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Difficulty: MediumDepressive Disorders

A 29-year-old man presents to the outpatient clinic reporting a 6-week history of feeling "down and hopeless." He states that he has lost interest in his usual hobbies, has very low energy, and is sleeping up to 12 hours a day. His appetite has increased, leading to a 4-kg (8.8-lb) weight gain. He was recently reprimanded at work for excessive absences because he could not find the motivation to get out of bed. He has no significant past medical history and takes no medications. He does not use tobacco, alcohol, or illicit substances. He mentions that occasionally, just as he is falling asleep, he hears a voice calling his name. Physical examination reveals a flat affect and psychomotor retardation, but no other abnormalities. He requests to be started on an antidepressant medication. Which of the following is the most appropriate next step in the management of this patient?

  1. Assess for a history of elevated mood and decreased need for sleepAnswer
  2. B
    Initiate citalopram monotherapy and schedule a follow-up appointment in 4 weeks
  3. C
    Initiate citalopram therapy and advise that it can be discontinued upon symptom remission
  4. D
    Inquire about a continuous 6-month history of auditory hallucinations and disorganized speech
  5. E
    Prescribe a selective serotonin reuptake inhibitor and a monoamine oxidase inhibitor concurrently

Answer

The most appropriate next step is to assess for a history of elevated mood and decreased need for sleep.
The correct answer is to assess for a history of elevated mood and decreased need for sleep. This patient is presenting with a severe major depressive episode characterized by depressed mood, anhedonia, hypersomnia, weight gain, profound fatigue, and functional impairment lasting >2 weeks. However, a major depressive episode can be the presenting phase of either Major Depressive Disorder (MDD) or Bipolar Disorder. Because the cross-sectional depressive symptoms are identical in both conditions, the standard of care mandates that all patients presenting with depression be explicitly screened for a history of manic or hypomanic episodes (e.g., periods of persistently elevated or irritable mood, decreased need for sleep, impulsivity, grandiosity) before initiating antidepressant medication. Prescribing antidepressant monotherapy to a patient with unrecognized bipolar disorder carries a significant risk of precipitating an acute manic or hypomanic episode (often referred to as a "manic switch"). The patient's auditory hallucination as he is falling asleep is a hypnagogic hallucination, which is a normal variant and does not mandate a primary psychotic disorder workup.

Step-by-Step Solution

1
Identify the patient's primary syndrome based on the clinical presentation.
The patient is experiencing a major depressive episode.
He has >5 symptoms of depression (depressed mood, anhedonia, fatigue, hypersomnia, weight gain) lasting >2 weeks with significant functional impairment.
2
Evaluate the reported auditory phenomenon.
The patient is experiencing hypnagogic hallucinations.
Hearing a voice or name just as one is falling asleep is a normal physiological variant and does not indicate a true psychotic disorder like schizophrenia.
3
Determine the necessary evaluation step prior to initiating pharmacotherapy.
Screen for a history of bipolar disorder (mania or hypomania).
Major depressive episodes can occur in both Major Depressive Disorder and Bipolar Disorder. Unopposed antidepressant monotherapy in a patient with bipolar disorder can precipitate a manic switch. Therefore, all patients must be screened for past manic/hypomanic episodes before antidepressants are prescribed.

Key Concept

Prior to initiating antidepressant monotherapy for a major depressive episode, patients must be explicitly screened for a history of manic or hypomanic episodes to rule out bipolar disorder and prevent antidepressant-induced mania.
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Topics

Depressive Disorders

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