Hostname: page-component-cd9895bd7-gvvz8 Total loading time: 0 Render date: 2024-12-27T14:34:33.111Z Has data issue: false hasContentIssue false
  • English
  • Français

Non-lithium pharmacological treatment of manic depression: a review

Published online by Cambridge University Press:  13 June 2014

Brian O'Shea
Brian O'Shea*
Affiliation:
Newcastle Hospital, Greystones, Co. Wicklow; Clinical Lecturer in Psychiatry, University College, Dublin
Get access Rights & Permissions [Opens in a new window]

Abstract

Objectives: To examine the reasons why manic-depressive patients often fail to respond to lithium and, the chief purpose of this paper, to review the present state of knowledge concerning alternative pharmacotherapies to lithium in this disorder. Method: Literature review. Findings: Lithium produces a clinically useful effect in 70-80% of cases. Factors such as non-compliance, side-effects, serum levels, and enduring psychosocial influences on the patient must be considered before treatment failure is diagnosed. Carbamazepine is the most studied alternative drug to date, and the most likely predictors of response to this agent are rapid-cycling, absence of a family history of affective disorder, mania, severe illness, and non-response to lithium. Conclusions: In view of the 20-25% of patients who do not respond to lithium, and the increased likelihood that lithium-responders may fail to respond again once the drug has been stopped for a period, further research is needed to find better and safer prophylactics against depression in bipolar disorders and to refine our knowledge of the indications for use of those already available.

Keywords

Manic-depressive disorderBipolar affective disorderSchizoaffective disorderRapid-cyclingAlternativesLithiumCarbamazepineValproateKindlingAcute treatmentProphylaxis
Type
Review Articles
Information
Irish Journal of Psychological Medicine , Volume 10 , Issue 2 , June 1993 , pp. 114 - 120
Copyright
Copyright © Cambridge University Press 1993

Access options

Get access to the full version of this content by using one of the access options below. (Log in options will check for institutional or personal access. Content may require purchase if you do not have access.)

