Which of the following would indicate an increased suicidal risk? (Select all that apply)

Choice A reason: Valproic acid does not typically require thyroid function tests, as it primarily affects liver metabolism via glucuronidation and mitochondrial pathways. Thyroid dysfunction is not a common side effect, unlike with lithium, which impacts thyroid hormone synthesis. This instruction is irrelevant, as valproic acid’s toxicity risks are hepatic, not thyroid-related.

Choice B reason: Expecting a gradual decrease in valproic acid dosage is incorrect, as it is titrated to therapeutic levels for conditions like seizures or bipolar disorder, based on serum levels (50–100 mcg/mL). Dosage adjustments depend on efficacy, not routine reduction, as stable neural excitability is needed, making this scientifically inaccurate.

Choice C reason: Taking aspirin for pain with valproic acid is risky, as both inhibit platelet function, increasing bleeding risk via synergistic effects on prostaglandin synthesis. Valproic acid’s hepatic metabolism also raises hepatotoxicity concerns, making aspirin inappropriate. Alternative analgesics like acetaminophen are safer, rendering this instruction incorrect.

Choice D reason: Valproic acid requires regular liver function monitoring, as it is hepatically metabolized and can cause hepatotoxicity, particularly in the first 6 months, due to mitochondrial dysfunction and oxidative stress. Elevated liver enzymes or rare fulminant hepatitis necessitate early detection to prevent liver failure, making this a critical instruction.

Choice A reason: Understanding the medication regimen is important for long-term bipolar management, stabilizing mood via dopamine and serotonin modulation. In acute mania, however, hyperactivity and reduced intake increase dehydration risk, which exacerbates cerebral dysfunction. Hydration is a more immediate physiological need than cognitive understanding during an acute episode.

Choice B reason: Acute mania in bipolar disorder involves hyperactivity and reduced self-care, driven by dopamine dysregulation, leading to dehydration. This impairs cerebral perfusion and electrolyte balance, risking seizures or organ damage. Maintaining hydration is the priority, as it stabilizes physiological function, supporting neural recovery during the acute manic phase.

Choice C reason: Practicing problem-solving skills aids long-term bipolar management by enhancing prefrontal cortex function. In acute mania, however, impaired insight and hyperactivity from dopamine excess limit cognitive engagement. Dehydration poses a greater immediate risk to cerebral and systemic stability, making this goal secondary during an acute episode.

Choice D reason: Identifying relapse indications supports long-term bipolar management by recognizing dopamine-driven mood shifts. In acute mania, immediate physiological risks like dehydration from hyperactivity take precedence, as they threaten cerebral and systemic stability. This goal is less urgent, as it addresses future prevention rather than current physiological needs.