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Difficulty: EasyDepressive Disorders

A concerned spouse brings her 28-year-old husband to the office for evaluation of severe lethargy and persistent low mood. For the past month, the patient has spent most days in bed, stopped attending his weekly basketball games, and experienced a 4-kg (9-lb) weight gain. During the interview, he appears visibly psychomotor retarded. Further history gathering from the spouse reveals a distinct two-week timeframe last summer when the patient slept roughly two hours nightly, exhibited pressured speech, and impulsively purchased an expensive sports car he could not afford. The patient is physically healthy and takes zero prescription or over-the-counter supplements. Which of the following is the most appropriate pharmacotherapy for this patient's current episode?

  1. QuetiapineAnswer
  2. B
    Escitalopram
  3. C
    Venlafaxine
  4. D
    Fluoxetine and phenelzine
  5. E
    Observation for six months to exclude schizophreniform disorder

Answer

Quetiapine
Quetiapine is a second-generation antipsychotic with mood-stabilizing properties, and it is an appropriate, FDA-approved treatment for bipolar depression. This patient's history of a distinct manic episode (decreased sleep, pressured speech, marked impulsivity) indicates a diagnosis of bipolar disorder rather than unipolar major depressive disorder. In bipolar depression, mood stabilizers or specific atypical antipsychotics are required, whereas antidepressant monotherapy is contraindicated.

Step-by-Step Solution

1
Identify the patient's current clinical syndrome.
The patient has a 1-month history of severe low mood, anhedonia, hypersomnia, and psychomotor retardation, consistent with a major depressive episode.
Establishing the current phase of the psychiatric illness is the first step in evaluation.
2
Evaluate the patient's past psychiatric history.
The spouse describes a prior 2-week episode of decreased sleep, pressured speech, and impulsivity, consistent with a past manic episode.
Past history is critical to distinguish unipolar depression from bipolar disorder.
3
Establish the comprehensive diagnosis.
The combination of a past manic episode and a current major depressive episode solidifies the diagnosis of bipolar I disorder, currently depressed.
The correct diagnosis dictates the safety and efficacy of pharmacological options.
4
Select the appropriate pharmacotherapy.
Quetiapine is an FDA-approved medication for bipolar depression, whereas antidepressant monotherapy is avoided.
Antidepressants can precipitate a manic switch in patients with bipolar disorder.

Key Concept

Patients presenting with a major depressive episode must be screened for a history of mania or hypomania; bipolar depression should be treated with mood stabilizers or specific atypical antipsychotics (e.g., quetiapine, lurasidone) rather than antidepressant monotherapy to avoid precipitating a manic switch.
Estimated Time:1m 0s
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Topics

Depressive Disorders

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