Relationship between budget deficits and tax cutting

Table of Contents Introduction Current situation on budget deficits The problem Economic explanation of the problem and reasons Economic explanation of the solution Conclusion Works Cited Introduction A budget deficit comes about when the government’s spending exceeds government revenue. That is, income from taxes and other sources are not adequate to meet the expenditure. In most cases, budget deficit calls for either external or internal borrowing or increase of taxes. On the other hand, tax cuts refer to reduction in the rate of taxes. Tax cuts impact the economy by reducing the real income of the government while increasing the real income of the taxpayers.Advertising We will write a custom assessment sample on Relationship between budget deficits and tax cutting specifically for you for only $16.05 $11/page Learn More Current situation on budget deficits In the United States, the famous Bush Tax Cuts were introduced in 2001 and 2003. Thes e cuts were supposed to expire in 2010 but President Obama agreed to extend them to the next two years up to 2012. His reasons behind tax cutting were to encourage investors and enhance creation of employment. Within the first four years of the tax cut, revenues had gone down by around $474 billion with the overall decrease being $2.4 trillion to date (CBO 18). President Obama has also assented tax-cutting laws, including the American Recovery and Reinvestment Act (AARA) and the Recovery Act, which is worth $243 billion by the year 2012. These are meant to benefit each American household and reduce family’s income tax payments by $800. The December 2010 taxes deal â€Å"Tax Relief, Unemployment Insurance Reauthorization, and Job Creation Act of 2010, is said to cost $400 billion† (CBO 20). All these cuts put together, are going to amount to $654 billion in 2011 and 2012. The difference between Obama’s tax cuts and Bush’s is that, Obama mostly targeted the middle class and even distribution of wealth, while bush was skewed to the few rich. Secondly, Obama’s tax cuts are temporary and most likely to expire next year. The problem In august 2011, the monthly deficit was $44 higher than the amount recorded last year the same time. In total, the government spent $303 billion and gathered $169 billion. The deficit skyrocketed to $1.41 trillion in the 2009 financial year. According to the 2012 budget of the United States federal government issued on February 14, 2011, by President Obama, the total expenditure is going to be $2.627 while the total revenue collected will amount to an estimated $3.729 trillion. This implies that there is an estimated $1.101 trillion budget deficit in 2012 (CBO 115). As indicated by statistics in the current situation, tax cuts have led to a reduction in government revenue, whether permanent or temporary. Some economists argue that the tax cuts initiated by Bush were meant to benefit the high-income hous eholds by far. He allegedly gave tax cuts to the rich along with tax breaks, although others claim that the benefits extended to both the middle and lower income earners.Advertising Looking for assessment on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More The10 year’s tax cut decreased the revenues because they led to the rich paying fewer taxes, yet they should make the biggest contributions to government revenue. The tax cuts did not benefit middle and low class, and thus provision for services called for greater spending. Bush did not look at the long-term effects of the tax cut. Some look at it as a case where the tax cuts could not â€Å"pay for themselves.† Although, the policy could have worked in the first quarters, in the overall, it left the economy with 9.1% unemployment and fall in revenues. Economic explanation of the problem and reasons When Bush came up with the tax cuts in 2001 and 2003, perh aps he was being influenced by supply-side economics. According to supply-side economics, tax reductions can be used to stimulate investments and create employment. However, this effect cannot be achieved without balancing the decrease in revenue and reduction in government spending. This is because a tax cut leads to a fall in real income for the government, but a rise in real income to those whose tax has been cut. When investors experience increased real incomes, they lead to increase in investments, and thus creating more jobs. If the real income of consumers increase, they are more likely to spend and thus stimulate small and medium enterprises and the economy in general. However, this economic phenomenon is determined by behavior of taxpayers (business or consumers) (CBO 35). If this concept does not work, then investments and growth expected will not materialize. If the government accommodates tax cuts, it must initiate measures to reduce government services and spending in g eneral and enhance its capacity to redistribute wealth to avoid income inequalities. Tax cuts cause budget deficit when governments spending does not reduce to compensate the effect of lost revenue. They also cause deficit if the tax cut benefits the upper class wealth owners and thus real incomes of consumers do not increase to stimulate investments leading to employment and growth of output. This leads to increased spending on unemployment benefits, heath care, and Medicaid, therefore leading to deficits. Additionally, implementation of tax cut should be as progressive as possible to ensure that tax savings do not go to rich investors or executives who might not use it to create employment. Economic explanation of the solution To address budget deficit, various fiscal methods can be adopted. First, the government can raise taxes to increase their revenues to match their expenditure. Secondly, the government can reduce its public spending especially on capital projects that do not have short-term effect on economic growth.Advertising We will write a custom assessment sample on Relationship between budget deficits and tax cutting specifically for you for only $16.05 $11/page Learn More The government can as well reduce expenditure on services like freezing non-defense optional spending, capping subsidies for instance in some sectors like farming, reducing Medicaid rate by around 5%, substituting Medicare drug benefit with drug card, and sinking entitlement on spending by 2 or 3 percent through target of fraud, waste, and exploitation(CBO 135). The worst available option is to borrow, because the interest rates get sour in deficits. In addition, this further accumulates public debt hence possibility of the economy falling. Increasing taxes is the most appropriate way to curb budget deficit due to its ability to increase government’s income and at the same time reduce income inequalities. Income inequalities hinder many econo mic tools that are used to run the economy, both fiscal and monetary. When an equitable tax system is used, it achieves both the objectives of increasing investments, employment, and output. The raise in taxes should be realistic to avoid scaring off investors or disadvantaging a section of the society especially low-income earners who influence government spending. The best solution is to have a mixture of both increase in taxes and reduced government expenditure. Conclusion Tax cuts undoubtedly affect budget deficit in a big way especially due to revenue. If tax cuts are meant to stimulate growth, the government should majorly focus on the behavior of the taxpayer and economic climate like inflation, otherwise it could lead to large deficits. The government should target a certain group of the public that is more likely to compensate revenue lost in form of taxes. It is also important to avoid or carefully examine long-term effects of tax cuts. To get a solution to budget deficits , it is important to instill a mix of reducing government expenditure and equitable rise in taxes. Works Cited Congress of the United States: Congressional Budget Office (CBO). Reducing the deficit: spending and revenue options. 2011- September 30, 2011. https://www.cbo.gov/ftpdocs/120xx/doc12085/03-10%20ReducingTheDeficit.pdfAdvertising Looking for assessment on business economics? Let's see if we can help you! Get your first paper with 15% OFF Learn More This assessment on Relationship between budget deficits and tax cutting was written and submitted by user Axel Mcguire to help you with your own studies. You are free to use it for research and reference purposes in order to write your own paper; however, you must cite it accordingly. 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Marketing Mix Paper

