Mixed features, rapid cycling, and polarity-safe treatment — structured clinical viva

Nosology. Working diagnosis: bipolar I disorder, current episode manic (or hypomanic if impairment/hospitalisation thresholds not met — here suicidal plan and severity likely mania-level risk), with mixed features, rapid cycling course (five full episodes in 11 months). Escitalopram monotherapy is polarity-unsafe and a likely accelerator.^[5]

Assessment priorities. Detailed suicide risk (intent, plan, means, access to multi-storey sites, alcohol, protective factors), violence, MSE with quoted mixed content, medical exclusion, baselines before lithium/SGA, TFT, capacity/legal status, collateral. This is an admission-level presentation until risk is contained.^[5]

Acute treatment. Means restriction and low-stimulation environment. Stop antidepressant monotherapy. Restore sleep (short-term benzodiazepine). Start antimanic cover: e.g. olanzapine 10–20 mg oral and/or lithium titrated to 12-hour trough about 0.8–1.2 mmol/L in acute mania; combination often needed when severe. Olanzapine has analyses in mania with DSM-5 mixed features.^[2][5] ECT if risk remains extreme or response fails.

Evidence against antidepressants. STEP-BD: adjunctive antidepressants did not improve durable recovery versus mood stabiliser plus placebo — monotherapy is even harder to defend, especially with mixed features and rapid cycling.^[1]

Maintenance and monitoring. After stabilisation, lithium-first prevention when tolerated (BALANCE; anti-suicide meta-analysis), with metabolic and lithium monitoring (eGFR, TFT, calcium, levels). Address drivers: no AD monotherapy, sleep, substances, thyroid. Psychoeducation and early-warning plan with supports.^[3][4][5]