Mood stabilisers including lithium

1. Introduction

Version followed: NICE guideline CG185 Bipolar disorder: assessment and management (PDF, first published 24 September 2014, last updated 21 December 2023; NICE quality standard QS95 refers to a 2025 update whose changes are not drawn on [uncertain]); US FDA prescribing information for lithium carbonate (generic capsule label rev. 10/2019), Depakote (rev. 03/2026), Lamictal (rev. 10/2025) and Equetro (rev. 10/2022); MHRA National Patient Safety Alert NatPSA/2023/013/MHRA on valproate (28 November 2023).

What it is. "Mood stabilisers" is a clinical umbrella term, not a single therapy: medicines prescribed to treat mania or hypomania, and to reduce the risk of further mood episodes in bipolar disorder. In current labelling and guidelines the core group is lithium plus three anticonvulsants with bipolar indications (valproate, carbamazepine, lamotrigine); some antipsychotics are also used in this role but belong to a separate entry. NICE names lithium as the first-line long-term treatment for bipolar disorder and states it is effective for mania, recurrent depression and reducing the risk of further episodes and of suicide [source: NICE CG185 rec 1.7.7; NICE QS95 statement 5].

Who delivers it. These are prescription-only medicines started and managed by a psychiatrist or other prescriber; in the UK, NICE says lithium should not be started in primary care for someone new to it except under shared-care arrangements, with GP and specialist sharing prescribing and blood monitoring [source: NICE CG185 recs 1.2.7, 1.10.14; NICE QS95]. The psychotherapist does not prescribe, adjust or advise on these medicines. This guide is written for the therapist working alongside the prescriber.

How change happens (as the sources frame it). The medicine reduces the frequency and severity of mood episodes; psychological work designed for bipolar disorder adds understanding of the illness, self-monitoring, recognition of triggers and early warning signs, and a relapse plan [source: NICE CG185 recs 1.7.3–1.7.4]. Lithium's narrow gap between effective and toxic blood concentrations is why blood monitoring, hydration and interaction awareness are part of treatment itself [source: NICE QS95; FDA lithium label boxed warning]. The therapist's contribution is to make the combined package workable for the client: informed choice, honest talk about ambivalence, early detection of relapse and side effects, and fast routing to the prescriber [synthesis].

2. Framework

There are no therapy "phases" in the labelling. The stages below follow the treatment course as NICE and the labels describe it, with the therapist's tasks at each [source: NICE CG185 recs 1.7.1–1.7.4, 1.10.14–1.10.33; framing of therapist tasks = synthesis].

Format and session count. Medicine reviews are set by the prescribing team. NICE recommends that psychological interventions for bipolar disorder be structured, specifically designed for it, with a published evidence-based manual, delivered by therapists trained and experienced in bipolar disorder; individual, group or family formats [source: NICE CG185 recs 1.6.1–1.6.2, 1.7.3]. For bipolar depression in adults NICE also lists CBT, IPT or behavioural couples therapy; for young people, manualised individual CBT or IPT for at least three months, with a multidisciplinary review if response is limited [source: NICE CG185 recs 1.6.1, 1.11.11–1.11.12]. Session numbers for adult relapse-prevention programmes are [uncertain].

