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Bipolar disorder often starts on childhood or adolescence but is too often poorly recognized and treated leading to the evolution of an illness with considerable disability.  While lithium is widely recognized a first line treatment option its use is declining in comparison to other less effective agents.  Here we review the major assets of lithium a drug that can prevent many aspects of illness progression as a function of increased numbers of episodes experienced.  More episodes are related to faster and more severe recurrences cognitive deficits, and treatment refractoriness. Many of the side effects of lithium, such as renal dysfunction, are based on earlier and uncontrolled literature and are over emphasized. Given lithium's unique therapeutic profile, a re-evaluation of its under-utilization is definitely indicated.