lithium and the promoted brands

lithium is a salt. nobody owns it, so nobody sells it the way a brand is sold. it also has one of the best records in psychiatry for keeping people with bipolar disorder out of hospital. this page puts those two facts next to what medicare spends, what drugmakers pay clinicians to talk about, and how prescribing changed. then it gives the real reasons doctors avoid lithium, because some of them are good ones.

read this first. nothing here is a reason to start, stop or switch a medication. lithium needs regular blood tests, can affect the kidneys and thyroid, is dangerous in overdose, and is not right for everyone. stopping a mood stabilizer suddenly carries its own risks. the question this page is built to help you ask is: what does the evidence say works best for someone like me, and why am i on what i am on?

the record

in finland, 18,018 people with bipolar disorder were followed for years and each was compared with themselves, on each drug and off it. lithium was tied to the lowest risk of going back into psychiatric hospital among mood stabilizers, a third lower (hazard ratio 0.67), and the lowest risk of hospital for any reason. the most used antipsychotic managed 0.92.^[1] in UK primary-care records, lithium lasted longest before treatment failed: 2.05 years until three in four had failed, against 0.76 years for quetiapine and about a year for valproate and olanzapine.^[2] across 48 randomised trials, lithium beat placebo on suicides, with a wide margin of error because suicides are rare.^[3] the full hospital comparison is on does psychiatric medication keep you out of hospital.

what happened to its use

among US psychiatrist visits for bipolar disorder, lithium fell from 30.4 percent of visits in 1997 to 2000 to 17.6 percent in 2013 to 2016. antipsychotics went from 12.4 percent to 51.4 percent. the authors’ summary: newer antipsychotics “in large measure supplanting traditional mood stabilizers.”^[4] in scotland from 2009 to 2016, lithium prescribing kept falling and only 5.9 percent of patients were on lithium alone.^[5] in sweden, by contrast, lithium use rose from 2010 to 2023, so the drop is a choice systems make, not a law of nature.^[6]

the money, side by side

how to read it. spending is medicare’s gross cost before manufacturer rebates, which are confidential, so the brand figures overstate the net somewhat. the people counts sum rows and can count someone twice. payments are everything the maker reported to the federal Open Payments file with that brand as the first product: meals, speaker fees, consulting, travel, to all kinds of clinicians. on their current FDA labels (DailyMed, read 2026-09-29), vraylar is approved for bipolar I mania and depression, schizophrenia and add-on treatment of depression; caplyta for bipolar depression, schizophrenia and add-on treatment of depression; rexulti for schizophrenia, add-on treatment of depression and agitation in alzheimer’s dementia, not for bipolar disorder. so not every dollar is a bipolar dollar, and rexulti is here as one of the most heavily paid-for psychiatric brands, not as a lithium alternative. a payment is legal and disclosed, and it is not proof of any one prescribing decision.^[7][8] the speaker-program side of the same money, 2,622 paid talks by twenty psychiatrists in one year, is on how psychiatric drug marketing feeds itself.

the dinners

the most common industry payment to a doctor is a meal. in a study linking five months of federal payment records to medicare prescribing, 95 percent of the payments were meals, averaging under $20. doctors who got a single meal promoting a brand-name antidepressant, desvenlafaxine (sold as pristiq by wyeth, a pfizer subsidiary, per its FDA label), had about twice the odds of prescribing it over the other SSRIs and SNRIs (odds ratio 2.18), and more meals, or more expensive ones, went with more prescribing.^[9] that one study cannot show the meal caused the prescription; companies court the doctors who already prescribe. but a 2021 review of 36 studies found payments linked to more prescribing of the paying company’s drug in every study, with timing and dose-response evidence in many, which its authors read as suggestive of cause.^[10] and when medical schools restricted gifts, their graduates were less likely to reach for a newly marketed antipsychotic over the older ones.^[11]

why doctors avoid lithium, and when they are right

• it harms some kidneys and thyroids. in oxford laboratory data, lithium was tied to nearly twice the risk of stage 3 kidney disease and more than twice the risk of an underactive thyroid, most of all in women under 60 and at higher blood levels.^[13]
• the trade-off runs both ways. in UK records, lithium had more kidney and hormone problems but less weight gain than valproate, olanzapine or quetiapine, and no difference in severe kidney disease.^[14]
• it does not prevent every kind of suicide risk. a VA trial adding lithium for veterans after a suicide attempt was stopped for futility, with no difference from placebo, though the blood levels reached were low.^[12]
• it needs monitoring: regular blood levels, kidney and thyroid tests, and care with dehydration and some common painkillers. the UK authors write that lithium “is often avoided because of its side effect profile.”^[2]
• some newer drugs won bipolar approvals during the years lithium’s share fell, so part of the shift followed the label, not only the marketing.^[4]

what it adds up to

a drug with one of the best records in its field lost ground to drugs that cost about a hundred times as much, in a system where the makers of those drugs spend millions a year on meals, talks and consulting and nobody spends a dollar on lithium. none of that makes any one prescription wrong. it does mean the information reaching your prescriber is weighted toward whatever someone is paid to talk about. the question to ask is yours: what does the evidence say works best for someone like me, and why am i on what i am on?

