2009 is the 60th anniversary of the MJA publication by John Cade of the effectiveness of Lithium in mania. This report marked the beginning of the psychopharmacology revolution. Lithium treatment was dogged with questions of safety overshadowed by the discovery of Chlorpromazine and met with scepticism. The establishment of its efficacy and safety took 20 years.

The demonstration that Lithium could prevent episode recurrences, not only of mania, but also depression ushering in the concept of the "mood stabilizer" of which Lithium was the prototype and the gold standard against which newer drugs, anticonvulsants and antipsychotics have been compared. The evidence base for efficacy applies predominantly to the treatment of bipolar 1 disorder. It is most extensive for episodes of mania with similar effect sizes for Lithium, anticonvulsants and atypical antipsychotics, compared to placebo.

Studies in the maintenance phase of bipolar disorder show differing drug profiles in preventing episodes of mania and depression, suggesting they may have complementary roles in long term treatment. Treatment of episodes of bipolar depression remain the least studied and the most challenging. Antidepressants are still widely used, however, their benefit-to-risk remains controversial. Both acute and long term safety and efficacy data should be considered when selecting first line treatment. Syndromal remission should be the goal in the treatment of acute episodes. Sub-syndromal symptoms, particularly depression, occur in a high percentage of patients between episodes, impacting on functional recovery and increasing the risk of recurrence. Psychotherapeutic interventions have emerged as significant adjunctive treatment in improving mood stabilization and functional outcome. Lithium remains a firstline treatment and shows unique antisuicidal properties.