RESISTANCE TO LITHIUM - WHAT ALTERNATIVES EXIST

Lithium is highly valued for the treatment of mania and depression. Re sistance may occur to one of its two main indications: firstly for the treatment of acute episodes of mania, and secondly for the prevention of relapse either of bipolar affective disorder (manic depression) or of unipolar affective disorder (recurrent depression). For the manage ment of manic episodes, alternative possibilities include neuroleptics , carbamazepine, electroconvulsive therapy (ECT) and sodium valproate. Neuroleptics are effective, but may precipitate depression. Carbamaze pine is effective either alone or as a supplement to the lithium. ECT is an impressively powerful treatment for mania. Valproate appears to be effective but more studies are desirable. Alternatives to lithium i n the prevention of relapse of recurrent affective disorders include a ntidepressants, carbamazepine and ECT. For the prevention of relapses of bipolar affective disorder antidepressants have the disadvantage of increasing the frequency of manic episodes. In unipolar disorder they are a valid alternative to lithium but with some disadvantages. Carba mazepine is effective in the prophylaxis of bipolar affective disorder and should be considered especially in patients with rapid cycling or those with psychotic features.Only open studies are available on ECT and valproate as prophylactic agents. Preliminary work has been carrie d out on verapamil, flupenthixol, clonazepam, methylene blue, clorgyli ne, clonidine, tryptophan and 5-hydroxy tryptamine.