Outline: Fighting the Wave of Bipolar Disorder

Supervision Series – Clinical Teaching Points

I. Rethinking the Classic Model

• Mood stabilizers are traditionally first-line (lithium, valproate, lamotrigine)

• Not all patients respond well to classic agents

  • Poor tolerance

  • Subtherapeutic response

  • Life stage (e.g., pregnancy, geriatrics)

II. Adapting to Real-World Complexity

• In some cases, the mood stabilizer may be removed due to:

  • Side effects

  • Nonresponse

  • Patient preference

• Clinical adaptation may involve:

  • Antipsychotics as primary mood stabilizers (e.g., aripiprazole, quetiapine, lurasidone, cariprazine)

  • Carefully monitored use of antidepressants in bipolar II or depressive-predominant presentations

III. When Guidelines Don’t Fit, Supervision Matters

• Not every patient fits protocol; flexibility requires:

  • Clinical reasoning

  • Careful risk-benefit analysis

  • Supervisor consultation before deviating from standard care

IV. Case Management Tips

• Always ask: What phase is the patient in? Depression, mania, mixed?

• Consider trajectory and not just diagnosis

  • History of polarity

  • Past treatment response

  • Functional impact

V. Antipsychotic Management as a Flexible Tool

• Dosing can shift based on phase

• Useful across mood episodes (mania, mixed, depression)

• Monitor for metabolic side effects and sedation

VI. When Using Antidepressants

• Only consider in bipolar II or depressive-predominant patterns

• Always with supervision and mood-stabilizing coverage

• Monitor for activation, insomnia, or early signs of mania

VII. Clinical Pearls

• Treat the current phase, prepare for the next

• Document rationale clearly when deviating from guidelines

• Use gradual tapering when removing long-term medications

• Involve patients in decision-making and planning

• Supervision isn’t optional—it’s part of clinical safety