's important not to expect too much when starting treatment. It may take six months to a year to achieve a full effect as a preventive treatment.

Lithium works better for some conditions than others. It's good at helping people diagnosed with bipolar disorder who have been having serious mood swings. It also helps others who have had two, or more, periods of mania or hypomania (a less severe form of mania).

In general, lithium seems to be more successful in treating:

• pure manic episodes that follow a cyclical pattern, in which episodes of mania and depression are followed by stable periods
• people who have a family history of bipolar illness
• forms of the problem where there is no rapid cycling between mania and depression.

Lithium is less satisfactory for people whose mood swings tend to be towards depression only (sometime called unipolar depression). It's still considered as an option for someone who has had three, or more, periods of serious depression within five years, involving hospital admission, especially if there were symptoms of psychosis.

However, in these situations, people often experience repeated episodes, even with lithium treatment.

It's always important to weigh the benefits to be expected from lithium against the possible side effects, and against the benefits you might get from other forms of treatment.

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What are the side effects?

You may not get any adverse effects at all; many people taking lithium experience none. Some side effects are relatively mild and only occur during the early part of treatment, while your body is adjusting to lithium. Others take longer to appear, but are easy to treat. A few, however, indicate that lithium is reaching unacceptable levels within the body, and that you need instant attention to avoid serious poisoning.

Early side effects
These happen as the body adjusts to the lithium. They are not usually medically serious, and most get better or go away after a few weeks. You should tell your doctor about them at routine appointments, unless they become particularly unpleasant, in which case you should tell your doctor at once. They include:

• feeling thirstier
• needing to urinate more often
• gaining weight
• feeling sick
• mild stomach cramps
• shaky hands
• sleepiness
• slight muscular weakness
• a dry mouth
• loss of interest in sex
• slight dizziness
• worsening acne or psoriasis.

Intermediate side effects
These persist after your body has adjusted to lithium, or may emerge during the course of treatment. You should keep your doctor informed, since persistent side effects may mean that your dosage needs adjusting, or that you may be helped by additional medication. It's also possible that changing your diet and the time of day when you take your dose could help.

Intermediate side effects may include:

• gaining too much weight
• needing to urinate too often
• skin rash
• changes in kidney functioning, which may lead to damage
• mild thirst
• memory problems
• loss of mental sharpness
• shaky hands
• high blood calcium levels after long-term treatment
• thyroid changes.

Reduced thyroid activity can cause sleepiness, tiredness, a slow-down in your thinking, feeling cold, headaches, dry skin, constipation, muscle aches and unusual weight gain. Symptoms of increased thyroid activity or hyperactivity include nervousness, a fast heartbeat, feeling emotional, being uncomfortable in the heat and sweating.

Always report a skin rash or widespread itching at once, since it may be the signal of an allergic reaction to a lithium product.

Serious side effects
Although there may be other causes for these symptoms, they could indicate that the lithium level in your blood is becoming dangerously high. If you get any of these symptoms, stop taking lithium and contact your doctor at once.

Serious side effects may include:

• further loss of appetite
• persistent diarrhoea
• vomiting or severe nausea
• serious hand tremors
• frequent muscle twitching
• muscle weakness and lack of coordination
• blurred vision
• confusion
• drowsiness
• severe discomfort
• swelling of legs and feet
• any severe abnormality.

Signs of severe overdose
Symptoms of lithium overdose include:

• loss of coordination
• heavy shakes
• muscle stiffness
• difficulty speaking
• confusion.

In very severe cases, this may lead to stupor, coma and then death.

Long-term side effects
Provided that the level of lithium in the blood remains within safe levels, there should be no long-term damage. However, some users have pointed out that it's difficult to keep to the advised dosage, especially during illness, and this may lead to toxicity. Regular tests of kidney and thyroid function should help to minimise the risks and avoid long-term damage.

Do tell your doctor immediately about any adverse effects you notice. Remember that although many symptoms may be caused by lithium, they could also be an indication of a separate illness, so it's all the more important to talk it over with your GP.

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How long will I have to be on lithium for?