3. Guiding principles

• Stay in role: never advise starting, stopping or changing a medicine. Practical meaning: every medicine question ends with "take that to your prescriber", and you help the client prepare the question [source: NatPSA/2023/013 "not stop … without advice from their specialist"; synthesis].
• Route warning signs immediately. Possible lithium toxicity, serious rash, signs of liver or pancreas problems, or new suicidal thinking are same-day medical matters, not therapy material [source: FDA labels; MedlinePlus].
• Monitoring is part of the treatment. Treat missed blood tests as clinically important, the way you would a missed session [source: NICE QS95; CG185 rec 1.10.15].
• Narrow safety margin with lithium. Dehydration, vomiting or diarrhoea, acute illness and some common medicines (notably over-the-counter NSAIDs) can push levels up; prompt the client to seek medical advice when these occur [source: NICE CG185 recs 1.10.17–1.10.18; FDA lithium label].
• Reproductive safety is a standing topic. Valproate carries major pregnancy risks and is restricted; lithium, carbamazepine and lamotrigine also carry pregnancy, breastfeeding or contraception issues per labels. Clients should tell the prescriber promptly about pregnancy or plans [source: NatPSA/2023/013; NICE CG185 rec 1.10.17; FDA labels].
• Collaborative care with consent. Agree early who you may talk to and what you share; carers need to understand risks and the person's view [source: NICE CG185 recs 1.1.7, 1.3.4].
• Ambivalence is expected, not defiance. Explore it with curiosity; the aim is an informed decision made with the prescriber, not compliance with you [synthesis].
• Psychological work designed for bipolar disorder sits alongside medicine. Use structured, manualised approaches and be trained in them [source: NICE CG185 recs 1.6.2, 1.7.3].
• Watch mood in both directions. Monitor for emerging mania/hypomania as well as worsening depression during psychological work [source: NICE CG185 rec 1.6.1].
• Suicide risk is live. Antiepileptic mood stabilisers carry a class warning on suicidal thoughts and behaviour; bipolar disorder itself carries high risk. Keep risk assessment and crisis plans current [source: Lamictal, Equetro, Depakote labels; NICE CG185 rec 1.4.1].
• Physical health is mental health care. Support attendance at annual checks and lifestyle programmes [source: NICE CG185 recs 1.2.11–1.2.14, 1.8.1–1.8.2].

4. Intervention inventory

Part A describes, at a descriptive level only, how each medicine is delivered and monitored as official labelling, regulators and NICE state it. It contains no doses, target levels, titration, switching or stopping instructions; those belong to the prescriber. Part B is the psychotherapist's own work.

