Bipolar Disorder

A single patient, three days from his first manic episode. No guideline ranks lithium, valproate, or an atypical antipsychotic above the others for maintenance — the choice turns on which risk profile fits this particular 24-year-old, not on which drug is theoretically strongest.

A single patient, three years past a serious suicide attempt and now facing recurrent depressive breakthroughs. Lithium is the one mood stabilizer with evidence for reducing completed suicide — and the one whose own overdose toxicity maps most directly onto her documented history.

Two patients, same underlying risk. One received antidepressant monotherapy with no hypomania screen and was unmasked as bipolar by the switch itself; the other had known bipolarity and established mood-stabilizer coverage before any antidepressant was added.

A single patient, six weeks into a breakthrough depressive episode on lithium. STEP-BD found no average benefit from adding an antidepressant to a mood stabilizer — but this patient has his own prior positive response to the same drug, and the two kinds of evidence point in different directions.

A single patient, sliding into a depressive episode despite lamotrigine. Four FDA-approved options exist for bipolar depression, and none is simply the strongest choice — each fails a different piece of her actual schedule, insurance, or timeline.

A single patient, two days into an involuntary hold for his first manic episode. Several atypical antipsychotics have real acute-mania efficacy, but a newly discovered prediabetic lab value changes which one's metabolic cost is acceptable tonight.

A single patient, six years stable on lithium, asking to stop before recording her first album. Her complaint about blunted creativity is real and documented, not denial — and it sits against relapse data that is just as real.

A single patient, twelve years stable on lithium, now facing acute kidney injury that requires stopping it immediately — the one mood stabilizer whose abrupt discontinuation carries its own distinct, time-concentrated relapse risk.

Two patients, one drug, two different points on the perinatal timeline. One is weighing lithium's revised, smaller teratogenicity risk during pregnancy; the other stopped lithium for that same fear and is now living through the postpartum relapse risk it left unprotected.

A single patient, 9 weeks into an unplanned pregnancy, already exposed to valproate for weeks before the pregnancy was known. It is the only agent that has ever controlled her illness — and the most teratogenic mood stabilizer available.

A single patient, three weeks postpartum and six years stable on lamotrigine. Continuing it through breastfeeding carries a real, monitorable infant exposure risk — stopping it carries the highest relapse risk of her entire illness course.

A single patient, three weeks into another depressive episode within a rapid-cycling pattern. Two prior antidepressant trials each preceded apparent cycle acceleration — a documented, subgroup-specific risk that sits directly against her real, ongoing suffering.

A single patient in urgent psychiatric care, presenting with manic and depressive symptoms at once. His suicidal ideation makes an antidepressant-leaning approach intuitive — but mixed-features episodes carry a documented risk that antidepressants worsen, not just fail to help.

A single pediatric patient referred for suspected bipolar disorder. The real diagnostic question turns on a pattern, not severity — whether discrete manic episodes exist, or whether this is the chronic irritability DSM-5's DMDD diagnosis was created to capture.

A single patient, four years stable on lithium, with a childhood ADHD diagnosis now causing real functional impairment. Stimulants carry a documented mania-triggering risk in bipolar disorder — a risk established mostly without mood-stabilizer coverage already in place.

A single patient, three months into acute grief-related panic attacks. A benzodiazepine would likely help fast — but her own six years of hard-won recovery from alcohol use disorder makes that specific class of relief specifically risky for her.

A single patient, three days into catatonia within a treatment-resistant bipolar depressive episode. A benzodiazepine challenge is the standard first step — but her worsening medical fragility raises a real question of how much time that first step should be allowed to take.

A single patient, fully adherent and stable on lamotrigine for two years, now manic. Lamotrigine's trial evidence has always been strong for preventing depression and thin for mania — this breakthrough is that known asymmetry showing up, not a drug failure.

A single patient, three hospitalizations in two years, each tied to a logistical gap in refilling oral medication, not poor insight. A long-acting injectable would fix that gap directly — if a monthly clinic visit fits his schedule any better than a daily pill did.