questions people ask

sources

1. Lähteenvuo M, Tanskanen A, Taipale H, et al. Real-world effectiveness of pharmacologic treatments for the prevention of rehospitalization in a Finnish nationwide cohort of patients with bipolar disorder. JAMA Psychiatry 2018;75(4):347-355. 18,018 people, each compared with themselves on and off each drug. Psychiatric rehospitalization: “lithium carbonate (HR, 0.67 [95% CI, 0.60-0.73])”; all-cause hospitalization “lithium (HR, 0.71 [95% CI, 0.66-0.76])”; quetiapine, the most used antipsychotic, “showed only modest effectiveness” (HR 0.92). Gabapentin and long-acting injectable risperidone had nominally lower hazard ratios than lithium, but only lithium and long-acting injections held up across sensitivity analyses. Several authors report industry ties. PMID 29490359. https://pubmed.ncbi.nlm.nih.gov/29490359/
2. Hayes JF, Marston L, Walters K, et al. Lithium vs. valproate vs. olanzapine vs. quetiapine as maintenance monotherapy for bipolar disorder: a population-based UK cohort study using electronic health records. World Psychiatry 2016;15(1):53-58. “Treatment failure had occurred in 75% of those prescribed lithium by 2.05 years … compared to 0.76 years … quetiapine, 0.98 years … valproate, and 1.13 years … olanzapine”; the authors add: “Lithium is often avoided because of its side effect profile.” PMID 26833609. https://pubmed.ncbi.nlm.nih.gov/26833609/
3. Cipriani A, Hawton K, Stockton S, Geddes JR. Lithium in the prevention of suicide in mood disorders: updated systematic review and meta-analysis. BMJ 2013;346:f3646. 48 randomised trials, 6,674 participants: “Lithium was more effective than placebo in reducing the number of suicides (odds ratio 0.13, 95% confidence interval 0.03 to 0.66) and deaths from any cause (0.38, 0.15 to 0.95).” Suicides were rare, so the interval is wide. PMID 23814104. https://pubmed.ncbi.nlm.nih.gov/23814104/
4. Rhee TG, Olfson M, Nierenberg AA, Wilkinson ST. 20-year trends in the pharmacologic treatment of bipolar disorder by psychiatrists in outpatient care settings. American Journal of Psychiatry 2020;177(8):706-715. National Ambulatory Medical Care Survey, psychiatrist visits for bipolar disorder: antipsychotics “increasing from 12.4% of outpatient visits for bipolar disorder in the 1997-2000 period to 51.4% in the 2013-2016 period”; full text: “a decrease in use of lithium from 30.4% to 17.6% (adjusted odds ratio of 0.46, 95% CI 0.29–0.71)”; conclusion: “second-generation antipsychotics in large measure supplanting traditional mood stabilizers.” The authors suggest psychiatrists “may have become increasingly uncomfortable prescribing medications with the potential for serious and acute medical side effects, such as lithium.” Some antipsychotics gained bipolar approvals in this window. Two authors list industry ties. PMID 32312111, PMC7577523. https://pmc.ncbi.nlm.nih.gov/articles/PMC7577523/
5. Lyall LM, Penades N, Smith DJ. Changes in prescribing for bipolar disorder between 2009 and 2016: national-level data linkage study in Scotland. British Journal of Psychiatry 2019;215:415-421. 23,135 patients: “only 5.90% of patients receiving lithium monotherapy”; “prescribing of lithium decreased (odds ratio 0.83, 95% CI 0.82-0.85)”. PMID 30816839. https://pubmed.ncbi.nlm.nih.gov/30816839/
6. Hakimi NH, et al. BMC Psychiatry 2026;26:354. Norway, Sweden and Denmark 2010-2023: “Lithium use was stable in Denmark, decreased in Norway, and increased in Sweden,” while antipsychotic use rose in all three. The decline is not universal. PMID 41877043. https://pubmed.ncbi.nlm.nih.gov/41877043/
7. Centers for Medicare & Medicaid Services. Medicare Part D Prescribers, by Geography and Drug, data year 2024, national rows (data.cms.gov data-api dataset 9b4c142c-69cc-4a96-a09a-7cf2ba7f5816), queried 2026-09-29. Total drug cost is gross, before manufacturer rebates, which are confidential; per-person figures are our arithmetic (total cost ÷ beneficiaries, rows summed, an upper bound on distinct people). https://data.cms.gov/provider-summary-by-type-of-service/medicare-part-d-prescribers/medicare-part-d-prescribers-by-geography-and-drug
