Bipolar I disorder — structured clinical viva

This is bipolar I with mixed features (manic-spectrum activation plus depressive affect and suicidality) in early pregnancy, with a likely antidepressant-related destabilisation and subtherapeutic/borderline lithium maintenance level. Immediate priorities are safety (likely admission), stop sertraline, restore sleep, urgent senior obstetric–psychiatry liaison, and optimise polarity-safe treatment. Mixed features elevate suicide risk — means restriction, continuous observation threshold, and collaborative safety planning with supports as appropriate under privacy law.^[4]

Medication errors to name. Adding an SSRI without ensuring adequate mood-stabiliser cover is high risk in bipolar I; STEP-BD challenges casual adjunctive antidepressant benefit, and monotherapy would be worse. Check urgent 12-hour lithium trough, adherence, interacting drugs, and renal function; previous 0.55 mmol/L may be low for this patient’s prevention needs and must be re-measured correctly.^[1][5]

Pregnancy. Do not start valproate as a “stronger mood stabiliser” rescue — valproate is at the top of the teratogenicity hierarchy. Lithium decisions are shared: Patorno et al. quantify increased cardiac malformation risk with nuance on absolute risk compared with older dogma; balance maternal relapse risk (including suicide and postpartum peak risk) against fetal risk, involve obstetrics, and plan anomaly screening if lithium continues. Consider SGA options with metabolic monitoring when indicated. Frame lithium’s anti-suicide evidence while being honest about monitoring burden.^[2][3][4]