Part A1. Lithium: how it is delivered and monitored

• Purpose and status: US FDA label: monotherapy for bipolar I disorder, for acute manic or mixed episodes and for maintenance; use established from age 7 [source: FDA lithium carbonate label rev. 10/2019]. NICE: first-line long-term treatment for bipolar disorder [source: NICE CG185 rec 1.7.7]. UK formulations named by the NHS: standard and slow-release tablets (lithium carbonate) and a liquid (lithium citrate); NHS says it may take several weeks or months to work [source: NHS "About lithium"]. CQC advises it is prescribed by brand name because brands may be absorbed differently, and that brand or formulation changes after hospital discharge should be checked [source: CQC lithium page].
• Before starting (NICE): weight or BMI; blood tests for electrolytes, calcium, kidney function (eGFR), thyroid function and full blood count; ECG for people with cardiovascular disease or risk factors; national safety information given; shared care set up with the GP; the person told that poor adherence or abrupt stopping may raise relapse risk [source: NICE CG185 rec 1.10.14].
• Blood-level monitoring: frequent checks after starting and after every change until stable, then at regular intervals, more often for older people, people taking interacting medicines, people at risk of kidney or thyroid problems or raised calcium, people with poor symptom control or adherence, and people whose last level was high [source: NICE CG185 recs 1.10.15, 1.10.19–1.10.20]. Results are recorded in the client's lithium record book; NHS asks people to carry a lithium alert card [source: NHS "About lithium"]. The sample is timed relative to the last dose, which is why clients are given specific instructions for test day [source: CQC lithium page].
• Kidney, thyroid, calcium, weight: monitored periodically, more often if kidney or thyroid function worsens, calcium rises, or mood changes might be thyroid-related; if kidney markers become abnormal, monitoring intensifies and continuing lithium is weighed against kidney and cardiovascular risk, possibly with a renal specialist [source: NICE CG185 recs 1.10.21–1.10.23]. The FDA label lists nephrogenic diabetes insipidus (excessive urination and thirst), chronic kidney disease, hypothyroidism (and, rarely, hyperthyroidism) and hypercalcaemia/hyperparathyroidism [source: FDA lithium label].
• Neurotoxicity: NICE asks for checks at every appointment for tremor, unsteadiness, altered sensation or cognitive change, noting these can occur even at levels within range [source: NICE CG185 rec 1.10.24].
• Lithium toxicity warning signs: the FDA boxed warning states toxicity is closely related to blood concentration and can occur near therapeutic levels [source: FDA lithium label]. Signs the label asks patients to report include abnormal heartbeat, vomiting, diarrhoea, clumsiness, drowsiness, muscle weakness or twitching, blurred vision, ringing in the ears, confusion, slurred speech, seizures or coma [source: FDA lithium label, patient counselling]. MedlinePlus distinguishes acute (one large intake), chronic (gradual build-up, often unintended, influenced by dehydration, other medicines and illness) and acute-on-chronic toxicity; chronic toxicity can be hard to recognise early and some memory or mood effects may be permanent [source: MedlinePlus "Lithium toxicity", reviewed 14 Oct 2025]. Suspected toxicity is an emergency: emergency services or poison advice (US: Poison Help) [source: MedlinePlus]; in UK care settings CQC says contact the GP, with local urgent escalation for severe cases [source: CQC lithium page].
• Dehydration and illness: NICE advises people to seek medical attention for diarrhoea, vomiting or acute illness, and to keep fluid intake up after sweating (exercise, heat, fever), during prolonged immobility, or with chest infection [source: NICE CG185 rec 1.10.17]. The label advises a consistent diet with normal salt intake; NHS advises avoiding low-salt diets [source: FDA lithium label; NHS "About lithium"].
• Interactions: NICE: warn people not to take over-the-counter NSAIDs, and avoid prescribing them where possible [source: NICE CG185 rec 1.10.18]. FDA label: diuretics, NSAIDs, ACE inhibitors, angiotensin receptor blockers and metronidazole can raise lithium levels; serotonergic medicines raise serotonin-syndrome risk; antipsychotics raise neurological-reaction risk (including an encephalopathic syndrome); some other medicines lower levels [source: FDA lithium label]. CQC: check with a health professional before any over-the-counter medicine [source: CQC lithium page].
• Other label warnings: Brugada syndrome unmasking, raised intracranial pressure (pseudotumor cerebri), low sodium [source: FDA lithium label].
• Pregnancy and breastfeeding: possible fetal cardiac malformations (including Ebstein's anomaly; evidence described as inconclusive), neonatal toxicity late in pregnancy; breastfeeding not recommended per the US label; NICE asks people to tell their doctor promptly about pregnancy or plans [source: FDA lithium label; NICE CG185 rec 1.10.17].
• Watch for (therapist): missed blood tests, a new GP prescription or self-purchased painkiller, gastroenteritis, heatwaves or heavy exercise, new tremor or slowed thinking, thirst and frequent urination, crash dieting or salt restriction [source: as above; framing synthesis].