This will vary from person to person, depending on the course of the condition, and it's something to discuss with your doctor at the beginning. You should not start on the drug if you are not prepared to take it for quite a long period. Lithium is not a cure for bipolar disorder, but a preventive medicine. At the very least, it usually needs to be taken for two years to be beneficial, but you may need to take it for the rest of your life. Psychiatric research shows that a large number of lithium users will relapse if they stop taking lithium, but it's not possible to tell, in advance, who will have further mood swings and who will not.

You should have regular reviews with your doctor to discuss whether you still need to take it. If you have been completely free of relapses while taking lithium for three to four years, some doctors may be willing to reduce and stop your lithium for a trial period, under supervision, if this is something you would like to try. As lithium can take a long time to become effective as a preventive treatment, you may run the risk of a lengthy period of instability.

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What's the best way to withdraw?

There is no evidence to indicate that people taking lithium become physically dependent on it. However, some research suggests that some people may find their original symptoms coming back when they stop taking lithium, or they may have an episode of 'withdrawal mania'. The research suggests that when the recurrence of symptoms is due to withdrawal from lithium, rather than the original condition for which lithium was prescribed, the best way to treat the symptoms is to go back on lithium briefly.

It's important to withdraw at your own pace, and to get plenty of support. Ideally, you should stop the lithium gradually, over two to three months, but in not less than four weeks. If you stop taking lithium over a very short period, you are more likely to relapse, or have an episode of mania with the withdrawal.

Lithium treatment can be safely stopped for brief periods, and it's wise to stop taking it for 24 hours before any major operation. Usually, it's safe to restart it soon after the operation.

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How else can I treat bipolar disorder (manic depression)?

Anticonvulsants
There are two anti-epileptic drugs that are well-established alternatives to lithium for the treatment of mania and as mood stabilisers. They are carbamazepine (brand names, Tegretol, Tegretol Retard, Teril CR, Timonil Retard) and valproate (brand names Epilim, Epilim Chrono). But they are not suitable for recurrent depression.

Valproic acid or semisodium valproate (Depakote) was licensed in 2002 for the treatment of bipolar disorder, but is not suitable for depression. The difference between this and sodium valproate is in the kind of salt. Sodium valproate is still used, but is unlicensed for the treatment of this condition.

Anticonvulsant drugs are more effective in treating:

• mixed episodes of mania and depression combined
• rapid cycling
• families with no or little history of bipolar disorder
• very severe mania with psychosis
• additional anxiety disorders or substance abuse
• symptoms that occur after neurological illness or brain injury.

Antidepressants
If you are someone for whom the depressive part of the condition is a serious problem, your doctor may suggest you take antidepressants. These can be combined with lithium, although this should be done with caution in the case of the SSRI antidepressants. (For more information about antidepressants, see Mind's booklet Making sense of antidepressants .)

Antipsychotics
These drugs may be used in bipolar disorder for several reasons. Sometimes, during a manic phase, people may have disturbances in thinking or perception, which are considered psychotic, and can be helped by antipsychotic drugs. Also, the newer antipsychotics (known as atypical antipsychotics) have anti-manic properties and can add to the effects of lithium, or control symptoms early in treatment, before the lithium has had time to become fully effective.

Some people may be given a supply of antipsychotic drugs to take, as necessary, if they feel that they are becoming high or psychotic. In addition, some antipsychotics are used in low doses to treat anxiety.

When antipsychotic drugs are taken at the same time as lithium, the neuromuscular side effects of the antipsychotics may be increased. The dosage used is important. High levels of lithium taken with high doses of antipsychotics could cause severe neurological symptoms, high temperature, impaired
consciousness and irreversible brain damage (see Mind's booklet Making Sense of antipsychotics ).

Cognitive behaviour therapy (CBT)
CBT aims to help you to live your life more successfully, by looking at the way you respond to what happens to you. It helps you find a way to change that response, so that you cope better with challenges, and are less likely to have a crisis. CBT is used in the treatment of bipolar disorder to:

• increase people's knowledge of the condition
• try to create routines for sleep, meals, and exercise, so that they are less likely to relapse
• increase awareness of changing moods
• anticipate potentially stressful events, so as to minimise crises
• develop crisis management strategies.

Successful CBT may decrease the need for lithium treatment. (See Making sense of cognitive behaviour therapy .)

Getting the right support
Lithium is not a cure for bipolar disorder, but is an important element of a much wider approach, which treats the whole person and includes help with the social consequences of the diagnosis, including supportive counselling, financial help and information, and advice on employment, diagnosis and treatment.