References

1.Van Putten, T. Why do patients with manic-depressive illness stop their lithium? Compr Psychiatry 1975; 16: 179–83.CrossRefGoogle ScholarPubMed
2.Jamison, KR, Gerner, RH, Goodwin, FK. Patient and physician attitudes toward lithium: relationship to compliance. Arch Gen Psychiatry 1979; 36: 866–9.CrossRefGoogle ScholarPubMed
3.Seltzer, A, Roncari, I, Garfinkel, P. Effects of patient education on medication compliance. Can J Psychiatry 1980; 25: 638–45.CrossRefGoogle ScholarPubMed
4.Spurkland, I, Vandvik, IH. Rapid cycling depression in adolescence. Acta Psychiatr Scand 1989; 80: 60–3.CrossRefGoogle ScholarPubMed
5.Frank, E, Kupfer, DJ, Perel, JM, Cornes, C, Jarrett, DB, Mailinger, AG, et al.Three-year outcomes for maintenance therapies in recurrent depression. Arch Gen psychiatry 1990; 47: 1093–9.CrossRefGoogle ScholarPubMed
6.Post, RM. Non-lithium treatment for bipolar disorder. J Clin Psychiatry 1990; 51 (8, suppl.): 9–16.Google ScholarPubMed
7.Ballenger, JC. The clinical use of carbamazepine in affective disorders. J Clin Psychiatry 1988; 49 (4, suppl.): 13–9.Google ScholarPubMed
8.Abou-Saleh, MT, Coppen, A. Who responds to prophylactic lithium? J Affect Disord 1986; 10: 115–25.CrossRefGoogle ScholarPubMed
9.Dunner, RT, Fieve, RR. Clinical factors in lithium prophylactic failure. Arch Gen Psychiatry 1974; 30: 229–33.CrossRefGoogle Scholar
10.Misra, PC, Burns, BH. “Lithium non-responders” in a lithium clinic. Acta Psychiatr Scand 1977; 55: 32–40.CrossRefGoogle Scholar
10a.Post, RM, Leverich, GS, Altshuler, L, Mikalauskas, K. Lithium-discontinuation-induced refractoriness: preliminary observations. Am J Psychiatry 1992; 149: 1727–9.Google ScholarPubMed
11.Ballenger, JC, Post, RM. Therapeutic effects of carbamazepine in affective illness: a preliminary report. Communications in Psychopharmacology 1978; 2: 159–75.Google ScholarPubMed
12.Albright, PS, Burnham, WM. Development of a new pharmacological seizure model: effects of anticonvulsants on cortical- and amygdala-kindled seizures in the rat. Epilepsia 1980; 21: 681–9.CrossRefGoogle ScholarPubMed
13.Dalby, MA. Behavioural effects of carbamazepine. In: Penry, JK, Daly, DD, editors. Complex partial seizures and their treatment: advances in neurology, vol. 11. New York: Raven Press, 1975: 331–44.Google Scholar
14.Muller, AA, Stoll, K-D. Carbamazepine and oxcarbazepine in the treatment of manic syndromes: studies in Germany. In: Emrich, HM, Okuma, T, Muller, AA, editors. Anticonvulsants in affective disorders. Amsterdam: Excerpta Medica, 1984: 134–47.Google Scholar
15.Emrich, HM, Dose, M, von Zerssen, D. The use of sodium valproate, carbamazepine and oxcarbazepine in patients with affective disorders. J Affect Disord 1985; 8: 243–50.CrossRefGoogle ScholarPubMed
16.Brown, D, Silverstone, T, Cookson, J. Carbamazepine compared to haloperidol in acute mania. Int Clin Psychopharmacol 1989; 4: 229–38.CrossRefGoogle ScholarPubMed
17.Emrich, HM. Studies with oxcarbazepine (Trileptal) in acute mania. Int Clin Psychopharmacol 1990; 5 (1, suppl.): 83–8.Google Scholar
18.Kramlinger, KG, Post, RM. Adding lithium carbonate to carbamazepine: antimanic efficacy in treatment resistant mania. Acta Psychiatr Scand 1989; 79: 378–85.CrossRefGoogle ScholarPubMed
19.Kramlinger, KG, Post, RM. The addition of lithium carbonate to carbamazepine: antidepressant efficacy in treatment-resistant depression. Arch Gen Psychiatry 1989; 46: 794–800.Google ScholarPubMed
20.Post, RM, Uhde, TW, Roy-Byrne, PP, Joffe, RT. Correlates of antimanic responses to carbamazepine. Psychiatry Res 1987; 21: 71–83.CrossRefGoogle ScholarPubMed
21.Okuma, T, Yamashita, I, Takahashi, R, Itoh, H, Otsuki, S, Watanabe, S, et al.Comparison of the antimanic efficacy of carbamazepine and lithium carbonate by double-blind controlled study. Pharmacopsychiatry 1990; 23: 143–50.CrossRefGoogle ScholarPubMed
