Match each patient's clinical presentation with the most appropriate next step in management.
- A 58-year-old man presents with a 4-week history of pervasive sadness, anhedonia, early morning awakenings, and a 10-lb weight loss. These symptoms began shortly after he suffered an uncomplicated acute myocardial infarction. He has no prior psychiatric history.Initiate sertraline monotherapy
- A 27-year-old woman complains of a 6-week history of severe depression, sleeping 12 hours a day, increased appetite, and feeling like her arms and legs are "made of lead." She casually mentions that during college, she had a 5-day episode where she felt euphoric, needed only 2 hours of sleep a night, and impulsively bought $5,000 worth of designer clothes.Initiate quetiapine monotherapy
- A 32-year-old woman is brought to the emergency department by her husband 3 weeks after giving birth to a healthy term infant. She exhibits a severely depressed mood, psychomotor retardation, and tearfully confesses that she is hearing a voice telling her that her baby is demonically possessed and must be drowned.Admit to an inpatient psychiatric unit for acute stabilization
- A 35-year-old man with major depressive disorder has been treated with escitalopram 20 mg daily for the past 8 weeks. He reports his mood has improved and he is no longer tearful, but he continues to struggle significantly with low energy, poor concentration, and an inability to focus on his work.Augment current antidepressant regimen with bupropion
Answer
The post-MI patient requires sertraline; the bipolar II patient requires quetiapine; the postpartum psychotic patient requires inpatient admission; the partial SSRI responder with fatigue requires bupropion augmentation.
Each clinical presentation dictates a specific algorithmic path in managing depressive disorders. Cardiovascular safety dictates sertraline post-MI. A history of hypomania dictates bipolar-specific therapies like quetiapine and contraindicates SSRI monotherapy. Psychosis with risk of harm to a newborn dictates immediate inpatient admission. Residual fatigue on an SSRI dictates bupropion augmentation to target dopamine and norepinephrine.
Step-by-Step Solution
Key Concept
Individualizing the management of depressive disorders requires screening for bipolar disorder, assessing for medical comorbidities (e.g., recent myocardial infarction), recognizing psychiatric emergencies (e.g., psychosis with risk of harm), and tailoring pharmacotherapy to residual symptoms.
Estimated Time:2m 0s