Examkin

Question

Difficulty: EasyDepressive Disorders

A 24-year-old graduate student presents to the clinic reporting that she has felt "down and empty" for the past 6 weeks. She describes poor appetite, waking up multiple times during the night, low energy, and an inability to enjoy her usual hobbies. She feels guilty about her recently declining academic performance. She has no significant past medical history and takes no medications. Her physical examination is unremarkable. The physician determines that she meets the criteria for a major depressive episode and considers initiating pharmacotherapy with an antidepressant. Which of the following is the most appropriate next step in the psychiatric evaluation prior to prescribing this medication?

  1. Assess for a history of elevated mood, rapid speech, and decreased need for sleepAnswer
  2. B
    Initiate monotherapy with fluoxetine immediately to address her depressive symptoms
  3. C
    Begin treatment with haloperidol to prevent the development of psychotic features
  4. D
    Prescribe levothyroxine to empirically treat potential subclinical hypothyroidism
  5. E
    Combine a selective serotonin reuptake inhibitor with a monoamine oxidase inhibitor for rapid relief

Answer

Assess for a history of elevated mood, rapid speech, and decreased need for sleep
The correct answer is to assess for a history of elevated mood, rapid speech, and decreased need for sleep. A major depressive episode can be the presenting phase of either Major Depressive Disorder (unipolar depression) or Bipolar Disorder. The DSM-5 criteria for Major Depressive Disorder explicitly state that there must never have been a manic or hypomanic episode. Furthermore, prescribing antidepressant monotherapy (such as an SSRI or SNRI) to a patient with unrecognized bipolar disorder carries a significant risk of inducing a manic switch. Therefore, screening for past hypomania or mania is a mandatory step before initiating antidepressant treatment.

Step-by-Step Solution

1
Identify the primary clinical syndrome.
The patient has a 6-week history of low mood, anhedonia, insomnia, fatigue, and guilt, meeting the criteria for a major depressive episode.
Establishing the current syndrome is the first step in psychiatric diagnosis.
2
Determine the safety requirements before initiating antidepressant therapy.
Antidepressants can trigger a manic episode in patients with bipolar disorder. Therefore, a major depressive episode cannot be definitively diagnosed as Major Depressive Disorder until a history of mania or hypomania is ruled out.
Diagnostic criteria for Major Depressive Disorder explicitly require that there has never been a manic or hypomanic episode.
3
Select the appropriate next clinical action.
The clinician must ask about prior episodes of elevated mood, decreased need for sleep, and increased energy/activity.
This screening prevents the iatrogenic harm of inducing a manic switch with antidepressant monotherapy.

Key Concept

Prior to prescribing antidepressant monotherapy for a major depressive episode, clinicians must screen for a history of mania or hypomania to rule out bipolar disorder and prevent an iatrogenic manic switch.
Rate this question

Topics

Depressive Disorders

More questions from this topic