Patient: 34-year-old man

Present illness: The patient recalls having had his first major depressive episode during his freshman year soon after entering a renowned college in his country. At the time, he received no treatment and had to repeat his freshman year, as he lay almost immobile for several months, but since then he remained relatively stable and well adjusted. He graduated with honours, found a job in a large manufacturing company, married a woman he met there and the couple have one boy and one girl. It was when, at the age of 31, he took charge of a new section in the company that his first manic episode broke out. He became sleepless, talkative and aggressive as he prepared for the start-up of the new section. He presented his grandiose plan at a section meeting; when his plan was rejected, he fled from the company and his family, stayed in various hotels and spent all his money; finally, his case was brought to the attention of the police because he could not pay the hotel bills. The family was notified and the patient was admitted to the hospital. He had another manic episode 1 year later when he stopped taking lithium against medical advice. He has been relatively adherent with the treatment since then, as his wife threatened him with divorce should he not follow the advised treatment (lithium 800 mg/day, with serum concentration around 0.9 mEq/L: no sign of hypothyroidism on annual checks).

Present status: At work he has been assigned a position within a section with understanding colleagues and has managed to keep his job for a year now. However, his wife noted that he has been rather despondent and interacting less with his children in the past month. His supervisor at the company also …