excitement, accompanied by biological symptoms (increased energy, restlessness, decreased need for sleep, increased sex drive), loss of social inhibitions, irresponsible behaviour and grandiosity. Psychotic features may be present, particularly disordered thinking manifested by grandiose delusions and 'flight of ideas' (acceleration of the pattern of thought with rapid speech). Hypomania is a less dramatic and dangerous presentation but retains the features of elation or irritability and the biological symptoms, abnormalities in speech being limited to increased talkativeness and in social conduct to overfamiliarity and mild recklessness. Depressive episodes may include any of the depressive symptoms described before and may include psychotic features.
Lithium salts were known anecdotally to have beneficial psychotropic effects as long ago as the middle of the 19th century but scientific evidence of their efficacy followed a serendipitous discovery. In 1949, during a search for biologically active substances in mania, urine from manic patients was injected into guinea pigs. The animals appeared to be affected by the accompanying large amounts of urea and it was postulated that administration of urate would exacerbate manic effects. Lithium urate, which is highly soluble, was selected to conduct investigations into urate toxicity. It was found to be sedative and to protect against manic urine toxicity. Lithium carbonate was tried in manic patients, was found to be effective in the acute state and, later, to prevent recurrent attacks.3
Lithium salts are ineffective for prophylaxis of bipolar affective disorder in around 35% of patients and cause several unwanted effects. The search for alternatives has produced drugs that are more familiar as anticonvulsants, notably carbamazepine and sodium valproate, and possibly lamotrigine.
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