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Difficulty: MediumBipolar and Related Disorders

A 28-year-old male fitness coach presents to the psychiatry clinic with a 5-week history of profound sadness, anhedonia, and sleeping up to 14 hours a day. He reports significant fatigue and difficulty concentrating on his clients' workout plans. Past psychiatric history reveals an episode 3 years ago characterized by 10 days of feeling "invincible," sleeping only 2 hours nightly, and maxing out several credit cards to start an ill-advised supplement company. His medical history is unremarkable. Vital signs are within normal limits. Mental status examination reveals psychomotor retardation, poor eye contact, and a constricted affect. Which of the following pharmacological interventions are appropriate for the acute management of this patient's current episode? (Select all that apply)

  1. Prescribe lurasidoneAnswer
  2. Prescribe olanzapine combined with fluoxetineAnswer
  3. C
    Prescribe sertraline as a single agent
  4. D
    Prescribe bupropion as a single agent
  5. E
    Prescribe amitriptyline as a single agent

Answer

The appropriate interventions are prescribing lurasidone and prescribing olanzapine combined with fluoxetine.
The patient's presentation of a major depressive episode accompanied by a clear history of a manic episode (decreased need for sleep, grandiosity, and severe impulsivity lasting at least 7 days) confirms the diagnosis of Bipolar I Disorder, currently in a depressed episode. The pharmacological treatment of acute bipolar depression differs significantly from unipolar depression. First-line treatments with demonstrated efficacy and safety include lurasidone, quetiapine, cariprazine, and the olanzapine-fluoxetine combination. These agents target depressive symptoms without excessively risking mood destabilization.

Step-by-Step Solution

1
Evaluate the current presenting symptoms.
The patient has a 5-week history of profound sadness, anhedonia, hypersomnia, and fatigue.
These symptoms fulfill the DSM-5 criteria for a major depressive episode.
2
Analyze the patient's past psychiatric history.
The patient experienced a 10-day episode of grandiosity, decreased need for sleep, and severe impulsivity (financial irresponsibility).
This distinct period of elevated mood and increased energy lasting over 7 days confirms a past manic episode.
3
Formulate the correct overarching diagnosis.
The combination of a lifetime manic episode and a current depressive episode yields a diagnosis of Bipolar I Disorder, current episode depressed.
A single manic episode is sufficient to diagnose Bipolar I Disorder, distinguishing it from Major Depressive Disorder.
4
Determine the appropriate evidence-based pharmacological treatments.
Lurasidone and the olanzapine-fluoxetine combination are selected.
These medications are first-line treatments with established efficacy for acute bipolar depression that do not carry the high risk of mood destabilization seen with antidepressant monotherapy.

Key Concept

The first-line pharmacological management of acute bipolar depression includes agents such as lurasidone, quetiapine, cariprazine, or the olanzapine-fluoxetine combination, while strictly avoiding antidepressant monotherapy.
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Topics

Bipolar and Related Disorders

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