This review introduces the concepts that multiple actions of lithium are critical for its therapeutic effect, and that these complex effects stabilize neuronal activities, support neural plasticity, and provide neuroprotection. Three interacting systems appear most critical. (i) Modulation of neurotransmitters by lithium likely readjusts balances between excitatory and inhibitory activities, and decreased glutamatergic activity may contribute to neuroprotection.(ii) Lithium modulates signals impacting on the cytoskeleton, a dynamic system contributing to neural plasticity, at multiple levels, including glycogen synthase kinase-3, cyclic AMPdependent kinase, and protein kinase C, which may be critical for the neural plasticity involved in mood recovery and stabilization. (iii) Lithium adjusts signaling activities regulating second messengers, transcription factors, and gene expression. The outcome of these effects appears likely to result in limiting the magnitudes of fluctuations in activities, contributing to a stabilizing influence induced by lithium, and neuroprotective effects may be derived from its modulation of gene expression.Keywords: lithium; bipolar disorder; inositol; glutamate; cyclic AMP; AP-1 Recent research suggests that understanding how lithium works in the treatment of bipolar disorder requires a different way of thinking about drug action. The vast majority of drugs are designed, by evolution or synthesis, to interact with single proteins, such as a specific receptor or enzyme. However, it now seems likely that multiple sites affected by lithium contribute to its mood-stabilizing action. Thus, the therapeutic action of lithium in bipolar disorder appears not to result from an effect at a single target site, but rather as the culmination of an integrated re-orchestration of a complex concert of events which effectively adjusts neuronal activity at multiple levels. Numerous effects of lithium have been identified, and some of these may each provide a necessary, but individually insufficient, component of the therapeutic response. One of the current challenges is to distinguish those critical effects from the many known biochemical actions of lithium, many of which may have little discernible effect, contribute to side effects, or lead to toxicity. Another challenge is to integrate the multiple effects of lithium into a comprehensive picture of how neuronal function is modulated by lithium. In retrospect, considering the complexities of mood, it perhaps should not be surprising that mood stabilization by lithium is also a complex process involving multiple actions. It is also important to keep in mind that lithium has efficacy as an antimanic agent, as a prophylactic agent for mania and depression, as a relatively weak antidepressant, and as an augmenter of the effects of many antidepressants. These multiple therapeutic effects of lithium along with the complexities of mood disorders and the multiplicity of affected systems inherent in these illnesses suggest that it is unlikely that all these ...