Unfortunately, there are few published data to guide the optimal pharmacological management of patients with bipolar spectrum disorders comorbid with SUDs, with few placebo-controlled, randomized, double-blind studies and no head-to-head trials of one agent versus another. However, there is indirect evidence to suggest picking anticonvulsants (valproic acid or carbamazepine) over lithium as first-line agents. First, substance abuse is a predictor of poor response to lithium. Second, mixed/rapid-cycling variants are more prevalent in bipolar patients with co-occurring SUDs, and these variants are more likely to respond to anticonvulsants than to lithium (Brady et al. 2003). Third, there is some evidence that valproic acid decreases heavy drinking in patients with bipolar I disorder comorbid with alcohol dependence (Salloum et al. 2005). However, lithium is still a viable option given it is the only mood stabilizer with known antisuicide properties, and it has greater antidepressant and depression prophylactic properties than the anticonvulsants (Baldessarini et al. 2006). Also, one randomized, double-blind, placebo-controlled study by Geller et al. (1998) suggested that lithium treatment of bipolar disorder with secondary SUD in adolescents was effective in reducing both affective symptoms and substance use. There is also emerging evidence that lamotrigine may be useful in this patient population by reducing both mood symptoms and substance use (Brown et al. 2006).