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Difficulty: MediumPsychopharmacology and Psychological Therapies

A 24-year-old woman comes to the outpatient psychiatric clinic due to a 4-week history of feeling severely depressed, lacking energy, and sleeping 12 to 14 hours a day. She reports a loss of interest in her usual hobbies and a 5-kg (11-lb) weight gain over this period. The patient has no significant past medical history. Upon further questioning, the patient's roommate states that 8 months ago, the patient had a 10-day episode where she was extremely energetic, required only 3 hours of sleep per night, and spoke so rapidly it was difficult to interrupt her. During that time, she spontaneously booked an expensive, non-refundable trip to Europe that she could not afford. She was not hospitalized and eventually returned to her baseline. Which of the following is the most appropriate pharmacotherapy for this patient's current condition?

  1. A
    Sertraline
  2. B
    Venlafaxine
  3. QuetiapineAnswer
  4. D
    Nortriptyline
  5. E
    Dextroamphetamine

Answer

The correct answer is quetiapine, which is indicated for the treatment of acute bipolar depression.
The correct answer is quetiapine. This patient's current presentation of depressed mood, hypersomnia, weight gain, and anhedonia is consistent with a major depressive episode. However, her history of a distinct 10-day period of elevated energy, decreased need for sleep, pressured speech, and impulsive behavior indicates a past manic or hypomanic episode. Therefore, her underlying diagnosis is bipolar disorder, and she is currently experiencing acute bipolar depression. The most appropriate initial pharmacotherapy for acute bipolar depression includes certain second-generation antipsychotics (e.g., quetiapine, lurasidone) or mood stabilizers (e.g., lithium, lamotrigine). Quetiapine is FDA-approved as a monotherapy for this condition and is an excellent first-line choice.

Step-by-Step Solution

1
Identify the patient's current clinical syndrome.
The patient is experiencing a major depressive episode, characterized by depressed mood, hypersomnia, weight gain, fatigue, and anhedonia for 4 weeks.
Establishing the current phase of the mood disorder is necessary to guide symptom-specific treatment.
2
Evaluate the patient's psychiatric history for prior mood episodes.
The patient had a previous 10-day episode of decreased need for sleep, rapid speech, increased energy, and impulsivity (booking an expensive trip).
A history of mania or hypomania fundamentally changes the diagnosis from major depressive disorder to bipolar disorder.
3
Determine the appropriate pharmacotherapy for acute bipolar depression.
Select an agent with proven efficacy for bipolar depression that does not risk inducing a manic switch, such as quetiapine.
Antidepressant monotherapy is contraindicated in bipolar disorder due to the risk of mood destabilization and manic switch.

Key Concept

Management of acute bipolar depression and avoidance of antidepressant monotherapy
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Topics

Psychopharmacology and Psychological Therapies

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