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Difficulty: EasyBipolar and Related Disorders

A 23-year-old woman comes to the clinic reporting profound sadness, low energy, and poor concentration over the past 6 weeks. She sleeps up to 12 hours a day and has lost interest in her usual hobbies. Her medical history is notable for a psychiatric hospitalization three years ago. At that time, she experienced a two-week period of feeling 'invincible,' requiring only 2 to 3 hours of sleep per night, and impulsively spending her entire savings on luxury handbags. Her current vital signs and physical examination are unremarkable. Laboratory results, including a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone (TSH) level, are within normal limits. Which of the following is the most appropriate initial medication for this patient's current symptoms?

  1. A
    Amitriptyline
  2. B
    Levothyroxine
  3. Lithium carbonateAnswer
  4. D
    Haloperidol
  5. E
    Citalopram

Answer

Lithium carbonate
The correct answer is Lithium carbonate. This patient's current presentation of prolonged sadness and hypersomnia represents a major depressive episode. However, her history of a severe, hospitalized episode characterized by a decreased need for sleep, grandiosity, and excessive spending confirms a diagnosis of bipolar I disorder. The cornerstone of treatment for bipolar depression includes mood stabilizers (such as lithium or valproate) and certain second-generation antipsychotics (such as quetiapine or lurasidone). Lithium is highly effective in treating acute bipolar depression and serves as an excellent maintenance therapy to prevent future manic and depressive relapses.

Step-by-Step Solution

1
Analyze the current clinical presentation.
The patient has a 6-week history of depressed mood, hypersomnia, and anhedonia, indicating a major depressive episode.
To determine the acuity and phase of the current mood disturbance.
2
Evaluate the past psychiatric history.
The patient had a previous 2-week episode of grandiosity, decreased need for sleep, and excessive spending requiring hospitalization, which meets the criteria for a manic episode.
To differentiate between major depressive disorder (unipolar) and bipolar disorder.
3
Establish the diagnosis.
Bipolar I disorder, current episode depressed.
A lifetime history of at least one manic episode defines Bipolar I disorder, regardless of the current symptom presentation.
4
Select the appropriate pharmacotherapy.
Lithium carbonate.
Lithium is a first-line agent for acute bipolar depression. Antidepressant monotherapy is contraindicated due to the risk of inducing a manic switch.

Key Concept

Patients presenting with depressive symptoms must be screened for a history of mania. Bipolar depression requires treatment with mood stabilizers (e.g., lithium, valproate) or approved atypical antipsychotics; antidepressant monotherapy is contraindicated due to the risk of precipitating a manic switch.
Estimated Time:45s
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Topics

Bipolar and Related Disorders

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