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A 29 year old female architect was referred for psychiatric assessment by her general practitioner because of a four-month history of increasing and eventually deep despair, agitation, frequent spontaneous crying spells and an inability to cope with work demands.

She was diagnosed as suffering from a major depressive episode, for which she was treated with the selective serotonin reuptake inhibitor paroxetine, as well as supportive psychotherapy.

After four months of successful treatment, management was transferred back to her general practitioner. Within three months of this transfer, her increasing self-confidence developed into grandiose and delusional preoccupations. For example, she believed that God had recognised her unusual architectural flair to the extent that he had chosen her to design a series of multidenominational religious temples in Australian capital cities. She believed that this project would dramatically reduce inter-racial disharmony throughout the country. She resigned from her job in order to work on the project, but did not commence it because of marked distractibility, manifested in part by her superficial involvement with a large and growing list of environmental and animal welfare causes. She had many other manic symptoms, including severe pressure of speech, sleeplessness and a reckless series of purchases of artworks and period furniture.

Diagnosed as suffering from severe bipolar disorder with psychotic features, she was admitted to a private psychiatric hospital by her psychiatrist and was commenced on lithium carbonate. Initial behavioural control was obtained with coadministered chlorpromazine. Although her delusions faded and she was less frenetic after several weeks' treatment, she remained quite disinhibited and overactive. Her treatment was subsequently changed to sodium valproate, which gave better symptom control.

Her management is mainly undertaken by her general practitioner, but she has six-monthly appointments with her psychiatrist, as well as seeing him as soon as a relapse is suspected by her GP (the patient tends to have poor insight at times of relapse). She has had two mild depressions and one hypomanic episode in the three years since her initial manic episode. These have been treated without further hospitalisation.

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