Stabilizing the Triple Comorbidity: A Case Report of Oral Glutamatergic Augmentation in a Patient with Bipolar I, OCD, and ADHD

Comorbid bipolar I disorder, obsessive–compulsive disorder and attention-deficit/​hyperactivity disorder form a notoriously unstable clinical constellation. Conventional stimulants risk precipitating mania, whereas high-dose antidepressants seldom quell the mood-linked obsessions and may themselves cause switching. We detail the course of a 31-year-old man who illustrated these pitfalls. After methylphenidate produced early hypomanic signs—fragmented sleep, increased impulsive spending and heightened drive—his treatment was redirected toward a fully oral glutamatergic strategy. The regimen combined dextromethorphan for NMDA antagonism, pharmacokinetically extended by the mild, reversible CYP2D6 inhibition provided by melitracen within Deanxit, with piracetam to potentiate AMPA signalling and L-glutamine to support presynaptic glutamate balance. All adjustments were made in routine outpatient follow-up. Across three months the patient showed steady gains: depressive affect lifted, intrusive ruminations quieted and impulse control improved, while the need for methylphenidate fell from daily dosing to occasional use without loss of attentional capacity. When he later stopped dextromethorphan and piracetam on his own initiative—yet continued valproate and antipsychotic cover—both low mood and obsessive thinking re-emerged, then abated rapidly once the glutamatergic agents were reinstated. This single case suggests that a multi-target oral glutamatergic approach can stabilise mood, reduce obsessions and preserve attention in a comorbidity cluster where traditional pharmacotherapy frequently destabilises the illness. Further systematic study is warranted to confirm the safety and durability of NMDA/AMPA modulation as a non-stimulant alternative in complex bipolar-spectrum presentations.