Marketing Mix Paper Marketing Mix PAGE 1IntroductionIn marketing there are many essential tools that aide in creating successful marketing strategies, however a solid understanding of the most important set of tools is the marketing mix. By use of example of a successful company the marketing mix will be further explored through discussion of the Four P's, analyzing the impacts that the marketing mix may have on the overall marketing strategy, in addition to exploring the implementation of each of the Four P's.Starbucks CoffeeStarbucks Coffee located in Seattle, Washington was founded in 1971 at the well known Pikes Place Market (Starbucks Coffee, 2007). The company is known around the world and can be spotted on numerous streets by their green store signs and creative circular logo offering delectable rich roasted coffee creations. As the company grew so did the Starbucks product line, introducing sweets to accompany beverages, essential equipment for at home brewing, groovy sounds on CD that are play ed in store and a nice selection of gifts that any coffee drinker would enjoy receiving.Deutsch: Zusammenhang zwischen Marketing-Mix, 4 Ps...As a top global brand and world leader in lipsticks, fragrances and anti-aging skincare, Avon continues to revolutionize the beauty industry by launching innovative, first-to-market products using Avon-patented technology. In addition, our growth vision includes expanding into new geographies, bringing our high-quality products and personalized service to more women. Throughout the years, Avon has always been a legacy, for brand name product, and the reputation to earn a responsible corporate pay. The founder, David H. McConnell, built this company on solid values and principles with a longstanding commitment to the highest standards of ethics and integrity. As a result, Avon has been consistently recognized as one of the most admired companies and one of the best companies to work for, with a highly diverse...

