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Difficulty: EasyBipolar and Related Disorders

A 26-year-old male software engineer is evaluated in the clinic for a 4-week history of low mood, hypersomnia, and poor concentration. He reports that he feels exhausted despite sleeping up to 12 hours a day and has lost interest in his usual hobbies. He has no significant past medical history. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 2.1 µU/mL (normal: 0.5-5.0 µU/mL) and free T4 of 1.2 ng/dL (normal: 0.9-1.7 ng/dL). During the psychiatric interview, the patient casually mentions that three years ago he experienced a two-week period where he felt 'invincible.' During that time, he slept only 3 hours per night, had racing thoughts, and spent his entire life savings on impulsive business ventures. He is not currently taking any medications. Which of the following is the most appropriate next step in the management of this patient?

  1. Initiate quetiapineAnswer
  2. B
    Initiate escitalopram
  3. C
    Initiate levothyroxine
  4. D
    Initiate escitalopram and phenelzine
  5. E
    Diagnose schizophreniform disorder and initiate risperidone

Answer

The most appropriate next step is to initiate quetiapine.
The patient is presenting with a major depressive episode but has a distinct history of a manic episode (decreased need for sleep, racing thoughts, impulsive spending lasting at least one week), confirming the diagnosis of Bipolar I Disorder. First-line pharmacotherapy for acute bipolar depression includes specific second-generation antipsychotics (e.g., quetiapine, lurasidone) or mood stabilizers (e.g., lithium) to effectively treat the depressive symptoms without precipitating a manic switch.

Step-by-Step Solution

1
Identify the current clinical syndrome.
The patient has had low mood, hypersomnia, and anhedonia for 4 weeks, indicating a major depressive episode.
Establishing the current phase of illness is necessary to target therapy.
2
Evaluate the patient's psychiatric history for previous mood episodes.
The patient had a 2-week period of decreased need for sleep, grandiosity ('invincible'), racing thoughts, and impulsive spending, which meets criteria for a manic episode.
A history of mania changes the diagnosis from Major Depressive Disorder to Bipolar I Disorder.
3
Select the appropriate pharmacotherapy for acute bipolar depression.
Quetiapine is selected as it is a first-line agent for bipolar depression.
Antidepressant monotherapy must be avoided in bipolar disorder due to the risk of precipitating mania.

Key Concept

Patients presenting with a major depressive episode must be screened for a history of mania; if Bipolar I Disorder is diagnosed, acute depression is treated with mood stabilizers or specific second-generation antipsychotics (e.g., quetiapine) rather than SSRI monotherapy to avoid inducing a manic switch.
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Bipolar and Related Disorders

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