In the late 1960s and early 1970s, open and double-blind randomized treatment and discontinuation studies revealed highly significant effects of lithium in long-term prophylaxis. These studies followed shortly after a series of studies demonstrating lithium's acute antimanic effects, in comparison with both placebo and the existing neuroleptic treatments. High rates of response were touted and lithium clinics were established with the hope that the 60 to 80 per cent response rates revealed in the controlled clinical trials would be mirrored by clinical practice. However, over the past decade, there has been increasing recognition of the inadequacy of lithium in both the acute treatment of mania and its long-term prophylaxis even when utilized with a variety of combinations and adjunctive treatments. In the 1980s, these included largely the addition of acute typical neuroleptic treatment for mania and antidepressants for breakthrough bipolar depression.

Given this increasing cognizance of lithium's less than dramatic efficacy in many patients with bipolar illness, alternative and adjunctive treatments have been sought. Carbamazepine and valproate are now well recognized as potential mood-stabilizing anticonvulsants, and initial promising data are emerging for lamotrigine as well/1,2,,3 and 4) The data are more equivocal for gabapentin, particularly in monotherapy, although a variety of studies suggest its efficacy in bipolar illness as an adjunctive treatment.(5) These drugs are considered in Ch§pter..6..2.6.

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