I've never been on lithium, but Moncrioff has been adamant, too, that antipsychotics (and I was on Haldol for many years) are just sedatives, all they do is drug people down.
Making blanket statements like this isn't liberatory or respectful of madpeople! Because if you listen to US and what WE have to say, we'll report fairly different experiences with antipsychotics. For some people some medications are experienced as having a more targeted effect, not just a tranquilizing one.
Of course, people can be wrong about what effects a medication have on them, that's why we have RCTs. But we do have pro tanto reasons to trust people when they talk about their own experiences, we need some REASON to dismiss personal testimony. For instance, if people who claim more targeted effects from antipsychotics couldn't tell whether they got Haldol or Xanax (say) in a blinded trial, then we'd have reason to distrust their testimony. But in the absence of such blinded trials (which would probably be too complicated to do anyway - you'd have to make sure the study wasn't disturbed by discontinuation effects - and unethical to boot), we should trust people's testimony. Not go "well there's no objective evidence supporting what you say about your own experiences, so I'm gonna assume you're just wrong and confused".
Thank you for another judicious and nuanced discussion, Awais. It is disappointing to me, as a (now retired) psychopharmacolgist [1], that there is still unwarranted skepticism—even cynicism—about a medication that has probably saved thousands of lives, over the past six decades.
Attempts by various parties to discredit lithium is, in my view, part of a larger trend in antipsychiatry circles to denigrate or disparage psychiatric medications—which is not to say that all criticism is unwarranted. As most psychiatrists would acknowledge, the antidepressants and antipsychotics leave much to be desired, and a good deal could be said regarding their limitations and substantial side effects—a subject for another time. (I do feel compelled to point out, however, that some of the same critics who disparage lithium have falsely and misleadingly claimed that antidepressants act merely by “numbing” depressive feelings—see [2]).
Skeptics need not take the word of psychiatrists regarding the benefits of lithium. Here is the verdict of Prof. Edward Shorter, the social historian of medicine and psychiatry:
“With the exception of ECT, lithium is the single most effective treatment in psychiatry. Its side effects are easily manageable, and many patients stay on low-dose lithium for decades. Its benefits, in terms of the relief of mania and the prophylaxis of depression, are incalculable.” [3]
That said, a modicum of humility is warranted when it comes to confident pronouncements regarding lithium’s putative “anti-suicidal” effects. While I am in agreement with Dr. Ghaemi’s overall conclusions [4], I don’t believe the case is quite closed in lithium’s favor. As the excellent paper by Baldessarini and Tondo point out, “…it must be emphasized that such [an anti-suicidal] role of lithium treatment is not securely demonstrated and has proved difficult to assess by use of randomized, controlled trials.” [5]
Finally, it is deeply misleading to characterize lithium as “a highly toxic, sedative substance.” When carefully monitored and adjusted to the particular patient’s needs, lithium is safe, well-tolerated, and effective in patients with bipolar spectrum illnesses. Opinions to the contrary, in my view, usually reflect inexperience or lack of sophistication in using this medication.
Kind regards,
Ronald W. Pies, MD
1. Pies RW. Handbook of Essential Psychopharmacology, 2nd ed., American Psychiatric Press, 2005
3. Shorter E. The history of lithium therapy. Bipolar Disord. 2009 Jun;11 Suppl 2(Suppl 2):4-9. doi: 10.1111/j.1399-5618.2009.00706.x. PMID: 19538681; PMCID: PMC3712976.
4. Ghaemi SN. The pseudoscience of lithium and suicide: Reanalysis of a misleading meta-analysis. J Psychopharmacol. 2024 Jun 12:2698811241257833. doi: 10.1177/02698811241257833. Epub ahead of print. PMID: 38863399. [Disclosure: Dr. Ghaemi is a Tufts colleague and friend, as well as the co-developer (with me) of the Bipolar Spectrum Diagnostic Scale. https://www.gatewaypsychiatric.com/the-bipolar-spectrum-diagnostic-scale-bsds/]
5. Tondo, L, Baldessarini, RJ. Prevention of suicidal behavior with lithium treatment in patients with recurrent mood disorders
I've never been on lithium, but Moncrioff has been adamant, too, that antipsychotics (and I was on Haldol for many years) are just sedatives, all they do is drug people down.