Why tell the truth Essay Example | Topics and Well Written Essays - 250 words

Why tell the truth - Essay Example In the case of lying, a public speaker claiming that all those who suffer right now are being punished for their sins. This is lying since Job has also undergone adverse circumstances without having sinned. People are made to believe by the speaker that â€Å"contract faith† exists and not God’s will for his people. Bearing false witness is committed by a public speaker who tells his listeners that he was there when the crime happened when in fact he fabricated a story. This is often committed by people who are being paid to create a false witness. 2. The article â€Å"Why Tell the Truth† by Joseph Stowell explains clearly by citing biblical passages that telling a lie is definitely a violation of God’s will. Truth is fixed and should not be relative depending upon the culture or environment. The bible qualifies a righteous man by â€Å" The one whose walk is blameless, who does what is righteous, who speaks the  truth  from their heart â€Å" ( Psalm 15: 2, NIV). Also, telling the truth has repercussions as Proverbs 14 : 25 says â€Å" A   truthful witness saves lives, but a false witness is deceitful†. Lying is dangerous and can inflict misery upon the lives of both the liar and the victim. 3. Plagiarism is wrong because it constitutes stealing another person’s idea or work. Back in the olden days intellectual property did not exist then. People often covet material things or possessions that do not belong to them like other people’s spouse. Today, knowledge, information and data can be considered as commodities or goods that have a certain value in them. Plagiarism is another person’s creation similar to an artist’s paintings or a composer’s music sheet. It was explicitly commanded in the Bible that people should not steal and this refers to everything that a man owns. In Ephesians 4:28 ( ESV) it is stated that

Thesis amendments Example | Topics and Well Written Essays - 2000 words

Amendments - Thesis Example nglish is focused primarily on just learning the language without any reference to or intention of learning cultures associated with English, even if some cultural scenarios are included in the textbooks analysed. There also appears to be an inconsistency in the objective of the KSA Department of Education pertinent to English teaching in Saudi Arabia. Finally, it has been found out that studying English does not affect the learners’ appreciation of the Arabic culture. These results have been arrived at via the application of discourse analysis, which is the research methodology used, to some of the books used in teaching English in Saudi Arabia. The books that have been subjected to discourse analysis are Say It In English Series (SIIE) and English for Saudi Arabia Series (EFS). No other person’s work has been used without due acknowledgement in the main text of the thesis. This thesis has not been submitted for the award of any degree or diploma in any other tertiary institution. I am heartily thankful to my supervisor, Dr. Howard Nicholas, whose continuous support and encouragement helped me a lot to acquire the basic skills of writing my thesis. Also I am grateful for his unlimited help even in weekends. This study examines the English cultural elements presented in two Saudi English learning textbook series. Chapter one introduces the general background to teaching and learning English in Saudi Arabia, the cultural challenges this presents. It then identifies the main problem involved and the states the purpose of the study as well. Chapter two develops and discusses some arguments using secondary research regarding the integration of English and its culture and general views of how the foreign culture can be introduced. The historical background gives an overview of the important relationship between language and culture, discusses the rationale for and measures taken for providing protection to the native culture, details the Saudi experience, and

Ecological Footprint Analysis Article Example | Topics and Well Written Essays - 750 words

