To start with diagnosis, I have much sympathy with the educational component of the advice that is suggested in Parker's template. I am a little more cautious in accepting that hypomania is of unalloyed benefit to patients. While the subjective benefit of mood elevation may be obvious, the additional energy and self-confidence can lead both to a dissipation of goal-directed activity and increased conflict with others, which can produce a non-productive whirlwind of action. I am therefore rather cautious in accepting that even ‘bipolar-lite’ is anything better than friendly fire.

Aspects of Parker's medical management plan are delightfully unorthodox. To make SSRIs the first-line treatment both for mood stabilisation and for bipolar depression associated with mood disorder is not in any guideline! It is based very much on clinical experience and on the correct perception that the dangers of ‘switch’ in bipolar depression are rather overstated, particularly by American authorities.

However, in many Western countries there has been a sensitisation to the idea that SSRIs cause harm through their actions on arousal, or even ‘suicidality’. While this is not the place to address this litigation-fuelled belief, there is no doubt that it has affected, in an adverse way, the environment in which SSRIs are used. Furthermore, we have all seen mood instability or hypomania occur after prescribing a SSRI, whether or not we can be sure it is caused by it. So, my own preference is usually for lamotrigine when the burden of the illness or presentation is acute depression.