Question

A 58-year-old man is brought to the clinic by his wife due to an $8$-month history of progressive behavioral changes. His wife reports that he has become increasingly apathetic and socially withdrawn, frequently neglecting his personal hygiene. He recently began compulsively hoarding empty glass bottles and has made sexually explicit remarks to neighbors, which is entirely out of character. The patient has a history of bipolar I disorder following a single manic episode at age 22, but he has been euthymic and off psychiatric medications for over $30$ years. Mental status examination reveals an alert and oriented patient with a blunted affect. He displays poor insight and disinhibition during the interview. Memory recall is 3/3 after $5$ minutes, but he exhibits significant impairment on the Trail Making Test Part B. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $0.2 \mu U/mL$ (Normal: $0.4-4.0 \mu U/mL$) and a free thyroxine (T4) level of $0.6 ng/dL$ (Normal: $0.9-1.7 ng/dL$). The patient has a legally executed advance directive designating his eldest daughter as his sole healthcare proxy. However, the daughter is not present, and the wife vehemently demands the physician immediately start an antidepressant, believing his symptoms represent a severe depressive relapse. Which of the following is the most appropriate next step in management?