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Difficulty: MediumBipolar and Related Disorders

A 28-year-old woman is brought to the psychiatric outpatient clinic by her husband due to profound sadness, hypersomnia, and a 4.5-kg (10-lb) weight gain over the past 4 weeks. She reports feeling "slowed down" and states that she has begun hearing a voice repeatedly telling her she is worthless. Review of her medical history reveals that 2 years ago, she experienced a distinct 2-week period where she slept only 2 hours a night without feeling fatigued, spent their entire savings on luxury vehicles, and claimed she could communicate directly with angels; this episode required hospitalization. Her current medications include isocarboxazid, which was prescribed 2 weeks ago by a different physician for her depression. Vital signs are within normal limits. Physical examination shows a depressed affect and psychomotor retardation. Laboratory studies show a free thyroxine (T4) level of 0.5 ng/dL (normal: 0.9–1.7 ng/dL) and a thyroid-stimulating hormone (TSH) level of 1.5 µU/mL (normal: 0.5–5.0 µU/mL). Which of the following statements is most accurate regarding this patient's diagnosis and management?

  1. Her presentation is consistent with bipolar I disorder, currently in a depressed episode with psychotic features.Answer
  2. B
    Initiation of fluoxetine monotherapy is the most appropriate next step to manage her severe depressive symptoms.
  3. C
    Addition of citalopram to her current isocarboxazid regimen is indicated for synergistic antidepressant effects.
  4. D
    Her previous 2-week episode of hallucinations and grandiosity meets the diagnostic timeframe criteria for schizophreniform disorder.
  5. E
    Her laboratory findings confirm inadequately treated primary hypothyroidism as the underlying etiology of her symptoms.

Answer

Her presentation is consistent with bipolar I disorder, currently in a depressed episode with psychotic features.
The correct answer accurately synthesizes the patient's longitudinal history. A single manic episode (characterized by elevated mood, grandiosity, decreased need for sleep, and functional impairment lasting at least 1 week) is sufficient to diagnose bipolar I disorder. Her current symptoms of anhedonia, hypersomnia, weight gain, and mood-congruent auditory hallucinations signify a major depressive episode with psychotic features.

Step-by-Step Solution

1
Analyze the patient's prior psychiatric history.
The patient had a 2-week episode of grandiosity, decreased need for sleep, excessive spending, and hallucinations requiring hospitalization.
This establishes a history of a manic episode, which confirms a diagnosis of bipolar I disorder.
2
Assess the patient's current clinical presentation.
She presents with sadness, hypersomnia, weight gain, and auditory hallucinations for 4 weeks.
This meets the criteria for a major depressive episode with mood-congruent psychotic features.
3
Evaluate the laboratory findings.
Low free T4 (0.5 ng/dL) with a normal TSH (1.5 µU/mL).
This rules out primary hypothyroidism, which would present with an elevated TSH.
4
Evaluate the safety of pharmacologic interventions in the context of her current medications.
She is taking an MAOI (isocarboxazid). Adding an SSRI would cause serotonin syndrome. Furthermore, SSRI monotherapy is contraindicated in bipolar disorder.
This rules out options suggesting the use of fluoxetine or citalopram.

Key Concept

Diagnosis of bipolar I disorder requires at least one manic episode; SSRI monotherapy is contraindicated in bipolar depression due to the risk of a manic switch.
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Topics

Bipolar and Related Disorders

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