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Difficulty: HardDepressive Disorders

A 24-year-old woman is evaluated in the psychiatric clinic for worsening mood. For the past two months, she has experienced pervasive sadness, anhedonia, hypersomnia (sleeping 12 to 14 hours a day), and a 6-kg (13-lb) weight gain. She describes her arms and legs as feeling "heavy like lead," though she notes her mood brightens temporarily when her sister comes to visit. Three years ago, she was hospitalized for a one-week episode during which she slept only two hours a night, spoke extremely rapidly, and spent her entire savings. During that admission, she heard a voice telling her she was a prophet, but this hallucination resolved completely within 5 days alongside her other symptoms after she received acute treatment. She is currently taking fluoxetine, which was prescribed by her primary care physician three weeks ago, but she reports no improvement.

Which of the following is the most appropriate next step in management?

  1. Diagnose bipolar I disorder; discontinue fluoxetine and initiate quetiapineAnswer
  2. B
    Diagnose major depressive disorder; discontinue fluoxetine and initiate sertraline
  3. C
    Diagnose atypical depression; continue fluoxetine and add phenelzine
  4. D
    Diagnose schizophreniform disorder; discontinue fluoxetine and initiate risperidone
  5. E
    Diagnose schizophrenia; discontinue fluoxetine and initiate haloperidol

Answer

Diagnose bipolar I disorder; discontinue fluoxetine and initiate quetiapine
The correct answer accurately synthesizes the patient's current atypical depressive episode with her past history of a manic episode (decreased sleep, pressured speech, grandiosity, reckless spending requiring hospitalization for 1 week) to diagnose bipolar I disorder. Because SSRI monotherapy can trigger a manic switch in patients with bipolar disorder, the current fluoxetine must be stopped. Quetiapine is a second-generation antipsychotic with FDA approval and strong efficacy for treating acute bipolar depression.

Step-by-Step Solution

1
Analyze the current clinical presentation.
The patient is experiencing a severe depressive episode characterized by atypical features, including hypersomnia, leaden paralysis, weight gain, and mood reactivity.
To establish the current mood state.
2
Evaluate the psychiatric history for prior mood episodes.
The patient had a prior episode of decreased need for sleep, pressured speech, and reckless spending lasting one week and requiring hospitalization. This definitively meets the criteria for a manic episode.
To differentiate between unipolar major depressive disorder and bipolar disorder.
3
Assess the timing and duration of past psychotic symptoms.
The hallucinations (hearing a voice) occurred exclusively during the one-week manic episode and resolved simultaneously with the mood symptoms.
To rule out primary psychotic disorders (schizophrenia, schizophreniform) or schizoaffective disorder, which require different timelines or psychosis in the absence of mood episodes.
4
Determine the correct diagnosis and the safest next step in pharmacological management.
The diagnosis is bipolar I disorder, currently depressed. The current fluoxetine (an SSRI) must be discontinued to avoid inducing mania, and a bipolar-appropriate agent like quetiapine should be initiated.
SSRI monotherapy is contraindicated in bipolar disorder, whereas quetiapine is an FDA-approved first-line treatment for bipolar depression.

Key Concept

Patients presenting with depressive episodes must be carefully screened for a history of mania; if bipolar I disorder is diagnosed, SSRI monotherapy should be discontinued to prevent a manic switch, and an appropriate agent like quetiapine should be initiated.
Estimated Time:1m 30s
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Topics

Depressive Disorders

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