Examkin

Question

Difficulty: HardBipolar and Related Disorders

A 30-year-old male chef is brought to the emergency department by his husband due to worsening suicidal ideation. For the past month, the patient has experienced profound sadness, a 7-kg (15-lb) weight gain, hypersomnia, and a complete lack of energy. He has a history of major depressive disorder diagnosed in his early twenties. His husband reports that three years ago, the patient had a 3-week period where he slept only two hours per night, spoke so rapidly he was difficult to interrupt, and developed grandiose delusions that he had discovered the cure for aging. These delusions completely resolved when his mood returned to baseline. The patient is currently not taking any prescribed medications but consumes a high-dose St. John's wort supplement daily. Vital signs are within normal limits. Mental status examination reveals a cooperative patient with depressed mood, flattened affect, and psychomotor retardation. He denies current hallucinations or delusions. Which of the following is the most appropriate next step in management?

  1. Initiate lurasidoneAnswer
  2. B
    Initiate sertraline
  3. C
    Initiate venlafaxine
  4. D
    Initiate tranylcypromine
  5. E
    Initiate long-acting injectable paliperidone

Answer

Initiate lurasidone
This patient's history of a distinct period of decreased need for sleep, rapid speech, and grandiose delusions is diagnostic of a prior manic episode. Because the psychotic symptoms (delusions) resolved concurrently with the mood symptoms, the correct diagnosis is Bipolar I Disorder, not schizoaffective disorder. He is currently presenting with an acute bipolar depressive episode. First-line pharmacotherapy for acute bipolar depression includes specific second-generation antipsychotics such as lurasidone, quetiapine, or cariprazine. Lurasidone effectively targets the depressive symptoms without carrying the high risk of inducing a manic switch.

Step-by-Step Solution

1
Analyze the patient's past psychiatric history.
The patient had a distinct 3-week period of decreased sleep, rapid speech, and grandiose delusions that resolved with his mood.
Identifying past episodes of mania or hypomania is required to differentiate bipolar disorder from major depressive disorder.
2
Determine the correct diagnosis.
The history of a manic episode establishes a diagnosis of Bipolar I Disorder. The current presentation is an acute depressive episode.
The presence of delusions during the manic episode indicates bipolar disorder with psychotic features. Because the psychosis did not occur outside the mood episode, schizoaffective disorder is ruled out.
3
Select the appropriate pharmacotherapy.
Lurasidone is selected as it is a first-line agent for acute bipolar depression.
Antidepressant monotherapy must be avoided to prevent a manic switch, and potential drug interactions with St. John's wort must be considered.

Key Concept

Patients with Bipolar I Disorder presenting with an acute depressive episode should be treated with mood stabilizers or specific second-generation antipsychotics (e.g., lurasidone, quetiapine) to avoid the high risk of antidepressant-induced manic switch.
Rate this question

Topics

Bipolar and Related Disorders

More questions from this topic