Part A2. Valproate: restrictions and monitoring

• Purpose and status: FDA label (Depakote): treatment of manic episodes associated with bipolar disorder; the label notes long-term effectiveness was not shown in controlled trials [source: Depakote label rev. 03/2026].
• Boxed warnings (FDA): hepatotoxicity (including fatal liver failure, mostly in the first six months; higher risk in young children and people with POLG mitochondrial disorders), fetal risk (neural tube defects and other major malformations, decreased IQ, neurodevelopmental disorders), and pancreatitis [source: Depakote label].
• UK regulation: the MHRA states pregnancy exposure is linked to physical birth defects in about 11% of babies and neurodevelopmental disorders in up to 30–40% of children. Since 2018 valproate has been contraindicated in women of childbearing potential unless the Pregnancy Prevention Programme (PPP) is in place. From January 2024 it must not be started in anyone (male or female) under 55 unless two specialists independently document that no other effective or tolerated treatment exists or that reproductive risks do not apply; women and girls of childbearing potential are reviewed with a revised Risk Acknowledgement Form; men under 55 should read the leaflet and can discuss concerns with the GP [source: NatPSA/2023/013/MHRA]. The PPP includes at least annual specialist review with a signed annual risk acknowledgement form, use of effective contraception, pharmacy warning labels and patient information at each supply, and applies to all women and girls of childbearing potential, including those not sexually active, unless a specialist judges there is no pregnancy risk [source: CQC valproate page]. NICE CG185 mirrors the under-55 and PPP requirements; it notes the MHRA's September 2024 advice for men (contraception during treatment and for a period after) and that NICE was assessing its impact [source: NICE CG185 PDF, update information].
• Key MHRA patient message: patients "must be informed to not stop taking their treatment without advice from their specialist" [source: NatPSA/2023/013/MHRA].
• Monitoring (NICE): weight, liver function and full blood count at the start, at six months and then yearly; people and carers told how to recognise blood and liver problems [source: NICE CG185 recs 1.10.29–1.10.30, 1.10.33]. FDA label adds hyperammonaemia (unexplained lethargy, vomiting, mental-state change), low platelets and bleeding, somnolence in older people, DRESS and serious skin reactions, and the antiepileptic class warning on suicidal thoughts [source: Depakote label].
• Watch for (therapist): any mention of pregnancy, trying for a baby, stopping contraception or a new relationship in a woman or girl taking valproate; abdominal pain with vomiting; yellowing, unusual bruising, marked lethargy or confusion; new suicidal thinking [source: as above; framing synthesis].

Part A3. Carbamazepine

• Purpose and status: FDA label (Equetro extended-release capsules): acute manic or mixed episodes in bipolar I disorder [source: Equetro label rev. 10/2022, via Drugs.com].
• Boxed warnings: serious and sometimes fatal skin reactions (SJS/TEN), with much higher risk in people carrying HLA-B*1502, found mainly in people of Asian ancestry, so genetic testing is advised before starting in at-risk patients; aplastic anaemia and agranulocytosis [source: Equetro label].
• Other warnings: DRESS, antiepileptic suicidality warning, low sodium, birth defects including neural tube defects, reduced effectiveness of hormonal contraceptives, many drug interactions through liver-enzyme induction (including with lithium), cognitive and motor impairment; labelled monitoring includes blood counts, liver tests, eye examinations and urinalysis [source: Equetro label].
• Watch for (therapist): rash, mouth sores, blistering; fever, sore throat, bruising; yellowing; confusion or headache (possible low sodium); new depression or suicidal thoughts; contraception concerns [source: Equetro label].

Part A4. Lamotrigine

• Purpose and status: FDA label: maintenance treatment of bipolar I disorder to delay new mood episodes; not recommended for acute manic or mixed episodes; paediatric bipolar effectiveness not established [source: Lamictal label rev. 10/2025].
• Boxed warning: serious, potentially fatal rashes (SJS/TEN), higher in children; risk raised by certain co-medicines and by exceeding the recommended starting schedule; benign and serious rashes cannot be reliably told apart early, so the label treats any rash as needing prompt medical action [source: Lamictal label]. The summary also listed HLA-B*1502 as a risk factor; not verified against the label text [uncertain].
• Other warnings: HLH, multiorgan hypersensitivity/DRESS, cardiac rhythm effects, blood disorders, antiepileptic suicidality warning, aseptic meningitis, medication errors from name or formulation confusion (patients asked to check tablets at each refill), and withdrawal seizures if stopped abruptly; oestrogen-containing contraceptives can lower lamotrigine levels [source: Lamictal label].
• Watch for (therapist): any rash, fever, swollen glands, blistering, mouth or eye sores, severe headache with stiff neck, unusual bruising, new or worsening mood change or suicidal thoughts; starting or stopping a contraceptive pill [source: Lamictal Medication Guide section].

Part A5. Shared care and physical health monitoring

• What NICE describes: a care plan developed with the person (copies to the person and GP); when care returns to primary care, a plan with recovery goals, crisis plan, mental state assessment and a medication plan with review dates; at least annual physical health checks in primary care (weight, diet, activity, blood pressure, pulse, glucose or HbA1c, lipids, liver function and, for long-term lithium, kidney, thyroid and calcium); secondary care shares monitoring and offers healthy eating and activity programmes [source: NICE CG185 recs 1.2.11–1.2.14, 1.3.4, 1.8.1–1.8.2, 1.9.4].
• Who delivers: psychiatrist and/or GP under shared care; pharmacists dispense and counsel; specialists sign valproate risk forms [source: NICE CG185; CQC; NatPSA/2023/013].
• Therapist's relevance: know who holds which part of monitoring, so you can route concerns to the right person [synthesis].

