Most of the critical information on neurobiology and pharmacology was presented in the first five chapters. The final step in our symptom-based treatment algorithm is learning how to build a treatment plan for an individual patient by synthesizing all of this information. It is often the case with bipolar disorder that a combination of medications will have greater efficacy than any single medication; combining another agent with lithium or valproate is particularly common. This is where the knowledge derived from steps 1-4 in the symptom-based treatment algorithm can be particularly helpful. Chapter 6 introduces methods of individualizing treatment plans and monitoring patients. This includes a necessary discussion of common comorbidities, combination treatments, and supplementary or alternative treatment plans. Compliance with medication regime, mood stability, and overall quality of life can be dramatically improved with adjunct psychotherapy, and this should be considered an important component of treatment in all cases.

Specifically, 5HT2C and H1 antagonism is linked to weight gain, and M3 receptor antagonism can alter insulin regulation. Receptor “X” may increase the production of insulin resistance, resulting in elevated fasting plasma triglyceride levels. Some patients might be more prone than others to experience increased cardiometabolic risk on certain atypical antipsychotics.

The mechanisms of weight gain, dyslipidemia and cardiometabolic risk associated with valproate and sometimes with lithium are unknown.

When patients have dyslipidemia, are prediabetic or diabetic, or are obese, it is necessary to obtain their fasting glucose levels, blood pressure and waist circumference measurements just before starting treatment with mood stabilizers and throughout treatment. It may be best in these patients to avoid or switch from mood stabilizers that exhibit a higher risk of cardiometabolic side effects.

Blocking ion channels can also cause sedation in the case of valproate and carbamazepine. The mechanism of lithium's sedation is unknown.