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Abstract:
Answers have been sought to the following questions of current interest: Does lithium have a prophylactic action? The claim that such an action has never been demonstrated was based on wrong assumptions, biased selection of references, and unjustified generalizations. What effect does long-term lithium treatment have on the patients' suicidal behavior? There is a close association between long-term lithium treatment, on the one hand, and lowered mortality and reduced suicidal behavior, on the other; no such association has been demonstrated for other mood stabilizers. What are the effects of lithium when given during pregnancy and lactation? The risk/benefit ratio of lithium is lower than that of the anticonvulsant drugs. Are new drugs about to oust lithium? Among contending drugs the anticonvulsants carbamazepine and valproate have attracted particular interest, but the evidence for a prophylactic action in typical bipolar disorder is weak or missing. What are the requirements of the designs of future comparative trials? In order to prove new drugs prophylactically superior to lithium, trial designs must be such that they provide valid information; some proposals are outlined here. Which drug or drugs should be used for prophylactic treatment? In addition to prophylactic superiority over lithium the new drugs must be as good as or better than lithium as regards a number of other properties, including risk/benefit ratio during pregnancy and lactation, and a close association between long-term treatment and lowered suicidal behavior. The most urgent problem at the present time is to compare in a just and balanced manner the prophylactic efficacy and other relevant properties of new drugs with those of lithium. Many manic-depressive patients' health and sometimes life depend on whether at any time they are given the best prophylactic drug available.