Part B1. Recognising when to suggest a medical review

• Purpose: get the prescriber involved early when something in session points to a medical issue [synthesis, built on NICE CG185 and label warning signs].
• When to use: emerging mania or hypomania or deepening depression; any possible toxicity or serious-reaction sign from Part A; vomiting, diarrhoea or acute illness in a client on lithium; a new prescribed or bought medicine (especially painkillers); pregnancy or plans; missed blood tests; client says they have stopped or changed their medicine on their own.
• Steps: (1) Name what you noticed, factually. (2) Ask whether the prescriber knows. (3) Agree who will contact whom, and by when; possible toxicity, serious rash, jaundice, severe abdominal pain, confusion or new suicidal intent = same day or emergency services. (4) If you have consent, contact the team yourself. (5) Record what was said and done.
• Example language (illustrative): "You've had the shakes and been sick since yesterday. With lithium those are things your doctor wants to hear about today. Can we call them now, together?"
• Watch for: minimising ("it's just a bug"); the review actually happening; follow up next session.

Part B2. Referral, information-sharing and collaborative care

• Purpose: one shared picture across prescriber, GP, therapist and carers [source: NICE CG185 recs 1.1.7, 1.3.4, 1.9.4].
• When to use: at intake, and whenever care changes hands.
• Steps: (1) At intake, ask who prescribes, who does blood tests, and whether there is a care plan or crisis plan. (2) Get written consent for two-way communication, with clear limits. (3) Agree what you will pass on routinely (mood trajectory, early warning signs, reported side effects) and what triggers urgent contact. (4) Send brief written updates at agreed points. (5) If a client without a prescriber shows possible bipolar features, refer for psychiatric assessment via the GP [synthesis].
• Example language (illustrative): "I'm not involved in decisions about your medicine, but I'd like your psychiatrist and me to be working from the same page. What would you be comfortable with me sharing?"
• Watch for: consent drifting out of date; the client using you as a go-between to avoid the prescriber.

Part B3. Psychoeducation about mood stabilisers

• Purpose: help the client understand the official information they were given, so they can take part in decisions [source: NICE CG185 rec 1.7.1 (discuss the role of psychological and drug treatments and the risks of stopping); rec 1.10.14 (safety information)].
• Steps: (1) Ask what they already know and what they were told. (2) Go through their own leaflet, record book or alert card together, rather than your own summary. (3) Cover general themes only: why lithium needs blood tests, why fluids and salt matter, why new medicines must be checked, which signs need urgent help, the valproate pregnancy restrictions where relevant. (4) Write their questions down for the prescriber. (5) Check understanding with teach-back.
• Example language (illustrative): "Could you tell me in your own words why the blood tests matter? Then we'll know what to ask the doctor about."
• Watch for: you drifting into dose or level discussion (stop and redirect); information overload during a mood episode; misinformation from online sources.

Part B4. Supporting informed consent and shared decision-making

• Purpose: help the client reach a decision they own, with the prescriber [source: NICE CG185 rec 1.6.1 (discuss benefits, risks and preferences); synthesis].
• Steps: (1) Clarify the decision the prescriber has put to them. (2) Explore values (e.g. stability, creativity, family plans, work, side-effect worries). (3) Help them list benefits, risks and unknowns as the prescriber described them. (4) Rehearse how to say their preferences and questions. (5) For valproate, make sure a woman or girl knows the PPP exists and what it involves, so she can take part in the annual review [source: CQC valproate page]. (6) Where capacity fluctuates during episodes, help them record preferences while well (advance statement) and share with the team [synthesis].
• Example language (illustrative): "What matters most to you as you weigh this up? Let's write down what you'd like to ask before you see Dr X."
• Watch for: pressure from family or from you; decisions made during mania that the client later regrets.

