Treating Bipolar Disorder: Early Intervention and the Role of Lithium

BRAIN TRUST: CONVERSATIONS IN PSYCHOPHARMACOLOGY

-Series Editor Joseph F. Goldberg, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," spoke with Robert Post, MD, about evolving perspectives on bipolar disorder and treatment, emphasizing early intervention and the underutilization of lithium.

Post highlighted the high prevalence of childhood-onset bipolar disorder in the United States, noting that approximately a quarter of cases begin before age 13.¹ He underscored that earlier onset and longer delays to first treatment independently predicted poorer adult outcomes. Post posited, “untreated illness is the greatest threat to our children,” arguing that concerns about overprescription have overshadowed the risks of delayed or absent care.

Goldberg and Post discussed duration of untreated illness as a prognostic factor analogous to other areas of medicine, observing that delayed initiation of effective therapy diminished treatment responsiveness. Post cited emerging data suggesting that lithium was most effective when introduced after a first episode, potentially preserving cognitive function and preventing neuroprogression.² He reiterated that lithium’s benefits extended beyond mood stabilization, describing it as neuroprotective and potentially disease modifying. As Post explained, “the earlier you use it, the better it is, and that it avoids neurological and bone abnormalities and disease progression.”

Post expressed concern that lithium remained markedly underused, with far more patients receiving antidepressants despite bipolar diagnoses.^3,4 He attributed this pattern to overemphasis on lithium’s adverse effects and underrecognition of its broader benefits, including antisuicidal effects, neurogenesis, preservation of hippocampal volume, reduced all-cause mortality, and possible protection against bone fractures. Both experts suggested that delayed lithium initiation may create a self-fulfilling prophecy in which diminished responsiveness reinforces hesitancy to prescribe it. The discussion called for earlier, evidence-based intervention to improve long-term outcomes in bipolar disorder.

Dr Goldberg is a clinical professor of psychiatry at The Icahn School of Medicine at Mount Sinai in New York, NY and the immediate-past president of the American Society of Clinical Psychopharmacology.

Dr Post is an expert in bipolar disorder, founder of the Bipolar Collaborative Network, and professor of psychiatry at the George Washington University School of Medicine.

References

1. Post RM, Grunze H. The challenges of children with bipolar disorder. Medicina (Kaunas). 2021;57(6):601.

2. Berk M, Daglas R, Dandash O, et al. Quetiapine v. lithium in the maintenance phase following a first episode of mania: randomized controlled trial. Br J Psychiatry J Mental Sci. 2017;210(6):413-421.

3. Hidalgo-Mazzei D, Mantingh T, Pérez de Mendiola X, et al. Clinicians’ preferences and attitudes towards the use of lithium in the maintenance treatment of bipolar disorders around the world: a survey from the ISBD Lithium task force. Int J Bipolar Disord. 2023;11(1):20.

4. Steger CM, Birckhead B, Raghunath S, et al. Trends and determinants of prescription of lithium and antidepressants for bipolar disorder in a large health care system between 2017 and 2022. J Affect Disord. 2025;381:451-458.