Personalized treatment of bipolar I or II disorder that includes lithium does not appear to be superior to individualized care using other evidence-based treatments. The overall remission rate was 27% in the 6-month comparison by Nierenberg et al. (p. 102), with no difference in remission or adverse events between the lithium and nonlithium groups. Outcomes for lithium may be better with higher blood levels, as the average lithium blood level in this trial was below the therapeutic range. Lithium treatment does decrease use of second-generation antipsychotics. The editorial by Dunlop et al. (p. 9) draws attention to an ecologically important outcome measure, the number of “necessary clinical adjustments.”

An emerging approach to treating comorbid mood and substance use disorders is simultaneous pharmacologic treatment of each. Patients with both types of disorders often have severe illness that is more difficult to manage than either one alone. Treatment for the mood disorder often improves mood symptoms but not alcohol or drug use. Pettinati et al. (p. 23) point to FDA-approved medications specifically for alcohol and opiate dependence. Their previous study of sertraline plus naltrexone, in addition to cognitive-behavioral therapy, showed greater effects on both depression and alcohol use from the combined medications than from either alone (Am J Psychiatry 2010; 167:668). Co-occurring bipolar and substance use disorders are difficult to treat; adding a medication for the substance disorder to a bipolar disorder treatment does not consistently decrease use. However, treating the substance use disorder is especially indicated for patients with an early onset of bipolar disorder.

Awarding a chance to receive a prize in return for each stimulant-free urine sample reduces stimulant use in outpatients with serious mental illness and stimulant dependence. In a 3-month study of 176 patients with amphetamine, methamphetamine, or cocaine dependence, McDonell et al. (CME, p. 94) calculated the cost of urine testing and reinforcers to be $864 for each participant abstinent for 8 or more weeks, but the patients had only 14 total days of hospitalization, compared to 152 days for patients in a control condition. Stimulant abstinence is associated with improvements in additional outcomes, such as alcohol use, use of injected drugs, and psychiatric symptoms. Abstinence may persist for several months after the intervention ends. Editorialist Weiss (p. 6) applauds the integration of addiction treatment and psychiatry and emphasizes the potential financial advantage for payers, such as the Veterans Health Administration, which recently approved contingency management for drug dependence.