Part B5. Adherence and ambivalence conversations (never advising a change)

• Purpose: keep the client's doubts in the open and connected to the prescriber, since NICE notes poor adherence or abrupt stopping may raise relapse risk [source: NICE CG185 recs 1.7.1, 1.10.14].
• Steps: (1) Ask routinely and non-judgementally how taking the medicine is going. (2) Explore both sides: what they value and what they dislike (side effects, missing highs, identity, stigma, blood tests). (3) Reflect without arguing. (4) Separate the feeling from the action: wanting to stop is talked about; any change goes through the prescriber. (5) Link with their own relapse history and goals. (6) Help them plan the conversation with the prescriber. (7) If they have already stopped or reduced, do not judge or advise; encourage prompt contact with the prescriber and step up early-warning-sign monitoring.
• Example language (illustrative): "Part of you misses how you felt before, and part of you remembers how hard the last episode was. Both make sense. This is worth taking to your psychiatrist rather than deciding alone. Shall we plan what you'd say?"
• Watch for: your own views about medicine leaking in; ambivalence rising with early hypomania (loss of insight); secret stopping.

Part B6. Monitoring and passing on side effects and warning signs

• Purpose: help the team catch problems early [source: Part A labels; NICE CG185 rec 1.10.24].
• Steps: (1) Agree with the client a short list, taken from their own leaflet, of symptoms they want to track. (2) Briefly check at sessions: new shakiness, unsteadiness, thinking changes, thirst or urination changes, weight change, rash, gut symptoms. (3) Note the date and pattern. (4) Pass on to the prescriber with consent; urgent signs same day. (5) Never interpret what a symptom means for the dose.
• Example language (illustrative): "You mentioned feeling foggy and unsteady. That's something your leaflet says to report. Would you contact the clinic, or shall I?"
• Watch for: attributing cognitive slowing or low mood only to psychology when the label lists thyroid and neurotoxic effects [source: NICE CG185 recs 1.10.21, 1.10.24].

Part B7. Sick-day and everyday-life awareness (lithium)

• Purpose: link daily life to safety, as NICE and the label advise [source: NICE CG185 recs 1.10.17–1.10.18; FDA lithium label; NHS].
• Steps: (1) Before a holiday in a hot place, a sports event, a planned surgery or fasting, ask whether they have checked with their prescriber or pharmacist. (2) When they report vomiting, diarrhoea or fever, prompt medical contact. (3) Remind them to tell any doctor, dentist or pharmacist they take lithium (alert card). (4) Ask about painkillers bought over the counter and support checking with a pharmacist.
• Example language (illustrative): "With the heatwave and your marathon training, is this something to check with your pharmacist?"
• Watch for: low-salt or crash diets; heavy alcohol use; dehydration during mania.

Part B8. Reproductive-health conversations

• Purpose: make sure pregnancy plans reach the prescriber early [source: NICE CG185 rec 1.10.17; NatPSA/2023/013; labels].
• Steps: (1) For clients taking valproate, carbamazepine, lamotrigine or lithium, treat news of a new relationship, wish for a baby, stopping contraception or possible pregnancy as a prompt to contact the prescriber promptly. (2) Do not advise on stopping; MHRA states valproate should not be stopped without specialist advice. (3) Support the client emotionally through the PPP review and its forms. (4) For men on valproate, note the MHRA's 2024 advice is that they discuss contraception and concerns with their doctor [source: NICE CG185 PDF, update information].
• Example language (illustrative): "Thinking about a baby is a big and happy question. Your medicine is one of the things your specialist will want to plan with you, so it's worth booking that conversation soon."
• Watch for: shame or fear leading to secret stopping; unplanned pregnancy (urgent specialist contact).

