Lithium Looks Safer in Older Adults

Concerns about lithium’s safety in older adults may have it backwards

STUDY: Xu N et al, Acta Psychiatr Scand 2026

STUDY TYPE: Cross-sectional study

FUNDING: International Society for Bipolar Disorders

Background

Lithium is the go-to maintenance treatment for bipolar disorder, but clinicians have grown cautious about prescribing it to older patients over cardiovascular and renal concerns. Meanwhile, other medications have replaced it, bringing risks of their own.

This study used a large international dataset to compare comorbidities in bipolar patients on and off lithium.

The Study

• 2,873 adults with bipolar disorder (age 18-95) from 37 studies in 20 countries, 1,069 on lithium and 1,804 not, compared across eight organ systems.
• Models tested age’s effect on the lithium-comorbidity link.
• Cross-sectional design; no data on lithium dose, levels, or duration.

Results

Patients on lithium had a lower overall burden of physical comorbidities. The advantage grew with age for cardiovascular, respiratory, genitourinary, and endocrine conditions, with lithium users showing progressively lower rates above roughly age 32 to 59.

No differences appeared for gastrointestinal, hepatic, renal, or musculoskeletal disease.

Limitations

This cross-sectional design can’t separate a protective effect from prescription bias (clinicians steering lithium toward healthier patients) or survivorship bias (patients with complications may have stopped lithium and shifted into the comparison group). The sample leaned on clinical-trial cohorts, with no data on lithium levels or duration.

Practice Implications

1. Normally I wouldn’t post cross-sectional data like this, but the results are in line with other studies, pointing to lower medical risks, cardioprotective properties, and longer lifespans with lithium compared to other mood stabilizers.
2. Smaller studies suggest older adults are more responsive to lithium.
3. Aim for lower serum levels in older adults.
4. Learn more on how to improve lithium’s safety and tolerability in Difficult to Treat Depression.

—Chris Aiken, MD
Director, Psych Partners
Editor in Chief, Carlat Psychiatry Report

What’s Your Take? Share in Comments