There is a feeling that doctors and other professionals pay too little attention to these factors. There is a real need for improvement in the working relationship between family doctors, hospitals, social services, voluntary agencies, and people with the diagnosis. Families often need social support too.

People who have found ways of coming to terms with their disorder, who have affection and support, a secure home and work they enjoy, respond well to lithium treatment. They can often enjoy years of stability with greatly reduced episodes.

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References

The Bethlem and Maudsley NHS Trust Prescribing Guidelines (1999)
The Bipolar Disorder Survival Guide D. Miklowitz (Guilford Press 2002)
British National Formulary 44 (British Medical Association and Royal Pharmaceutical Society 2002)
'Cognitive therapy as an adjunct to medication in bipolar disorder' J. Scott (2001) British Journal of Psychiatry 178 (suppl 41)
Electronic medicines compendium (web: www.emc.vhn.net )
'Lithium: a review of its origins, application and management in mental health treatment' J. Wolfe, N. Wolfe (1999) Mental Health Care 21,10
'Use of antipsychotic drugs and lithium in mania' J. Cookson (2001) British Journal of Psychiatry 178 (suppl 41)
'Using lithium safely' Drug and Therapeutics Bulletin (1999) 37, 3

Useful organisations

British Association for Behavioural and Cognitive Psychotherapies (BABCP)
tel. 0161 797 4484
email: babcp@babcp.com
web: www.babcp.com
Can provide details of accredited therapists

Carers UK
20-25 Glasshouse Yard, London EC1A 4JT
carers line: 0808 808 7777, tel. 020 7490 8818
minicom: 020 7251 8969,
web: www.carersonline.org.uk
Information and advice on all aspects of caring

The Manic Depression Fellowship (MDF)
Castle Works, 21 St Georges Road, London SE1 6ES
tel. 020 7793 2600
web: www.mdf.org.uk
Works to enable people affected by manic depression to take control of their lives

UK Council for Psychotherapy (UKCP)
167-169 Great Portland Street, London W1W 5PF
tel. 020 7436 3002
web: www.psychotherapy.org.uk
The umbrella organisation for psychotherapy in the UK. Maintains a voluntary register of qualified psychotherapists

Further reading

The BMA new guide to medicines and drugs (5th ed) The British Medical Association (Dorling Kindersley 2000)
Drugs used in the treatment of mental health disorders S. Bazire (Academic Publishing Services 2002)
How to look after yourself (Mind 2002)
How to rebuild your life after breakdown (Mind 2000)
How to recognise the early signs of mental distress (Mind 2002)
Inside out: a guide to the self-management of manic depression (Manic Depression Fellowship 1995)
Keyfacts: genetics and mental health (Mind 2001)
Making sense of antidepressants (Mind 2003)
Making sense of antipsychotic (major tranquillisers) (Mind 2003)
Making sense of cognitive behaviour therapy (Mind 2001)
Making sense of herbal remedies (Mind 2000) Making sense of homeopathy (Mind 2001)
Making sense of sleeping pills (Mind 2000)
The Mental Health Act 1983: an outline guide (Mind 2003)
The Mind guide to advocacy (Mind 2000)
The Mind guide to food and mood (Mind 2000)
The Mind guide to managing stress (Mind 2003)
Mind rights guide 1: civil admission to hospital (Mind 2003)
Mind rights guide 2: mental health and the police (Mind 1995)
Mind rights guide 3: consent to medical treatment (Mind 2003)
Mind rights guide 4: discharge from hospital (Mind 2003)
Mind rights guide 5: mental health and the courts (Mind 1995)
Mind rights guide 7: managing your finances (Mind 1999)
Mind's Yellow Card for reporting drug side effects: a report of users' experiences A. Cobb, K. Darton, K. Juttla (Mind 2001)
Toxic psychiatry: a psychiatrist speaks out P. Breggin (HarperCollins 1993)
Your drug may be your problem: how and why to stop taking psychiatric medications P. Breggin, D. Cohen (Perseus 2000)

For a catalogue of publications from Mind, send an A4 SAE to:
Mind Publications
15 19 Broadway
London E15 4BQ
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This book was revised by K. Darton
First published by Mind in 1992 © Mind 2004
ISBN: 1-874690-04-9

No reproduction without permission