Part B9. Crisis and safety planning

• Purpose: an agreed plan for early warning signs, relapse and suicidal crises [source: NICE CG185 recs 1.4.1, 1.9.4].
• Steps: (1) Map triggers, early warning signs for both mania and depression, and personal relapse signature. (2) List coping strategies, people to contact and the team's crisis numbers. (3) Add medicine-related warning signs that need urgent help (Part A). (4) Include lethal-means steps agreed with the client and prescriber: safe storage of medicines, limiting stockpiles, involving a trusted person; any change to supply quantities is the prescriber's decision [synthesis, standard lethal-means counselling]. (5) Share the plan with the team and carers with consent. (6) Review after every episode.
• Example language (illustrative): "What are the first things you or your partner notice when you're getting high? And when you're going down? Let's put those in the plan, with who to call."
• Watch for: plans that exist only on paper; an overdose risk with stored medicines; suicidal thoughts in the antiepileptic class-warning context.

Part B10. Integrating psychotherapy for bipolar disorder

• Purpose: deliver the structured psychological work NICE recommends alongside medicine [source: NICE CG185 recs 1.6.1–1.6.2, 1.7.2–1.7.4, 1.11.11–1.11.16].
• Steps: use a published, manualised bipolar-specific programme you are trained in (individual, group or family). NICE says relapse-prevention programmes should cover: information about bipolar disorder; how thoughts and behaviour affect mood; self-monitoring of mood, thoughts and behaviour; relapse risk, distress and functioning; relapse management and a staying-well plan; and problem-solving for communication and daily difficulties, tailored through individual formulation [source: NICE CG185 rec 1.7.4]. For bipolar depression, CBT, IPT or behavioural couples therapy are options, with monitoring for switching into mania [source: NICE CG185 rec 1.6.1]. The specific manuals are not drawn on here; follow the one you are trained in [uncertain].
• Example language (illustrative): "Let's keep a daily mood and sleep chart, and bring it to your psychiatrist appointments too."
• Watch for: mood charts showing early warning signs (share as agreed); therapy content that pushes the client to choose between therapy and medicine.

Part B11. Family and carer involvement

• Purpose: carers can recognise early warning signs and support safety [source: NICE CG185 recs 1.1.6–1.1.9, 1.7.2].
• Steps: (1) With consent, invite carers to a session. (2) Give or point to written and verbal information on the illness, the team and crisis help. (3) Include them in the early warning and medicine-warning-sign plan. (4) Offer or signpost family intervention and carer support programmes. (5) Consider safeguarding for children or adults in the household.
• Example language (illustrative): "Your mum noticed you sleeping less before last time. Would it help if she knew what to look out for and who to call?"
• Watch for: carers policing medicine taking; conflicts over confidentiality.

Part B12. Support through changes and after treatment ends

• Purpose: steady support whenever the prescriber changes, reduces or stops a medicine, or after discharge [source: NICE CG185 recs 1.7.1, 1.9.4 (relapse risk and plans); CQC (brand changes after discharge)].
• Steps: (1) Ask the client to tell you when the prescriber plans a change. (2) Increase early-warning-sign monitoring during and after the change. (3) Revisit the crisis plan. (4) After hospital discharge, prompt the client or carer to check with pharmacy that brand and formulation are as intended. (5) Continue relapse-prevention work.
• Example language (illustrative): "While your doctor is making this change, could we check in a bit more often on sleep and mood?"
• Watch for: relapse in the months after change; clients reading a stable period as proof they no longer need care.

5. Handling problems

The official sources set the medical warnings; almost all of the therapist-side guidance below is my own synthesis built around them and is marked as such.

