Examkin

Question

Difficulty: HardBipolar and Related Disorders

A 23-year-old female law student is evaluated at the university student health clinic for a 4-week history of depressed mood, sleeping up to 14 hours a day, significant weight gain, leaden paralysis, and an inability to concentrate on her coursework. Her medical history is unremarkable. A detailed psychiatric history reveals that one year ago, she experienced a 3-week period where she felt 'invincible,' required only 2 hours of sleep per night, exhibited hypersexuality, and spent thousands of dollars on luxury items, which ultimately resulted in a brief psychiatric hospitalization. She is currently medically stable and taking no medications. The physician is planning the next steps in her management. Which of the following interventions are appropriate for this patient? (Select all that apply)

  1. Initiate quetiapine monotherapyAnswer
  2. Initiate lurasidone monotherapyAnswer
  3. C
    Initiate escitalopram monotherapy
  4. D
    Initiate a combination of citalopram and phenelzine
  5. E
    Disclose her diagnosis to the law school administration without her consent to facilitate academic accommodations

Answer

The correct interventions are to initiate quetiapine monotherapy and to initiate lurasidone monotherapy.
The patient is experiencing an acute depressive episode in the context of bipolar I disorder. Both quetiapine and lurasidone are second-generation antipsychotics with demonstrated efficacy and FDA approval as first-line monotherapy options for bipolar depression. They effectively target depressive symptoms without carrying a significant risk of inducing a manic switch.

Step-by-Step Solution

1
Identify the primary diagnosis based on the clinical history.
The patient has a history of a distinct manic episode (decreased sleep, hypersexuality, excessive spending leading to hospitalization) and currently presents with a major depressive episode. This confirms the diagnosis of bipolar I disorder, most recent episode depressed.
Establishing the correct polarity and subtype of the mood disorder is essential before selecting appropriate pharmacotherapy and avoiding harmful agents.
2
Evaluate the appropriateness of the proposed pharmacological interventions for bipolar depression.
Quetiapine and lurasidone are evidence-based, first-line monotherapies for bipolar depression. Escitalopram monotherapy is contraindicated due to the risk of manic switch. The combination of citalopram and phenelzine is contraindicated due to the risk of serotonin syndrome.
Treatment of bipolar depression differs significantly from unipolar depression; standard antidepressants must be avoided as monotherapy.
3
Evaluate the ethical action proposed.
Disclosing the diagnosis to the law school without the patient's explicit consent is an inappropriate breach of confidentiality.
There is no imminent threat of serious harm to the patient or others that would legally or ethically justify overriding her right to privacy.

Key Concept

First-line pharmacotherapy and contraindications in the management of acute bipolar I depression.
Rate this question

Topics

Bipolar and Related Disorders

More questions from this topic