22.Lusznat, RM, Murphy, DP, Nunn, CMH. Carbamazepine vs lithium in the treatment and prophylaxis of mania. Br J Psychiatry 1988; 153: 198–204.CrossRefGoogle ScholarPubMed
23.Ballenger, JC, Post, RM. Carbamazepine in manic-depressive illness: a new treatment. Am J Psychiatry 1980; 137: 782–90.Google ScholarPubMed
24.Post, RM, Uhde, TW, Roy-Byrne, PP, Joffe, RT. Antidepressant effects of carbamazepine. Am J Psychiatry 1986; 143: 29–34.Google ScholarPubMed
25.Post, RM. Time course of clinical effects of carbamazepine: implications for mechanisms of action. J Clin Psychiatry 1988; 49 (4 suppl.): 35–46.Google ScholarPubMed
26.Lenzi, A, Lazzerini, F, Grossi, E, Massimetti, G, Placidi, GF. Use of carbamazepine in acute psychosis: a controlled study. J Int Med Res 1986; 14: 78–84.CrossRefGoogle ScholarPubMed
27.Placidi, GF, Lenzi, A, Lazzerini, F, Cassano, GB, Akiskal, HS. The comparative efficacy and safety of carbamazepine versus lithium: a randomized, double-bling 3-year trial in 83 patients. J Clin Psychiatry 1986; 47: 490–4.Google Scholar
28.Joyce, PR. Carbamazepine in rapid cycling bipolar affective disorder. Int Clin Psychopharmacol 1988; 3: 123–9.CrossRefGoogle ScholarPubMed
29.Post, RM, Uhde, TW, Ballenger, JC, Squillace, KM. Prophylactic efficacy of carbamazepine in manic-depressive illness. Am J Psychiatry 1983; 140: 1602–4.Google ScholarPubMed
30.Post, RM, Leverich, GS, Rosoff, AS, Altshuler, LL. Carbamazepine prophylaxis in refractory affective disorders: a focus on long-term follow-up. J Clin Psychopharmacol 1990; 10: 318–27.CrossRefGoogle ScholarPubMed
31.Okuma, T, Kishimoto, A, Inoue, K. Anti-manic and prophylactic effects of carbamazepine (Tegretol) on manic depressive psychosis. A preliminary report. Folia Psychiatrica Japonica 1973; 27: 283–97.Google ScholarPubMed
32.Kravitz, HM, Fawcett, J. Carbamazepine in the treatment of affective disorders. Medical Science Research 1987; 15: 1–8.Google Scholar
33.Lipinski, JF, Pope, HG. Possible synergistic action between carbamazepine and lithium carbonate in the treatment of three acutely manic patients. Am J Psychiatry 1982; 139: 948–9.Google ScholarPubMed
34.Keisling, R. Carbamazepine and lithium carbonate in the treatment of refractory affective disorders. Arch Gen Psychiatry 1983; 40: 223.CrossRefGoogle ScholarPubMed
35.Moss, GR, James, CR. Carbamazepine and lithium carbonate synergism in mania. Arch Gen Psychiatry 1983; 40: 588–9.CrossRefGoogle ScholarPubMed
36.Shukla, S, Cook, BL, Miller, MG. Lithium-carbamazepine versus lithium-neuroleptic prophylaxis in bipolar illness. J Affect Disord 1985; 9: 219–22.CrossRefGoogle ScholarPubMed
37.Nolen, WA. Carbamazepine, a possible adjunct or alternative to lithium in bipolar disorder. Acta Psychiatr Scand 1983; 67: 218–25.CrossRefGoogle ScholarPubMed
38.Fawcett, J, Kravitz, HM. The long-term management of bipolar disorders with lithium, carbamazepine, and antidepressants. J Clin Psychiatry 1985; 46: 58–60.Google ScholarPubMed
39.Lovett, L, Watkins, SE, Shaw, DM. The use of alternative drug therapy in nine patients with recurrent affective disorder resistant to conventional prophylaxis. Biol Psychiatry 1986; 21: 1344–7.CrossRefGoogle ScholarPubMed
40.Nurnberg, HG, Finkel, JA. Carbamazepine in bipolar-depressed disorder complicated by tricyclic antidepressant switching [Case report]. J Clin Psychiatry 1985; 46: 487–88.Google ScholarPubMed
41.Laird, LK, Knox, EP. The use of carbamazepine and lithium in controlling a case of chronic rapid cycling. Pharmacotherapy 1987; 7: 130–2.CrossRefGoogle ScholarPubMed
42.Cabrere, J, Albreacht, J, Muller-Oerlinghausen B. Kombinierte rezidiv-prophylaktische behandlung der manisch-depressiven erkrankung mit lithium und Carbamazepin oder oxcarbazepin. Nervenarzt 1987; 58: 345–49.Google Scholar
