What is the recommended treatment plan for a patient with a history of major depressive disorder, obsessive‑compulsive disorder, bipolar disorder, ADHD, and borderline personality disorder who stopped lithium at age 16 and is currently taking bupropion (Wellbutrin), trazodone, and clonidine?

Treatment Recommendations for Complex Psychiatric Comorbidity

This patient requires immediate reinitiation of a mood stabilizer—specifically lithium or valproate—combined with cognitive-behavioral therapy (CBT), as the presence of bipolar disorder makes her current regimen dangerously inadequate and places her at high risk for mood destabilization, particularly given that bupropion monotherapy can trigger manic episodes. 1

Critical Safety Concerns with Current Regimen

The current medication regimen is fundamentally inappropriate for bipolar disorder:

• Bupropion (Wellbutrin) should never be used as monotherapy in bipolar disorder, as antidepressant monotherapy can precipitate manic episodes, rapid cycling, and overall mood destabilization 1
• The absence of a mood stabilizer since age 16 places this patient at extremely high risk, with over 90% of noncompliant patients experiencing relapse 1
• Risperidone (if "reperdone" refers to risperidone) without a mood stabilizer is insufficient for bipolar disorder management 1

Recommended Treatment Algorithm

Phase 1: Immediate Mood Stabilization (Weeks 1-8)

Reinitiate a mood stabilizer immediately:

• Lithium is the first-line choice given its superior evidence for long-term efficacy and unique anti-suicide effects (reduces suicide attempts 8.6-fold and completed suicides 9-fold) 1
• Target lithium level: 0.8-1.2 mEq/L for acute treatment 1
• Alternative: Valproate if lithium is contraindicated, with target levels of 50-100 μg/mL 1

Baseline monitoring before starting lithium:

• Complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test 1
• Ongoing monitoring: lithium levels, renal and thyroid function every 3-6 months 1

Phase 2: Address Comorbid Conditions

For OCD (after mood stabilization):

• First-line: CBT with exposure and response prevention (ERP) consisting of 10-20 sessions 2
• If CBT alone is insufficient: Add an SSRI (sertraline or escitalopram preferred) at maximum tolerated dose for at least 8 weeks, always combined with the mood stabilizer 2
• The presence of bipolar disorder modifies the OCD treatment algorithm—focus on mood stabilizers plus CBT rather than SSRI monotherapy 2

For ADHD (only after mood stability achieved):

• Stimulant medications may be helpful once mood symptoms are adequately controlled on a mood stabilizer regimen 1
• Alternative: Bupropion can be continued as adjunctive therapy for ADHD symptoms, but only in combination with a mood stabilizer 3, 4
• Bupropion 150-300mg/day has demonstrated efficacy for ADHD in adults with bipolar disorder without significant activation of mania when combined with antimanic agents 3

For Depression:

• If depressive symptoms persist after mood stabilization: Consider olanzapine-fluoxetine combination as first-line for bipolar depression 1
• Alternative: Continue bupropion as adjunct to mood stabilizer, as it has lower risk of mood destabilization compared to SSRIs 1, 4

For Borderline Personality Disorder:

• Psychotherapy is the primary treatment: Dialectical Behavior Therapy (DBT) or mentalization-based therapy 5
• Pharmacotherapy adjuncts: Omega-3 fatty acids, second-generation antipsychotics (low-dose), and mood stabilizers may benefit emotional dysregulation 5
• The extensive treatment history typical of borderline personality disorder underscores the need for integrated, long-term care 6

Phase 3: Optimize Adjunctive Medications

Current medications to continue:

• Trazodone: Appropriate for insomnia, typically 50-100mg at bedtime 7
• Clonidine: Reasonable for anxiety/ADHD symptoms, typically 0.1mg BID 1

Risperidone considerations:

• If continuing risperidone, use lowest effective dose (typically 2mg/day) in combination with mood stabilizer 1
• Monitor for metabolic side effects, particularly weight gain 1

Maintenance and Long-Term Planning

Duration of mood stabilizer therapy:

• Minimum 12-24 months after achieving mood stabilization 1
• Given history of multiple disorders and medication discontinuation, lifelong treatment may be necessary 1
• Withdrawal of lithium dramatically increases relapse risk, especially within 6 months 1

Psychosocial interventions (essential components):

• Psychoeducation about symptoms, course of illness, treatment options, and critical importance of medication adherence 1
• Family-focused therapy to improve medication supervision, early warning sign identification, and problem-solving skills 1
• CBT has strong evidence for depression, anxiety, and OCD components 1

Common Pitfalls to Avoid

• Never use antidepressants as monotherapy in bipolar disorder—this is the most critical error in this case 1
• Inadequate duration of maintenance therapy leads to relapse rates exceeding 90% 1
• Failure to monitor metabolic side effects of atypical antipsychotics 1
• Overlooking the need for psychotherapy alongside pharmacotherapy—medication alone is insufficient for borderline personality disorder 5
• Treating ADHD before mood stabilization—stimulants can worsen mood instability 1

Monitoring Schedule

First 8 weeks:

• Weekly visits to assess mood symptoms, medication adherence, and side effects 1
• Lithium level after 5 days at steady-state dosing, then as needed to maintain therapeutic range 1

Maintenance phase:

• Monthly visits initially, then every 3 months once stable 1
• Lithium levels, renal function, and thyroid function every 3-6 months 1
• Metabolic monitoring (BMI, blood pressure, glucose, lipids) if continuing risperidone 1