Sam, twenty-eight, horribly depressed, apathetic, treated since his teenage years with intensive psychotherapy and psychopharmacology, occasional substance abuse problems, comes in for help at the insistence of his therapist. Sam’s current psychotherapist, Wayne, felt that I would be a good member of his treatment team since Wayne felt that he needed to work with a therapist who could “collaborate. “ I begin my evaluation by looking into his past treatment experiences. I speak to his three previous psychotherapists and his two previous psychopharmacologists. I get his medical records. With Sam’s permission, I have lunch with the psychiatrist who treated him when he was fifteen. After I feel that I have the lay of the land, I begin to change Sam’s medication, seeing him weekly, while Wayne sees him three times a week. Sam does not seem to be improving. He continues to appear listless and flat. His episodes of binge drinking continue. He denies any experience of joy. He has never had a manic episode; he has no family history of bipolar disorder. He is not suicidal, but he has absolutely no enthusiasm for life. He had a girlfriend, but that relationship ended, with seemingly little emotional upheaval for Sam.
Sam is on antidepressants, but they do not seem to be helping his mood. Given that Sam has had multiple trials of psychotropic drugs, with little impact on his mental state, I decide to try Lithium as an adjunctive treatment for his depression. Lithium is a well established medication to help antidepressants work better. Sam and I have a long discussion about starting Lithium. He will need to have his blood checked every six months for possible kidney failure and possible hypothyroidism. Lithium might make him drink more and urinate more. At the same time, Lithium might help him enjoy his life. He agrees. After two weeks, Sam experiences a slight improvement in his mood. Wayne is stunned. “How can you give him Lithium?” he asks me. “Well, Sam has been on so many psychotropic medications without much relief, I thought that Lithium was a reasonable next step,” I replied. Wayne thought that Lithium was only for people with bipolar disorder and hence by Wayne’s way of thinking, Lithium was inappropriate for Sam.
Associations to medication whether by the patient or the patient’s therapist is a critical factor in treatment. For many people, Lithium is associated with psychiatric hospitalizations and a poor prognosis. Since Lithium came out in the late 1950s, many people think of it as an “old” and hence an “outdated” medication. Yet, that Lithium helps the chronically mentally ill does not mean that it cannot also help the less severely ill folks. Further, “old” does not mean “bad”. I find myself defending Lithium as if it were a political movement that needed a campaign. I also find myself wishing that psychiatry had a better public relations firm that helped psychotherapists and the public understand some general principles of psychopharmacology.
Sam is doing better. He feels better; he reports that he has not had a drinking binge since starting the Lithium. Maybe the Lithium is having a placebo effect. Maybe his work in psychotherapy is developing some momentum. Maybe the Lithium, in concert with his other antidepressants, is changing his brain chemistry in such a way that Sam can experience more joy. Maybe Wayne’s concern about the appropriateness of Lithium has made Wayne more alert to Sam’s mental state such that there has been a positive change in their relationship. Maybe the Lithium has made Sam less likely to binge drink because he is more afraid to drink while being on multiple psychotropic medications; his sobriety could be the key to his elevated mood. I will never have certainty about why Sam is improving, but I can say that two weeks after starting the Lithium, Sam reports feeling better. So far, the benefits outweigh the risks. If all goes well, he will be off of Lithium in six to nine months, with a stable improvement in his mood. Old medicines can be good medicines. I hope that will be true for Sam. Wayne might come around to agree.
