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Difficulty: MediumBipolar and Related Disorders

A 34-year-old female software developer comes to the physician's office with her husband. She reports feeling profoundly sad and exhausted for the past month. The patient states she has no energy, sleeps up to 12 hours daily, and struggles to concentrate on her programming tasks. Two weeks ago, her primary care provider diagnosed her with major depressive disorder and prescribed fluoxetine. However, she states her mood has not improved and she now feels increasingly restless. During the interview, her husband notes that three years ago, the patient had a discrete 6-day period where she was unusually energetic, required only three hours of sleep per night, spoke very rapidly, and compulsively reorganized their entire home. She did not require hospitalization at that time and returned to her normal baseline afterward. Her past medical history is unremarkable. Vital signs are within normal limits. Laboratory studies reveal a serum thyroid-stimulating hormone (TSH) level of 1.8 µU/mL and a free T4 of 1.2 ng/dL. On mental status examination, she exhibits psychomotor retardation and a flat affect. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

  1. Discontinue fluoxetine and initiate lithiumAnswer
  2. B
    Increase the dosage of fluoxetine
  3. C
    Discontinue fluoxetine and initiate venlafaxine
  4. D
    Continue fluoxetine and add phenelzine
  5. E
    Discontinue fluoxetine and initiate levothyroxine

Answer

Discontinue fluoxetine and initiate lithium
The patient's current presentation of a major depressive episode, combined with a history of a distinct 6-day period of elevated mood, decreased sleep, and increased goal-directed activity, confirms a diagnosis of bipolar II disorder. The prior provider misdiagnosed her with major depressive disorder and prescribed fluoxetine (an SSRI). Antidepressant monotherapy is generally contraindicated in patients with bipolar disorder due to the significant risk of precipitating a hypomanic or manic switch. The most appropriate next step is to immediately discontinue the offending antidepressant and initiate a medication approved for bipolar depression, such as lithium, quetiapine, or lurasidone.

Step-by-Step Solution

1
Identify the patient's current clinical presentation.
The patient is experiencing a major depressive episode, currently treated with fluoxetine monotherapy.
Establishing the current affective state is the first step in psychiatric management.
2
Analyze the collateral history provided by the husband.
The history of a distinct 6-day period of elevated energy, decreased need for sleep, and rapid speech indicates a past hypomanic episode.
A history of hypomania changes the primary diagnosis from major depressive disorder to bipolar II disorder.
3
Evaluate the safety and efficacy of the current treatment regimen.
Fluoxetine is an antidepressant monotherapy, which carries a high risk of inducing a manic or hypomanic switch in patients with bipolar disorder.
Antidepressant monotherapy is generally contraindicated in bipolar disorder.
4
Determine the safest and most appropriate pharmacologic intervention.
The SSRI must be stopped, and an approved mood stabilizer or atypical antipsychotic (such as lithium) should be initiated to treat bipolar depression.
Lithium effectively treats bipolar depression and provides prophylaxis against future mood episodes without the risk of manic switching.

Key Concept

Patients presenting with depressive symptoms must be carefully screened for a history of mania or hypomania; if bipolar disorder is diagnosed, antidepressant monotherapy should be avoided and a mood stabilizer should be initiated.
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Topics

Bipolar and Related Disorders

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