Working diagnosis: schizoaffective disorder, bipolar type
For: Dr. Marian Topolov
Review · 19 Jun 2026
Prepared by Joseph Harari
husband / primary caregiver · 18 Jun
Dr. Topolov: over the past three weeks Martina has had an early relapse of jealous paranoia and mild hypomania, caught much earlier than the November episode: no full mania, and no danger to herself or others. The likely triggers were completing the olanzapine taper to zero in mid-May and stress from her new tennis-coaching job. Following your 8 June instruction we ramped olanzapine back to 20 mg, and over the last few days she has clearly settled. Our main questions now are about driving and the plan from here.
Current regimen
Medication
Dose
Dose since
Aripiprazole Abilify
30mg–0–0
15 Nov 2025
Lithium
600mg–0–600mg
18 Apr 2026
Olanzapine Olfex
10mg–0–10mg
10 Jun 2026
Levothyroxine Euthyrox
25mcg–0–0
22 Apr 2026
Alprazolam Xanax
PRN
last taken15 Jun 2026
Recent change · Olanzapine (mg)
0from 17 May
›
54 Jun
›
106 Jun
›
158 Jun
›
2010 Jun
Ramped per your 8 June instruction. All other medication unchanged since April.
What we are hoping for
1Can she drive?
2How long should we hold olanzapine at 20 mg?
3When should we come back — and what should make us call sooner?
4Long-term plan for olanzapine — off entirely, or a maintenance dose?
Worth a check
Thyroid recheck overdue. TSH 7.81 in Apr (lithium-induced); TSH/FT4 recheck was due 6–8 wk after starting Euthyrox. May be feeding her fatigue/dizziness.
Lithium level. Last 0.77 (May); has run below the 0.8 acute target. Worth confirming during the relapse.
Iron / anaemia. Low iron in Apr — confirm supplementation was started (adds to dizziness).
Olanzapine & lipids. LDL was rising on olanzapine; relevant again now it is back at 20 mg.
Extra context
Likely trigger: her new tennis-coaching job (stress / anxiety), on top of olanzapine reaching zero. Symptoms: jealous paranoia — checking Joseph's location by video call, checking card history to confirm he was where he said, demanding to see his phone conversations with her sister, set the door chime to maximum to hear if anyone enters; early hypomania — sudden profile-picture changes / random Instagram posting (her reliable early-warning sign), grandiosity, irritability.
Safety: one attentional lapse — did not secure their daughter in the car seat and did not notice (8 Jun). Driving: Joseph currently drives her everywhere, especially to her coaching job, to keep her working. Trajectory: settling since 14 Jun; 18 Jun "much more stable."
Prepared by Joseph Harari (husband / primary caregiver), 18 Jun 2026, from a structured daily caregiver log and RamusLab results (15 Apr 2026, ID 21954110). Intended to support discussion, not to replace professional assessment.
Top: each medication and its dose over time — note olanzapine was tapered gradually from March to zero by mid-May, then restarted this month (red). Bottom: lithium level has stayed at the low end (~0.7) even as the dose rose from 1 g to 1.2 g; shaded band is the usual maintenance range, dashed line the 0.8 acute target.
Lab reference — RamusLab panel, 15 Apr 2026
TSH7.81 ▲(0.35–4.94; 6.08 Dec)
FT4 0.85 (0.70–1.48, low-normal)
Total chol6.56 ▲(<5.18)
LDL4.71 ▲(<3.0; rising on olanzapine)
Iron7.7 ▼(9–30.4; low MCH/MCHC)
Urea8.4 ▲(dietary; eGFR 97 normal)
Urine protein trace (no infection; quantify next draw)
Ruled out in Apr: lithium toxicity (0.70, stable) · diabetes / insulin resistance (HbA1c 5.2) · liver (AST/ALT/GGT normal) · electrolytes · renal failure (eGFR 97) · hyperparathyroidism (PTH/Ca normal). Prolactin was ordered but missing from the report.
Compiled from a structured daily caregiver log (Aug 2025 – Jun 2026) and RamusLab results (15 Apr 2026, ID 21954110). Prepared by Joseph Harari, 18 Jun 2026.