• "Should I stop / take less / change it?" Do not answer the medical question. Validate the wish, explore reasons (B5), and help the client book and prepare a prescriber conversation; note NICE's warning that abrupt stopping may raise relapse risk and the MHRA instruction for valproate not to stop without specialist advice [source: NICE CG185 rec 1.10.14; NatPSA/2023/013; response = synthesis].
• Client has already stopped or cut down on their own. Stay non-judgemental; encourage same-week (sooner if symptomatic) prescriber contact; step up early-warning-sign monitoring and review the crisis plan; with consent, inform the team [synthesis].
• Possible lithium toxicity or a serious reaction in session (vomiting with tremor and unsteadiness, confusion, slurred speech; spreading rash or blistering; jaundice; severe abdominal pain). Stop the therapy agenda; arrange urgent medical assessment or call emergency services; do not leave a confused client to travel alone [source: MedlinePlus; FDA labels; response = synthesis].
• Rising hypomania with loss of insight (client feels the medicine is no longer needed). Use the pre-agreed early-warning plan and any advance statement; contact the team as agreed; involve carers as consented [source: NICE CG185 recs 1.4.1, 1.9.4; synthesis].
• Side-effect distress (weight gain, tremor, thirst, cognitive dulling, "flatness"). Take it seriously, record it, help the client report it precisely to the prescriber; do not attribute everything to the medicine or to the illness. Cognitive and thyroid effects are in the labelling and NICE monitoring, so they are medical questions too [source: NICE CG185 recs 1.10.21, 1.10.24; FDA lithium label; synthesis].
• Avoidance of blood tests (needle fear, chaotic life, shame). Problem-solve practical barriers; for needle or blood-injury fear, graded exposure is possible only with the client's consent, attention to fainting risk and coordination with the clinic [synthesis].
• Client asks you to interpret a blood result or label detail. Say plainly this is outside your role and help them write the question for the prescriber or pharmacist [synthesis].
• Unplanned pregnancy on valproate (or any mood stabiliser). Urgent specialist contact; support distress; no advice on the medicine [source: NatPSA/2023/013; CQC valproate page; synthesis].
• You disagree with the prescribing plan, or the client plays team members off against each other. Raise concerns professionally and directly with the prescriber, not through the client; present a joint message; use supervision [synthesis].
• Rupture after you raise medicine ("you sound like my psychiatrist"). Acknowledge, repair, clarify that you are not there to enforce medicine and that the decision is theirs with the prescriber [synthesis].
• Stuck therapy because of low energy or slowed thinking. Adjust pacing (shorter tasks, written summaries); pass the observation to the prescriber in case it has a medical cause [source: NICE CG185 rec 1.10.24; synthesis].
• Suicidal crisis. Standard risk assessment; current safety plan; urgent team contact; lethal-means counselling covering safe storage, reducing stockpiles and involving a trusted person, with any change to supply decided by the prescriber; overdose of lithium is a medical emergency [source: NICE CG185 rec 1.4.1; MedlinePlus; synthesis].
• Alcohol, drug use or crash dieting. Explore as usual in therapy; flag to the prescriber because hydration, salt intake and other substances affect lithium and other mood stabilisers [source: FDA lithium label; NHS; synthesis].
• Carer pressure or coercion around tablets. Work with the family on support rather than policing; check safeguarding [source: NICE CG185 rec 1.1.9; synthesis].
• Online misinformation or a client wanting "natural" alternatives. Explore what appeals; encourage telling the prescriber and pharmacist about any supplement or herbal product, since the lithium label lists interactions including St John's wort [source: FDA lithium label; synthesis].

Sources

Sources:

• NICE CG185 Bipolar disorder: assessment and management, PDF (last updated 21 Dec 2023), copy hosted by the Lampard Inquiry
• NICE CG185 guidance page
• NICE QS95 Quality statement 5: Maintaining plasma lithium levels
• MedlinePlus: Lithium toxicity
• Lithium Carbonate Capsules USP prescribing information, Camber/Hetero (rev. 10/2019)
• MHRA National Patient Safety Alert NatPSA/2023/013/MHRA: Valproate
• CQC: High risk medicines: valproate
• CQC: High risk medicines: lithium
• NHS: About lithium
• Depakote prescribing information, AbbVie (rev. 03/2026)
• Lamictal prescribing information, FDA (rev. 10/2025)
• Equetro prescribing information (Drugs.com, label rev. 10/2022)

Not drawn on: the NHS lithium side-effects page [uncertain]; the bipolar-specific psychological treatment manuals NICE refers to [uncertain]; the MHRA September 2024 valproate advice for men (known here only through NICE's summary) [uncertain].