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Difficulty: MediumBipolar and Related Disorders

A 26-year-old female dental hygienist comes to the outpatient psychiatry clinic reporting two months of profound sadness, lack of motivation, and sleeping 12 to 14 hours a day. She states she has lost interest in her usual hobbies and feels intense, inappropriate guilt regarding a recent decline in her work performance. She has gained 5 kg (11 lb) over this period. Her medical history is unremarkable, and she currently takes no medications. Vital signs and physical examination are within normal limits. When specifically asked about past mood fluctuations, the patient recalls a distinct five-day period during her sophomore year of college when she felt "supercharged." During that time, she required only 3 hours of sleep per night, started multiple complex art projects, and felt highly productive. That period did not result in hospitalization or significant functional impairment. Mental status examination today reveals a cooperative woman with a blunted affect, psychomotor retardation, and slow speech. She denies suicidal ideation, auditory hallucinations, and paranoia. Which of the following is the most appropriate next step in pharmacotherapy?

  1. QuetiapineAnswer
  2. B
    Escitalopram
  3. C
    Venlafaxine
  4. D
    Amitriptyline
  5. E
    Bupropion

Answer

Quetiapine
The correct answer is Quetiapine. This patient's current presentation of hypersomnia, hyperphagia, and profound sadness indicates a major depressive episode. However, her history of a five-day period of elevated mood, decreased need for sleep, and increased goal-directed activity without significant functional impairment or hospitalization perfectly describes a hypomanic episode. Therefore, her diagnosis is Bipolar II disorder. The first-line pharmacological treatment for acute bipolar depression includes certain second-generation antipsychotics (such as quetiapine, lurasidone, and cariprazine) or the mood stabilizer lamotrigine. Quetiapine provides acute relief of depressive symptoms without the high risk of inducing a manic switch.

Step-by-Step Solution

1
Analyze the patient's presenting symptoms and psychiatric history.
The patient is currently in a major depressive episode (sadness, hypersomnia, weight gain) but has a history of a distinct 5-day period of elevated mood, decreased need for sleep, and increased activity without severe impairment.
Identifying past mood episodes is necessary to differentiate unipolar major depressive disorder from bipolar spectrum disorders.
2
Establish the correct diagnosis based on DSM-5 criteria.
The diagnosis is Bipolar II disorder, characterized by at least one major depressive episode and at least one hypomanic episode (lasting ≥\geq 4 days).
Accurate diagnosis dictates the pharmacological approach and prevents harmful prescribing errors.
3
Select the appropriate pharmacotherapy for acute bipolar depression.
Quetiapine is selected. All traditional antidepressant monotherapies are contraindicated.
Antidepressant monotherapy can precipitate a manic switch. Quetiapine is an FDA-approved second-generation antipsychotic for treating acute bipolar depression.

Key Concept

Patients presenting with major depressive episodes must be screened for past manic or hypomanic episodes to rule out bipolar disorder; if bipolar disorder is diagnosed, antidepressant monotherapy is contraindicated due to the risk of a manic switch, and agents like quetiapine, lurasidone, or lamotrigine should be used.
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Topics

Bipolar and Related Disorders

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