A 50-year-old man with a history of schizoaffective disorder, bipolar type, diabetes mellitus type 2, chronic kidney disease stage 3, and hypertension was brought to the emergency department for swelling of his face and extremities, questionable medication compliance, and recent unusual and threatening behavior. His psychiatric medications included divalproex sodium extendedrelease (2,000 mg nightly), long-acting injectable risperidone (25 mg every 2 weeks), and trazodone (100 mg nightly). The patient had been stable on this regimen for many years before the days leading up to his presentation in the emergency department. His total valproic acid level on presentation was 65 µg/ mL. His complete blood count was unremarkable. His basic metabolic panel was notable for blood urea nitrogen (22 mg/dL), his creatinine level was 2.1 mg/ dL, his estimated glomerular filtration rate was 34, his aspartate aminotransferase level was 65 IU/L, and his alanine aminotransferase level was 97 IU/L. The patient's urine drug screen was negative, and an ECG was unremarkable. He weighed 183 lbs and had a body mass index of 28. His bilateral lower extremities showed edema of 1+, and a neurological examination was unremarkable. Further workup revealed nephrotic syndrome with an albumin level of 2.2 g/dL (normal range, 3.6-4.8 g/dL).