Lithium in Mood and Bipolar Disorders

Lithium remains one of the most effective pharmacologic treatments for bipolar disorder, with well-established benefits in acute mania, long-term mood stabilization, and suicide prevention. Yet over recent decades, its clinical use has declined worldwide, often in favor of anticonvulsants and second-generation antipsychotics that are perceived as easier to prescribe and monitor. Understanding how lithium emerged, fell out of favor, and is now being re-examined may clarify its appropriate place in contemporary treatment algorithms. This narrative review traces lithium's trajectory from a 19th-century urate-lowering agent for gout to its rediscovery as a treatment for "psychotic excitement" and mania in the mid-20th century. Open and controlled trials established lithium as the first mood stabilizer and led to regulatory approval for acute mania and prophylaxis. For several decades, lithium was the dominant treatment for bipolar disorder, supported by randomized trials and meta-analyses demonstrating robust relapse prevention and a unique reduction in suicide risk. More recently, however, concerns about toxicity, the need for monitoring, and the availability of heavily marketed alternatives have contributed to declining use, despite guideline recommendations that still endorse lithium as a preferred long-term option for many patients. In parallel, advances in molecular neuroscience and neuroimaging have identified several convergent pathways that may underlie lithium's therapeutic actions. These include inhibition of inositol-related phosphomonoesterases and glycogen synthase kinase-3, modulation of neurotrophic and neuroprotective cascades, and normalization of frontolimbic circuitry involved in emotion regulation and impulsivity. Such mechanisms offer plausible links between lithium's cellular effects, mood-stabilizing properties, and antisuicidal benefits. Lithium's historical prominence, subsequent decline in routine practice, and renewed mechanistic interest together suggest that it is underutilized rather than obsolete. Reappraising lithium through both historical and mechanistic lenses may support its more systematic consideration as a first-line mood stabilizer-particularly in patients at elevated risk for suicide-while emphasizing the importance of careful monitoring and collaborative, informed decision-making. .