Ecological Footprint Analysis - Article Example Further on the most popular methodologies of environmental impact measurement, such as the Ecological Footprint Analysis (EFA) and the Carbon Footprint are considered. The Ecological Footprint Analysis (EFA) first occurred in 1996 and was focused on measurements of consumed natural resources. This concept is defined in the following way: â€Å"the total area of biologically productive land and water required by an entity to sustain its current consumption levels† (Haque 2005). EFA is a helpful tool defining the magnitude of consumption. Every nation has its own measurement of EFA. For example, Canadian footprint is 7.8 ha per capita (Schmidt 2002, p. N/A). Therefore, in average, every citizen of the planet consumes 2 hectares of earth. There are many benefits of EFA as the measurement method of ecological consumption. This measurement enables nations to develop patterns of consumption. Moreover, the EFA serves as a factor of sustainability influencing policy changes and practi ces. Nevertheless, there are also some drawbacks in EFA. This measurement is a static and consumption is presented as a static phenomenon measured at a certain point of time. Each person can consume less goods and services and in such a way, it is not a realistic way to appropriate and consumption measurement of ecological resources. There are many factors missed in measurement of EFA, such as toxic waste production and assimilation, but much attention is paid only to environmental impact of the consumption. Very often EFA is beneficial, because it is very quick and does not require numerous attributes to the sample. There are many impurities related to gas, crucible and accelerator. In average, carbon contribution to the carbon signal can be measured and calculated (York, 2009, p. N/A). There are numerous inconsistencies triggered by the levels of impurity and this affects a failure of exact measurements. The accuracy of determination is often questioned because of quick measuring methodologies. Basically, EFA refers to the amount of resources consumed by people, especially water and land. A Carbon Footprint is focused on greenhouse gases emission. EFA contains greenhouse gas calculations. Both of these methods are focused on human activities’ impact on the ecology and the environment. Actually, there is an evident difference between these two methods, such as operational mode of methods. EFA looks like an accounting balance sheet of the global world. Minus side of the sheet is occupied by resource-consuming activities supporting human life, such as energy consumption, logging, construction, fishing or hunting and waste caused by those activities. On the plus side there is the Earth's bio-capacity, i. e. the natural ability of the environment to replace the resources and consume the waste (Heddings and Wendy, 2009, p. N/A). Ecological footprints are focused on estimation of sea and forest areas, which absorb greenhouse gases. The strategy of carbon foo tprints measurements has been widely spread for a long period of time (Wheeler 2004, p. N/A). The areas of greenhouse gas waste are used for increasing awareness of the gas impact on climate change. People contribute much to burn fossil fuels directly impacts an ecological footprint. More greenhouse gases require more sea and forest

