There is insufficient evidence of benefit to offset such risk. The trials of aripiprazole were unblinded by akathisia (25%) and other side effects that can introduce rater bias. Aripiprazole was not efficacious by self-report depression measures, i.e., patients did not find it effective. In one study cited (3), efficacy was lacking in male subjects. In the meta-analysis, the number needed to treat was nine, signifying only borderline utility in this therapeutic context. The corresponding number needed to treat for lithium is four to five. The larger numbers of patients in the evidence base for atypical antipsychotic drugs, as noted by the authors, reflect the commercial interest in penetrating the depression market, but the manufacturers of these drugs have studiously avoided testing their products against lithium. These concerns about efficacy and relative efficacy were not addressed.