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Difficulty: MediumDepressive Disorders

During a routine visit to an outpatient clinic, a 29-year-old woman reports a 2-month history of persistent sadness, tearfulness, and profound fatigue. She states she has lost interest in reading and hiking, activities she previously enjoyed every weekend. The patient notes she has been waking up at 3 AM daily and is unable to fall back asleep. She has lost 4 kg (8.8 lb) over this period without actively dieting. She denies any substance use or suicidal ideation. She has no significant past medical history and currently takes no medications. Her physical examination is unremarkable. The patient requests to be started on a medication to help her mood, noting that a family member had significant improvement with fluoxetine. Which of the following is the most appropriate next step in the clinical evaluation of this patient?

  1. Ascertain if the patient has experienced prior periods of abnormally elevated mood and increased goal-directed activity.Answer
  2. B
    Initiate therapy with fluoxetine and schedule a follow-up appointment in one month to assess tolerability.
  3. C
    Determine if the patient has had hallucinations or delusions that lasted for at least two weeks in the absence of mood symptoms.
  4. D
    Prescribe the requested medication and counsel the patient on the necessity of a low-tyramine diet to prevent a hypertensive crisis.
  5. E
    Order a thyroid-stimulating hormone level and delay any further psychiatric history-taking until biochemical hypothyroidism is ruled out.

Answer

The most appropriate next step is to ascertain if the patient has experienced prior periods of abnormally elevated mood and increased goal-directed activity.
The correct action is to screen for a history of abnormally elevated mood and increased goal-directed activity. This patient presents with a classic major depressive episode. However, before prescribing any antidepressant monotherapy (such as the requested fluoxetine), it is mandatory to screen for a past history of manic or hypomanic episodes. If a patient has a history of mania or hypomania, the underlying diagnosis is bipolar disorder. Prescribing an antidepressant without a concurrent mood stabilizer in a patient with bipolar disorder carries a significant risk of inducing a manic episode, commonly known as a manic switch.

Step-by-Step Solution

1
Analyze the patient's presenting clinical symptoms.
The patient meets the diagnostic criteria for a major depressive episode based on low mood, anhedonia, early morning awakening, weight loss, and duration of 2 months.
To establish the current clinical syndrome requiring management.
2
Evaluate the patient's request for treatment.
The patient is requesting an antidepressant (fluoxetine) for her depressive symptoms.
To determine the potential risks and required screening before fulfilling the treatment request.
3
Determine the necessary safety screening prior to initiating antidepressant pharmacotherapy.
Screening for a history of manic or hypomanic episodes must be performed to differentiate unipolar depression from bipolar depression.
Antidepressant monotherapy in a patient with undiagnosed bipolar disorder can precipitate a dangerous manic switch.

Key Concept

Before initiating antidepressant monotherapy for a major depressive episode, clinicians must screen for a history of mania or hypomania to rule out bipolar disorder and prevent antidepressant-induced manic switching.
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Topics

Depressive Disorders

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