Performance Objectives At The Dell Company

Performance Objectives At The Dell Company Dell is concerned about the satisfaction of the customers requirements. The company is also having an eye on the price factor. Furthermore Dell is helping its own suppliers to improve the services they are offering to the company. In regards to Dell, here are the basic five performance objectives of Dell. This includes Quality, Speed. Dependability, Flexibility, Cost (Slack, N. Et al, 2001) The performance objectives in accordance to the company Dell. Quality Doing the things in the right way by providing the error free goods and services, which will satisfy the needs of customers, is known as the quality. According to many case studies, IBM products are ranked as the top of the year in the third party customer surveys. Dell Assembling and manufacturing process covers assembly and software installation of the computer system, also it includes the functional testing and quality control. Most of the company operations are done in house to measure and keep the quality high. Speed The second performance objective is the speed, which means that by doing things fastly is the key feature of the best companies. It also covers to minimise the time between the order and the availability of the product or service that the customer a speed advantage. The techniques of Dell are focused to the operations that have reduced complexity by using simple and small process which have reduced complexity. By arranging layout and flow to enhance simplicity improves speed of production. As the era of machines have minimised the working of the human beings. So the company Dell is using the most advanced and simple means of building and assembling the computers. Dependability Dependability is another performance objective of operations. It means that doing things in time for customers to receive the goods or the services when their delivery is promised. The Dell process includes Just-in- time (JIT) production system. To get the good result Dell is holding the multi skilled workers to cope up with its daily business operations. At Dell improving quality and efficiency is a concern for the managers and the technical staff and all other concerned employees. By doing this, Dell is giving a dependability advantage to its customers. Flexibility Dell have the philosophy of responding to the dynamic environment is that organization change their products and services the way do the business. This performance objective is known as flexibility. A clear result of responding to a dynamic environment is that organisation change their products and services and changes the way they do business. This performance objective is known as flexibility. According to research that we must learn to love change and develop flexible and responsive organizations to cope with the dynamic business environments (Peters, T., 1998) In the company Dell, the manufacturing means the ability to adopt its efficient resources so that it can develop new products. On contrary IBM was able to achieve high level of flexibility, producing relatively small batches of different products with little or no loss of productivity and quality. During the past years Dell, has provided range of options that customers are able to choose the example is customised computer system, which user can modify the parts according to their own needs by going on the website of Dell. Cost One of the major Dell operations objectives is to remain the low cost producer. Particularly the companies are competing on the pries is the cost factor. As the low price is the universal attraction for the customers, which can be achieved at producing the low cost. In order to do things cheaply, Dell is looking to be the low cost provider of goods and services. So already the company have planned and on other hand got some operations majorly in china where the cheap labour is available and the factors of production like resources physically available to be remained the low cost producer. Also internally, cost performance is helped by good performance in the other performance objectives that Dell has managed to produce high quality computers at a reasonable price. By improving the quality, speed, dependability, flexibility and cost operations performance, Dell is a global growth and high percentage of customer satisfaction. Because of the success in the production by using the Just-in-time system of manufacturing and developments, Dell is world known brand. Dell is world leader in supply chain management and it keeps the production cost down with the high quality, maximum speed, on time delivery, flexibility. Dell has the supplies from those companies which are also the market leader in the computer industry. Dell has shifted its operations to different countries like china, Korea and Taiwan in search of the cheap input (raw material and labour). This makes easier for Dell to produce products at a lower cost. Operating continuously gives dependability advantage to its customers by making it easy to deliver its production in the market palace. Using these operations objectives Del has managed to keep its customers happy and compete successfully with other companies in global market. Analysing these characteristics we can say that Dell is a world class company Quality Management Tools at Dell The company Dell is following the Japanese philosophy of lean manufacturing and Just-in-time system which is enabling the company to be the fastest growing company in the Technology market. The basic concept of this system is to reduce the waste and increase the productivity, side by side this system have the efficiency that it reduce the labour cost by cutting the idle working hours for the production of a particular product. Dell computer is participating in both of the above activities and that is why they are the industry leaders. Dell Company has got a warehouse space at their manufacturing plant in which suppliers keep parts directly on site which is a quintessential JIT layout. Further to this the company is using the JIT for its inventories purpose where they are keeping all the inventories for only four days and this is how they are solving the supply chain problems. On the other hand Del is maintaining the Just In Time inventory level as it is a part of JIT scheduling. By introducing such systems Dell Company is working to reduce inventory to the lowest possible working levels. Secondly by introducing such systems Dell is adjusting its schedule of ordering and delivering the computer systems. This is also filling the gap of communication both up and down of supply chain management. The word partnership is the only key to success for making JIT truly working. A firm particularly cannot implement the JIT system by itself. It must be having a complete cooperation with its supply chain. The company have successfully implemented the concept of JIT. For that reasons Dell have particularly formed and nurtured a demanding relationship with its partners. That is why Dell and its suppliers are working a one company. Why Dell is the best example of JIT, because Dell has its suppliers store raw materials directly at the manufacturing plants. The whole scenario of lean manufacturing can be shown in the diagram below: (www.dynarax.es) The other concepts of Just In Time system also needed to be introduced if the company is going for the lean manufacturing systems. The first thing that Dell makes is the rule of continuous improvement in its processes and products by means of quality and for production efficiency is another tool for that. To achieve its best Dell is always looking for the innovative ways to solve problems and increase focus on the quality of its suppliers. Dell believes that all are the cornerstones of JIT system. On the other hand Dell is working its best to the workforce to get indulge them into the JIT system. The company have the philosophy that without the dedication of the workforce, any invention will fail. On contrary Dell is using the simple way to achieve workforce commitment. Dell is providing the facility of training its employees outside their work environments and business functions and also company is helping them to increase the problem solving ability. Dell also believes that by practicing the above exercise the firm is empowering and giving the employees an overall view of the entire Dell operations, not just their single job. By doing this dell is supporting from the management side also they are increasing the resources to solve problems and an increase in employee roles and responsibilities. The workforce automatically feels empowered and works to make Just In Time a success for the business of Dell. Benefits to Dell Following are benefits which Dell has achieved so far by implementing the JIT system in its operations. JIT enabled Dell to be cost effective, more efficient and customer responsive. It enabled the company to purchase and store the components just before they are needed in the assembly line. This is how Dell is cutting the cost of housing and managing the idle parts of computers. The company Dell enabled its suppliers to store their products in the Dell owned warehouses near to the assembling plants which is enabling Dell to produce double as compared to its production in past. Dells keep the inventory for only four days; this is enabling the firm in operating context the size and the production technology management. JIT enabling the company to remain dealing with its other operation and process of production rather to stuck with inventory that may become obsolete. Dell is also enabled with the waste management system by introducing the JIT system. JIT In Practice Dell is a well known brand which is operating in the business of Technology. This is a only company that is effectively utilising Just in time system. Dell has the revolution of selling the personal computer system using the direct business model. According to this model Dell is taking the orders directly from the customers. This is how they are reducing the inventory and managing the distribution of its products. According to this model Dell start assembling the product when they receive the customer order. For this particular purpose Dell have introduced the pull system within the supply chain. A pull system is a reactive system, it start responding when customers order something from the company. This unique system is making Dell to remain competitive with in the industry on computer systems. The company Dell use to keep their inventory for a week almost. This is providing Dell with a time to market its product as a market leader. Also it is enabling the customers to get the fresh, latest and greatest technology of processors and all associated operating system currently introduced in the market. The minimal inventory helps Dell with the economic advantage. Because according to a research the value of the computer components and manufacturing material declines about one percent per week. The one week inventory system also minimises a customers ability to change their desires before they receive their product. The company Dell is using the JIT system which is resulting in the cost saving, superior customers satisfaction, limited waste and the ability to provide their suppliers with more information. In the end it is making Dell an industry leader and the company which holds minimal inventory (www.academicmind.com) Conclusion While concluding the report for Dell, it is important to say that there are many factors which ar enabling the company to be an effective organization and the operations objectives and the JIT system of manufacturing is also allowing the company to remain as the market leader in the computer industry.

