The Link Between Lithium Use and Tardive Dyskinesia

Psych Congress 2021 co-chair, Julie Carbray, PhD, FPMHNP-BC, PMHCNS-BC, APRN, clinical professor of psychiatry and nursing, University of Illinois at Chicago; administrative director, Pediatric Mood Disorder Clinic, Pediatric Brain Research and Intervention Center, Department of Psychiatry, Chicago, Illinois, moderates an audience question and answer session with Joseph F. Goldberg, MD, clinical professor of psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York, from his session, “Personalized Medicine for Bipolar Depression: Combining Evidence and Clinical Wisdom to Improve Clinical Outcomes.”

Dr Goldberg provides information on how lithium use for bipolar disorder can cause tardive dyskinesia and how to correctly identify and address this problem.

Read the transcript:

Dr Julie Carbray: Can lithium cause tardive dyskinesia? For a patient on lithium for over 30 years that suddenly developed shaking, what would be the course of action?

Dr Goldberg:  Lithium definitely causes tardive dyskinesia in case reports. When you look in the literature, they are there, and it's tough to know what to do with that.

People like me wave their wrist and say, "Well, there must be some effect on dorsal striatum, dopamine transmission," and the faster you wave your hand, the more you mean...I don't know what the mechanism is because lithium shouldn't be having a dopaminergic effect directly there, and yet, there are case reports. It's rare, you look for other explanations.

Remember, if you took an antipsychotic 10 years ago, you could still get TD down the road from that. It's often hard to do a perfect experiment, but if your diagnosis is TD, then there have been many presentations at this conference about what to do to treat TD if and when it's there when you do your AIMS exam.

If you see a tremor, now you have to evaluate the tremor. Lithium classically has a postural tremor. It's not a parkinsonian tremor, it's not a TD tremor, it's not a dystonia tremor. You don't have to become a tremor expert or movement-disorders expert, but you have to evaluate it.

Then after 30 years, you want to make sure the level hasn't drifted up, that the GFR hasn't drifted down, that a dose that was previously not causing adverse effects, it shouldn't newly be causing adverse effects, unless there's been a drift up or a drug interaction, or somebody put them on hydrochlorothiazide, and now, their level is climbing up.

You can get a postural tremor without it reflecting toxicity, that's our first concern. If I see a tremor, "Uh-oh, is that a benign lithium tremor or a sign of toxicity?" If it's a benign tremor in the absence of toxicity and it bothers you or the patient, you treat it with a beta-blocker or primidone, but you have to figure out why they're having it.

Dr Carbray:  Thank you.

Joseph F Goldberg, MD, is Clinical Professor of Psychiatry at the Icahn School of Medicine at Mount Sinai. He attended college at the University of Chicago, graduate school in neuroscience at the University of Illinois, and medical school at Northwestern University. He completed his residency and chief residency in psychiatry, and fellowship in psychopharmacology, at the Payne Whitney Clinic, New York Presbyterian Hospital, where he later served on the faculty and was site Principal Investigator at Weill-Cornell Medical Center for the NIMH STEP-BD program. He has published over 220 peer-reviewed papers on topics related mainly to the treatment and clinical features of bipolar disorder, as well as 4 books on bipolar disorder and psychopharmacology, most recently, "Practical Psychopharmacology: Translating Findings From Evidence-Based Trials Into Real-World Clinical Practice," with Stephen Stahl, MD, PhD, published in 2021 by Cambridge University Press. He serves on the Board of Directors for the American Society of Clinical Psychopharmacology and serves as a field editor for the Journal of Clinical Psychiatry and for CNS Spectrums. His research has been awarded funding from NARSAD, NIMH, the Stanley Foundation, and the American Foundation for Suicide Prevention. Dr Goldberg is a Distinguished Fellow of the American Psychiatric Association and has been listed for many years in Best Doctors in America and Castle Connolly's "America's Top Doctors."