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Difficulty: EasyDepressive Disorders

A 24-year-old woman is brought to the clinic by her husband due to severe sadness and social withdrawal for the past 6 weeks. She has been sleeping 12 to 14 hours a day, has poor appetite, and struggles to concentrate on daily tasks. She frequently complains of feeling cold. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 1.5 µU/mL and a normal free T4 level. Her husband notes that two years ago, she had a 3-week period where she barely slept, spoke so rapidly it was hard to interrupt her, and recklessly spent thousands of dollars on unneeded home renovations. The patient is currently not taking any medications. Which of the following is the most appropriate next step in management?

  1. Initiate quetiapineAnswer
  2. B
    Initiate sertraline
  3. C
    Initiate venlafaxine
  4. D
    Initiate levothyroxine
  5. E
    Initiate citalopram and phenelzine

Answer

Initiate quetiapine
The patient is currently experiencing a major depressive episode. However, her history of a 3-week period characterized by decreased need for sleep, rapid speech, and impulsive spending meets the criteria for a manic episode. This confirms a diagnosis of bipolar I disorder, currently in a depressed phase. The most appropriate treatment for bipolar depression includes atypical antipsychotics such as quetiapine or lurasidone, or mood stabilizers such as lithium. Quetiapine is a first-line agent for this presentation.

Step-by-Step Solution

1
Analyze the patient's current symptoms.
The patient has severe sadness, hypersomnia, poor appetite, and poor concentration lasting 6 weeks.
To establish the presence of a major depressive episode.
2
Identify key historical information.
The patient had a distinct 3-week episode of decreased need for sleep, rapid speech, and impulsive spending two years ago.
To differentiate between unipolar major depressive disorder and bipolar disorder.
3
Formulate a diagnosis.
The combination of a current major depressive episode and a past manic episode indicates a diagnosis of bipolar I disorder, currently in a depressed phase.
To guide appropriate pharmacotherapy selection.
4
Select the appropriate treatment.
Quetiapine is selected as it is an FDA-approved first-line treatment for bipolar depression.
Antidepressant monotherapy (like SSRIs or SNRIs) must be avoided to prevent a manic switch.

Key Concept

Bipolar I Disorder, Depressed Phase
Estimated Time:1m 0s
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Topics

Depressive Disorders

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