43.Glue, P. Rapid cycling affective disorders in the mentally retarded. Biol Psychiatry 1989; 26: 250–6.CrossRefGoogle ScholarPubMed
44.Forrest, DV. Bipolar illness after right hemispherectomy. Arch Gen Psychiatry 1982; 39: 817–9.CrossRefGoogle ScholarPubMed
45.Gross, RA, Herridge, P. A manic-like illness associated with right frontal arteriovenous malformation. J Clin Psychiatry 1988; 49: 119–20.Google Scholar
46.Stewart, JT, Hemsath, RH. Bipolar illness following traumatic brain injury: treatment with lithium and carbamazepine. J Clin Psychiatry 1988; 49: 74–5.Google ScholarPubMed
47.Arana, GW, Santos, AB, Knox, EP, Ballenger, JC. Refractory rapid cycling unipolar depression responds to lithium and carbamazepine treatment [Letter]. J Clin Psychiatry 1989; 50: 356–7.Google ScholarPubMed
48.Stromgren, LS. The combination of lithium and carbamazepine in treatment and prevention of manic-depressive disorder: a review and a case report. Compr Psychiatry 1990; 31: 261–5.CrossRefGoogle ScholarPubMed
49.DiCostanzo, E, Schifano, F. Lithium alone or in combination for the treatment of rapid-cycling bipolar affective disorder. Acta Psychiatr Scand 1991; 83: 456–9.CrossRefGoogle Scholar
50.McKeon, P, Manley, P, Swanwick, G. Manic-depressive illness – II: treatment outcome in bipolar disorder subtypes. Irish Journal of Psychological Medicine 1992; 9: 9–12.CrossRefGoogle Scholar
51.Ghose, K. Effect of carbamazepine in polyuria associated with lithium therapy. Pharmacopsychiatry 1978; 11: 241–5.CrossRefGoogle ScholarPubMed
52.Chaudhry, RP, Waters, BGH. Lithium and carbamazepine interaction: possible neurotoxicity. J Clin Psychiatry 1983; 44: 30–1.Google ScholarPubMed
53.Shukla, S, Godwin, C, Long, L, Miller, M. Lithium-carbamazepine neurotoxicity and risk factors. Am J Psychiatry 1984; 141: 1604–5.Google ScholarPubMed
54.Price, WA, Zimmer, B. Lithium-carbamazepine neurotoxicity in the elderly [Letter]. J Am Geriatr Soc 1985; 12: 876–7.CrossRefGoogle ScholarPubMed
55.Post, RM, Kramilinger, K, Uhde, TW. Carbamazepine-lithium combination: clinical efficacy and side effects. International Drug Therapy Newsletter 1987; 22(2): 5–8.Google Scholar
56.McGinness, J, Kishimoto, A, Hollister, LE. Avoiding neurotoxicity with lithium-carbamazepine combinations. Psychopharmacol Bull 1990; 26: 181–4.Google ScholarPubMed
57.Gallicchio, VS, Hulette, BC. In vitro effect of lithium on carbamazepine induced inhibition of murine and human bone marrow derived granulocyte-macrophage and megakaryocyte progenitor stem cells. Proc Soc Exp Biol Med 1989; 190: 109–16.CrossRefGoogle ScholarPubMed
58.Pellock, JM. Carbamazepine side effects in children and adults. Epilepsia 1987; 28: S64–70.CrossRefGoogle ScholarPubMed
58a.Trimble, M. Discussion. J Clin Psychiatry 1988; 49(4 suppl.): 21.Google Scholar
59.Jefferson, JW, Greist, JH. Lithium carbonate and carbamazepine side effects. In: Hales, RE, Frances, Aj, editors. American Psychiatric Association Annual Review. Vol 6. Washington, DC: American Psychiatric Press, 1987: 746–80.Google Scholar
60.Kramlinger, KG, Post, RM. Addition of lithium carbonate to carbamazepine: hematological and thyroid effects. Am J Psychaitry 1990; 147: 615–20.Google ScholarPubMed
60a.Pippenger, CE. Clinically significant carbamazepine drug interactions: an overview. Epilepsia 1987; 28 (3 suppl): 71–6.CrossRefGoogle ScholarPubMed
60b.Rawlins, MD, Collste, P, Bertillsson, L, Palmer, L. Distribution and elimination kinetics of carbamazepine in man. Eur J Clin Pharmacol 1975; 8: 91–6.CrossRefGoogle ScholarPubMed
60c.Baciewicz, AM. Carbamazepine drug interactions. Therapeutic Drug Monitoring 1986; 8: 305–17.CrossRefGoogle ScholarPubMed
