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