Early Intervention & Psychopharmacology in Bipolar Disorder With Robert M. Post, MD

Joseph F. Goldberg, MD, in this installment of "Brain Trust: Conversations in Psychopharmacology," sits down with Robert M. Post, MD, to discuss evolving perspectives on bipolar disorder and treatment, emphasizing early intervention and the underutilization of lithium.

There is a high prevalence of childhood-onset bipolar disorder in the United States, noted Post, with approximately a quarter of cases beginning before age 13. Earlier onset and longer delays to first treatment independently predict poorer adult outcomes. Post posited, “untreated illness is the greatest threat to our children,” arguing that concerns about overprescription have overshadowed the risks of delayed or absent care.

Goldberg and Post then discuss the duration of untreated illness as a prognostic factor analogous to other areas of medicine. Delayed initiation of effective therapy diminished treatment responsiveness. According to emerging data, lithium was the most effective when introduced after a first episode, potentially preserving cognitive function and preventing neuroprogression. He reiterated that lithium’s benefits extended beyond mood stabilization, describing it as neuroprotective and potentially disease modifying. As Post explained, “The earlier you use it, the better it is, and that it avoids neurological and bone abnormalities and disease progression.”

Despite this, lithium remains markedly underused, with far more patients receiving antidepressants despite bipolar diagnoses. Post attributed this pattern to overemphasis on lithium’s adverse effects and underrecognition of its broader benefits, including antisuicidal effects, neurogenesis, preservation of hippocampal volume, reduced all-cause mortality, and possible protection against bone fractures. Both Goldberg and Post suggested that delayed lithium initiation may create a self-fulfilling prophecy in which diminished responsiveness reinforces hesitancy to prescribe it. The discussion called for earlier, evidence-based intervention to improve long-term outcomes in bipolar disorder.