Depression Essay -- essays research papers fc

People suffering from depression experience a lasting and continuously depressed mood that interferes with the ability to function, feel pleasure, and even maintain interest in life. The occasional feeling of being â€Å"blue† does not usually cause a downward spiral into depression. People suffering from major depressive episodes may feel so fatigued that they cannot go to work, school, or even do the simple things we take for granted. They may sleep day and night, have problems concentrating, and feel so deeply sad and guilty. This could lead to infinite thoughts of suicide. Thus showing that depression has an effect on a person’s mind and personal life.   Ã‚  Ã‚  Ã‚  Ã‚  When depression ends, most people return to a â€Å"normal† emotional level. In some cases, however, people rebound to the opposite state, also known as, â€Å"mania.† The spectrum of manic symptoms can be quite severe, ranging from cyclothymia to severe delusional mania. Cyclothymia, which usually starts in the adolescent years or early adulthood, is also known as fluctuations of mood between mild elation and depression (Daly 1997). The most common form of manic depression is the bipolar disorder. Bipolar disorder is characterized by clinically marked mood swings between mania and depression (Daly 1997). These forms of manic depression are obtained in many ways. They can be passed on generation to generation within a family. It can also be obtained through the use of drugs as well as alcohol. Yet, one of the major causes for mania is neurological lesions or other states affecting the brain (Daly 1997).   Ã‚  Ã‚  Ã‚  Ã‚  When a person is diagnosed with manic depression, he or she will have certain outbreaks and episodes that range in severity and outcome. Clinical description and diagnosis of a manic depressant may begin abruptly, over the space of a few hours or days, or gradually over some weeks. The subjective experience of mania in its minor form usually includes heightened feelings of well being with increased alertness and drive, inflated self-esteem, and expansive sociability (Daly 1997). In addition to the increased sense, irritability may easily be evoked, and other mood states such as anxiety or sadness, brief but intensely expressed, may become apparent (Daly 1997). As mania deepens, over-activity and excessive talkativeness become more obvious. These are the signs of... ...tection or out of consideration for others (Gonzalez-Heydrich 1996).† As we grow older our minds expand. Depression can set in at an early point in your life or late into it. Traumatic episodes and even thoughts can play a role in the dilemma of depression. This disease can be controlled, yet think about those who cannot afford the treatment. Who do they turn to? They are going to live the rest of their lives in an altered state of depression forever. Works Cited Croghan, W. Thomas, Obenchain, L. Robert, and Crown E. William. July 1998. What does Treatment of Depression really Cost? Health Affairs. Daly, Ian. Mania. Lancet 1997:349 (9059): 1157-1160. Gonzalez-Heydrich, Joseph. The Depresses Child and Adolescent: Development and Clinical Perspectives. N Engl J Med; 334: 1410-1411. Hirschfeld, M.A. Robert, & Russell M., James. 1997. Current Concepts: Assessment and Treatment of Suicidal Patients. N Engl J Med; 337: 910-915. Partonen, Timo, & Lonnqvist, Jouko. 1998. Seasonal Affective Disorder. Lancet 1998; 352 (9137):1369-1374. Price, H. Lawerence, & Heninger, R. George. 1994. Drug Therapy: Lithium in the Treatment of Mood Disorders. N Engl J Med 1994; 331: 591-598.