Making blanket statements like this isn't liberatory or respectful of madpeople! Because if you listen to US and what WE have to say, we'll report fairly different experiences with antipsychotics. For some people some medications are experienced as having a more targeted effect, not just a tranquilizing one.
Of course, people can be wrong about what effects a medication have on them, that's why we have RCTs. But we do have pro tanto reasons to trust people when they talk about their own experiences, we need some REASON to dismiss personal testimony. For instance, if people who claim more targeted effects from antipsychotics couldn't tell whether they got Haldol or Xanax (say) in a blinded trial, then we'd have reason to distrust their testimony. But in the absence of such blinded trials (which would probably be too complicated to do anyway - you'd have to make sure the study wasn't disturbed by discontinuation effects - and unethical to boot), we should trust people's testimony. Not go "well there's no objective evidence supporting what you say about your own experiences, so I'm gonna assume you're just wrong and confused".
This is such a well written article. Added to my link-list folder.
Thank you for another judicious and nuanced discussion, Awais. It is disappointing to me, as a (now retired) psychopharmacolgist [1], that there is still unwarranted skepticism—even cynicism—about a medication that has probably saved thousands of lives, over the past six decades.
Attempts by various parties to discredit lithium is, in my view, part of a larger trend in antipsychiatry circles to denigrate or disparage psychiatric medications—which is not to say that all criticism is unwarranted. As most psychiatrists would acknowledge, the antidepressants and antipsychotics leave much to be desired, and a good deal could be said regarding their limitations and substantial side effects—a subject for another time. (I do feel compelled to point out, however, that some of the same critics who disparage lithium have falsely and misleadingly claimed that antidepressants act merely by “numbing” depressive feelings—see [2]).
Skeptics need not take the word of psychiatrists regarding the benefits of lithium. Here is the verdict of Prof. Edward Shorter, the social historian of medicine and psychiatry:
“With the exception of ECT, lithium is the single most effective treatment in psychiatry. Its side effects are easily manageable, and many patients stay on low-dose lithium for decades. Its benefits, in terms of the relief of mania and the prophylaxis of depression, are incalculable.” [3]
That said, a modicum of humility is warranted when it comes to confident pronouncements regarding lithium’s putative “anti-suicidal” effects. While I am in agreement with Dr. Ghaemi’s overall conclusions [4], I don’t believe the case is quite closed in lithium’s favor. As the excellent paper by Baldessarini and Tondo point out, “…it must be emphasized that such [an anti-suicidal] role of lithium treatment is not securely demonstrated and has proved difficult to assess by use of randomized, controlled trials.” [5]
Finally, it is deeply misleading to characterize lithium as “a highly toxic, sedative substance.” When carefully monitored and adjusted to the particular patient’s needs, lithium is safe, well-tolerated, and effective in patients with bipolar spectrum illnesses. Opinions to the contrary, in my view, usually reflect inexperience or lack of sophistication in using this medication.
Kind regards,
Ronald W. Pies, MD
1. Pies RW. Handbook of Essential Psychopharmacology, 2nd ed., American Psychiatric Press, 2005
2. https://www.psychiatrictimes.com/view/antidepressants-do-not-work-by-numbing-emotions
3. Shorter E. The history of lithium therapy. Bipolar Disord. 2009 Jun;11 Suppl 2(Suppl 2):4-9. doi: 10.1111/j.1399-5618.2009.00706.x. PMID: 19538681; PMCID: PMC3712976.
4. Ghaemi SN. The pseudoscience of lithium and suicide: Reanalysis of a misleading meta-analysis. J Psychopharmacol. 2024 Jun 12:2698811241257833. doi: 10.1177/02698811241257833. Epub ahead of print. PMID: 38863399. [Disclosure: Dr. Ghaemi is a Tufts colleague and friend, as well as the co-developer (with me) of the Bipolar Spectrum Diagnostic Scale. https://www.gatewaypsychiatric.com/the-bipolar-spectrum-diagnostic-scale-bsds/]
5. Tondo, L, Baldessarini, RJ. Prevention of suicidal behavior with lithium treatment in patients with recurrent mood disorders
Int J Bipolar Disord 12, 6 (2024). https://doi.org/10.1186/s40345-024-00326-x