8. Centers for Medicare & Medicaid Services. Open Payments, program year 2024 general payments, queried 2026-09-29 through the public datastore: payments whose first named product was each brand, summed by paying manufacturer, all recipient types; lithium searched in all five product fields. Our arithmetic. https://www.cms.gov/priorities/key-initiatives/open-payments/data
9. DeJong C, Aguilar T, Tseng CW, et al. Pharmaceutical industry-sponsored meals and physician prescribing patterns for Medicare beneficiaries. JAMA Internal Medicine 2016;176(8):1114-1122. Open Payments August-December 2013 linked to Part D: “Ninety-five percent of payments were meals, with a mean value of less than $20”; a single meal promoting the drug was associated with higher prescribing of the antidepressant desvenlafaxine (Pristiq; Wyeth Pharmaceuticals, a subsidiary of Pfizer, per the DailyMed label) over other SSRIs and SNRIs (“OR, 2.18; 95% CI, 2.13-2.23”); “Receipt of additional meals and receipt of meals costing more than $20 were associated with higher relative prescribing rates.” Desvenlafaxine was 0.6% of those prescriptions. The authors: an association, not cause and effect. PMID 27322350. https://pubmed.ncbi.nlm.nih.gov/27322350/
10. Mitchell AP, Trivedi NU, Gennarelli RL, et al. Are financial payments from the pharmaceutical industry associated with physician prescribing? A systematic review. Annals of Internal Medicine 2021;174(3):353-361. “Thirty-six studies comprising 101 analyses were included. Most studies (n = 30) identified a positive association between payments and prescribing in all analyses; the remainder (n = 6) had a mix of positive and null findings. No study had only null findings”; nine found a temporal association and 25 a dose-response relationship; 21 of 36 had serious risk of bias. PMID 33226858. https://pubmed.ncbi.nlm.nih.gov/33226858/
11. King M, Essick C, Bearman P, Ross JS. Medical school gift restriction policies and physician prescribing of newly marketed psychotropic medications: difference-in-differences analysis. BMJ 2013;346:f264. Graduates of schools that restricted gifts were less likely to prescribe paliperidone over older antipsychotics (odds ratio 0.25) and lisdexamfetamine over older stimulants (0.44); no significant effect for desvenlafaxine (1.54, 0.79 to 3.03). PMID 23372175. https://pubmed.ncbi.nlm.nih.gov/23372175/
12. Katz IR, Rogers MP, Lew R, et al. Lithium treatment in the prevention of repeat suicide-related outcomes in veterans with major depression or bipolar disorder: a randomized clinical trial. JAMA Psychiatry 2022;79(1):24-32. “The trial was stopped for futility after 519 veterans … were randomized”; “No overall difference in repeated suicide-related events between treatments was found (hazard ratio, 1.10; 95% CI, 0.77-1.55).” Lithium levels were low (0.54 and 0.46 mEq/L). PMID 34787653. https://pubmed.ncbi.nlm.nih.gov/34787653/
13. Shine B, McKnight RF, Leaver L, Geddes JR. Long-term effects of lithium on renal, thyroid, and parathyroid function: a retrospective analysis of laboratory data. Lancet 2015;386:461-468. Lithium was associated with stage 3 chronic kidney disease (HR 1.93), hypothyroidism (2.31) and raised calcium (1.43); “Women younger than 60 years and people with lithium concentrations higher than median are at greatest risk.” PMID 26003379. https://pubmed.ncbi.nlm.nih.gov/26003379/
14. Hayes JF, Marston L, Walters K, et al. Adverse renal, endocrine, hepatic, and metabolic events during maintenance mood stabilizer treatment for bipolar disorder: a population-based cohort study. PLoS Medicine 2016;13(8):e1002058. “Lithium use is associated with more renal and endocrine adverse events but less weight gain”; alternatives had more than 15% weight gain more often (olanzapine HR 1.84, quetiapine 1.67); no significant difference in stage 4 or worse kidney disease. PMID 27483368. https://pubmed.ncbi.nlm.nih.gov/27483368/

related: has your psychiatrist been paid by the industry? type in your zip code · how lithium was found

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