60d.Kutt, H. Interactions between anticonvulsants and other commonly prescribed drugs. Epilepsia 1984; 25 (2 suppl): 118–31.CrossRefGoogle ScholarPubMed
61.Post, RM, Uhde, Tw, Wolff, EA. Profile of clinical efficacy and side effects of carbamazepine in psychiatric illness: relationship to blood and CSF levels of carbamazepine and its – 10, 11-epoxide metabolite. Acta Psychiatr Scand 1984; 69 (313 suppl): 104–20.CrossRefGoogle Scholar
61a.Mitchell, PB, Parker, GB. Treatment of bipolar disorder. Med J Aust 1991; 155: 488–93.CrossRefGoogle ScholarPubMed
61b.Chouinard, G, Young, SN, Annable, L. Antimanic effect of clonazepam. Biol Psychiatry 1983; 18: 451–86.Google ScholarPubMed
62.Post, RM. Mechanisms of action of carbamazepine and related anticonvulsants in affective illness. In: Meltzer, H, Bunney, WEJ, editors. Psychopharmacology: a generation of progress. New York: Ravan Press, 1987: 567–76.Google Scholar
63.Post, RM, Uhde, TW. Anticonvulsants in non-epileptic psychosis. In: Trimble, MR, Bolwig, TG, editors. Aspects of epilepsy and psychiatry. London: John Wiley & Sons, 1986: 177–212.Google Scholar
64.Pratt, J, Jenner, P, Johnson, AL, Shorvon, SD, Reynolds, EH. Anticonvulsant drugs alter plasma tryptophan concentrations in epileptic patients: implications for antiepileptic action and mental function. J Neurol Neurosurg Psychiatry 1984; 47: 1131–3.CrossRefGoogle ScholarPubMed
65.Gold, PW, Robertson, GL, Ballenger, JC, Kay, W, Chen, J, Rubinow, DR, et al.Carbamazepine reduces the sensitivity of the plasma arginine vasopressin response to osmotic stimulation. J Clin Endocrinol Metab 1983; 57: 952–7.CrossRefGoogle ScholarPubMed
66.Olpe, H, Jones, R. The action of anticonvulsant drugs on the firing of locus coeruleus neurons: selective, activating effect of carbamazepine. Eur J Pharmacol 1983; 91: 107–10.CrossRefGoogle ScholarPubMed
67.Rubinow, DR, Post, RM, Gold, PW, Ballenger, JC, Wolff, EA. The relationship between Cortisol and clinical phenomenology of affective illness. In: Post, RM, Ballenger, JC, editors. Neurobiology of mood disorders. Baltimore: Williams & Wilkins, 1984: 271–89.Google Scholar
68.Kelleher, MJ. Carbamazepine in mood disorder – a practical guide. Dublin: AWARE Publications, 1992.Google Scholar
68a.Dam, M, Jakobsen, K. Oxcarbazepine in patients hypersensitive to carbamazepine. Acta Neurol Scand 1984; 70: 223.Google Scholar
68b.Houtkooper, MA, Lammertsma, A, Meyer, JWA, Goedhart, DM, Meinardi, H, van Oorschot, CAEH, et al.Oxcarbazepine (GP 47.680): a possible alternative to carbamazepine? Epilepsia 1987; 28: 693–8.CrossRefGoogle ScholarPubMed
69.Calabrese, JR, Delucchi, GA. Phenomenology of rapid cycling manic depression and its treatment with valproate. J Clin Psychiatry 1989; 50 (3 Suppl): 30–4.Google ScholarPubMed
70.Shaw, DM. Drug alternatives to lithium in manic-depressive disorders. Drugs 1988; 36: 249–55.CrossRefGoogle ScholarPubMed
71.Calabrese, JR, Delucchi, GA. Spectrum of efficacy of valproate in 55 patients with rapid-cycling bipolar disorder. Am J Psychiatry 1990; 147: 431–34.Google ScholarPubMed
71a. McElroy, SL, Keck, PE Jr, Pope, HG Jr, Hudson, JI. Valproate in the treatment of rapid-cycling bipolar disorder. J Clin Psychopharmacol 1988; 8: 275–9.CrossRefGoogle ScholarPubMed
71b.McElroy, SI, Keck, PE Jr, Pope, HG Jr, Hudson, JI. Valproate in psychiatric disorders: literature review and clinical guidelines. J Clin Psychiatry 1990; 50 (suppl): 23–9.Google Scholar
72.Kubanek, JL, Rowell, RC. The use of dilantin in the treatment of psychotic patients unresponsive to other treatment. Diseases of the Nervous System 1946; 7: 1–4.Google ScholarPubMed
73.Aronson, TA, Shukla, S, Hirschowitz, J. Clonazepam treatment for five lithium-refractory patients with bipolar disorder. Am J Psychiatry 1989; 146: 77–80.Google ScholarPubMed
