Only a few years ago our knowledge of therapeutic options beyond lithium was scant. There were no adequately powered randomized double-blind parallel group placebo controlled studies for any treatment until 1994. When lithium produced less than optimal results, the explanation often started and ended with consideration of whether a sub-optimal result reflected a sub-optimal lithium level. This discussion has been enriched by FDA approvals now granted to eight medications for treatment of mania, two for bipolar depression and four for maintenance indications. Furthermore, data is available supporting specific psychosocial interventions and service delivery models.