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Question

Difficulty: HardDepressive Disorders

A 32-year-old woman is evaluated in the outpatient psychiatric clinic for worsening mood. She delivered a healthy full-term infant 2 months ago. For the last 3 weeks, she has experienced profound sadness, anhedonia, loss of appetite resulting in a 3-kg (6.6-lb) weight loss, and extreme guilt about being a "terrible mother." For the past week, she reports hearing a persistent, derogatory voice telling her she should "disappear." Her husband notes that 6 years ago, she had a 3-week period where she abruptly quit her job, slept only 2 hours per night but felt fully energetic, exhibited pressured speech, and maxed out their credit cards. This previous episode required a brief psychiatric hospitalization, but she stopped taking her prescribed medications 5 years ago. She currently takes no medications. Vital signs are within normal limits. On examination, she exhibits a blunted affect and psychomotor retardation. Which of the following is the most appropriate next step in management?

  1. Initiate quetiapine monotherapyAnswer
  2. B
    Initiate sertraline monotherapy
  3. C
    Initiate risperidone for schizophreniform disorder
  4. D
    Initiate combination therapy with citalopram and phenelzine
  5. E
    Evaluate for primary hypothyroidism expecting a low TSH and low free T4

Answer

The most appropriate next step is to initiate quetiapine monotherapy.
The correct action is to initiate quetiapine monotherapy. This patient is currently experiencing a major depressive episode with psychotic features (auditory hallucinations, profound sadness, guilt, weight loss). However, her history of a distinct episode characterized by a decreased need for sleep, pressured speech, impulsivity, and hospitalization definitively indicates a past manic episode. Therefore, her underlying diagnosis is bipolar I disorder, and she is currently experiencing bipolar depression with psychotic features. Quetiapine is an atypical antipsychotic that is FDA-approved for bipolar depression; it will simultaneously target both her severe mood symptoms and her psychotic features without carrying the risk of inducing a manic switch.

Step-by-Step Solution

1
Identify the current clinical syndrome from the presentation.
The patient has a 3-week history of severe depressive symptoms and a 1-week history of auditory hallucinations, indicating a major depressive episode with psychotic features.
Characterizing the current episode is necessary before determining the overarching psychiatric diagnosis.
2
Review the patient's psychiatric history for previous mood episodes.
The patient had a distinct 3-week episode of decreased need for sleep, pressured speech, and reckless behavior requiring hospitalization.
A history of a manic episode changes the diagnosis from unipolar major depressive disorder to bipolar I disorder.
3
Formulate the correct comprehensive diagnosis.
The diagnosis is bipolar I disorder, currently in a depressive phase with psychotic features, with postpartum onset.
Accurate diagnosis prevents the use of contraindicated medications like SSRI monotherapy.
4
Select the appropriate pharmacological treatment.
Quetiapine is chosen as the next step in management.
Bipolar depression with psychotic features requires an agent that provides mood stabilization and antipsychotic effects. Quetiapine is an atypical antipsychotic approved for bipolar depression.

Key Concept

Discrimination between unipolar and bipolar depression with psychotic features, and selection of appropriate mood-stabilizing pharmacotherapy.
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Topics

Depressive Disorders

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