73a.Rackensperger, W, Fritsch, W, Schwarz, D, Stutte, KH, von Zerssen, D. Wirkung des beta-rezeptoren-blockers propranolol auf manien. Archives und Psychiatrica Nervenkreiten 1976; 222: 223–43.CrossRefGoogle Scholar
73b.Vassout, A, Delini-Stula, A. Effects of ß-bloquers (propranolol et exprenolol) et du diazepam sur differents modeles d'aggressivite chez le rat. Journal of Pharmacology 1977; 8: 5–14.Google Scholar
73c.Bernasconi, R. The GABA hypothesis of affective illness – influence of clinically effective antimanic drugs on GABA turnover. In: Emrich, HM, Okuma, T, Muller, AA, editors. Basic mechanisms in the action of lithium. Amsterdam: Excerpta Medica, 1982: 183–92.Google Scholar
74.Bauer, MS, Whybrow, PC. Rapid cycling bipolar affective disorder. II. Treatment of refractory rapid cycling with high-dose levothyroxine: a preliminary study. Arch Gen Psychiatry 1990; 47: 435–40.CrossRefGoogle ScholarPubMed
75.Prien, RF, Klett, CF, Caffey, EM. Lithium carbonate and Imipramine in prevention of affective episodes. Arch Gen Psychiatry 1973; 29: 420–5.CrossRefGoogle ScholarPubMed
76.Prien, RF, Gelenberg, AJ. Alternatives to lithium for preventive treatment of bipolar disorder. Am J Psychiatry 1989; 146: 840–8.Google ScholarPubMed
77.Davidson, J, Raft, D. The use of phenelzine in continuation therapy. Neuropsychobiology 1984; 11: 191–4.CrossRefGoogle ScholarPubMed
78.Dunner, DL, Clayton, PJ. Drug treatment of bipolar disorder. In: Meitzer, HY, editor. Psychopharmacology: the third generation of progress. New York: Raven Press, 1987.Google Scholar
79.Wehr, TA, Goodwin, FK. Rapid cycling in manic-depressives induced by tricyclic antidepressants. Arch Gen Psychiatry 1979; 36: 555–9.CrossRefGoogle ScholarPubMed
80.Ahlfors, UG, Baastrup, PC, Denckler, SJ, Elgen, K. Linjaerde, O, et al.Flupenthixol deconoate in recurrent manic depressive illness: a comparison with lithium. Acta Psychiatr Scand 1986; 64: 226–37.CrossRefGoogle Scholar
81.Naylor, GL, Martin, B, Hopwood, SE, Watson, Y. A two year double-blind crossover trial of the prophylactic effect of methylene blue in manic-depressive psychosis. Biol Psychiatry 1986; 21: 915–20.CrossRefGoogle ScholarPubMed
82.Hoschel, C, Kozeny, J. Verapamil in affective disorders: a controlled, double-blind study. Biol Psychiatry 1989; 25: 128–40.CrossRefGoogle Scholar
82a.Hullett, FJ, Potkin, SG, Levy, AB, Ciasca, R. Depression associated with nifedipine-induced calcium channel blockers. Am J Psychiatry 1988; 145: 1277–9.Google Scholar
83.Giannini, AJ, Loiselle, RH, Price, WA, Giannini, MC. Comparison of antimanic efficacy of Clonidine and verapamil. Journal of Clinical Pharmacology 1985; 307–8.CrossRefGoogle ScholarPubMed
84.Giannini, AJ, Pascarzi, GA, Loiselle, RH, Price, WA, Giannini, MC. Lithium in the treatment of mania. Am J Psychiatry 1986; 143: 1608–9.Google ScholarPubMed
85.Black, DW, Winokur, G, Nasrallah, A. Treatment of mania: a naturalistic study of electroconvulsive therapy versus lithium in 438 patients. J Clin Psychiatry 1987; 48: 132–9.Google Scholar
86.O'Shea, B. Antidepressants: uses and attitudes among consultant psychiatrists. Irish Journal of Psychological Medicine 1991; 8: 167–70.CrossRefGoogle Scholar
87.Post, RM, Uhde, TW, Putnam, FW, Ballenger, JC, Berrettini, WH. Kindling and carbamazepine in affective illness. J Nerv Ment Dis 1982; 170: 717–31.CrossRefGoogle ScholarPubMed
88.Joffe, RT, Post, RM, Uhde, TW. Effect of carbamazepine on body weight in affectively ill patients. J Clin Psychiatry 1986; 47: 313–4.Google ScholarPubMed
89.Coxhead, N, Silverstone, T, Cookson, J. Carbamazepine versus lithium in the prophylaxis of bipolar affective disorder. Acta Psychiatr Scand 1992; 85: 114–8.CrossRefGoogle ScholarPubMed
90.O'Shea, B, Falvey, J. A Textbook of Psychological Medicine. 2nd Ed. Dublin: EHB Print, 1988: 349.Google Scholar