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Difficulty: HardBipolar and Related Disorders

An emergency department physician evaluates a 31-year-old man who presents with a 4-week history of severe depressed mood, hypersomnia, and a 6-kg (13.2-lb) weight gain. He recently took a leave of absence from his job as an accountant because he "lacks the mental energy to look at spreadsheets." Review of his electronic medical record reveals a prior hospitalization one year ago for acute agitation, pressured speech, and decreased need for sleep lasting 10 days; during that admission, he was convinced he had discovered a secret formula for infinite energy. He currently takes no medications and has no other medical conditions. Vital signs are within normal limits. Laboratory evaluation shows a normal comprehensive metabolic panel, negative urine toxicology screen, and a normal thyroid-stimulating hormone (TSH) level. The physician is formulating a comprehensive management plan. Which of the following statements regarding the diagnosis and management of this patient are correct? (Select all that apply)

  1. Quetiapine monotherapy is an appropriate first-line pharmacological intervention for his current presentation.Answer
  2. B
    The patient should be started on sertraline monotherapy to rapidly resolve his vegetative depressive symptoms.
  3. Routine screening of fasting plasma glucose and a lipid panel is indicated before and during his planned psychopharmacologic treatment.Answer
  4. D
    The patient's history of a 10-day episode with grandiose delusions meets the criteria for brief psychotic disorder.
  5. E
    If the patient were currently taking phenelzine, the addition of escitalopram would be an appropriate next step for treatment-resistant symptoms.

Answer

The correct statements are that quetiapine monotherapy is an appropriate first-line treatment, and that routine screening of fasting plasma glucose and a lipid panel is indicated.
The patient's history of a manic episode with psychotic features (hospitalization for agitation, pressured speech, decreased need for sleep, and grandiose delusions) establishes a diagnosis of Bipolar I disorder. His current symptoms of hypersomnia, weight gain, and severe depressed mood represent an acute bipolar depressive episode. First-line pharmacotherapy for bipolar depression includes quetiapine, lurasidone, or lithium. Because quetiapine and other second-generation antipsychotics are associated with a risk of metabolic syndrome, standard of care requires obtaining a baseline fasting plasma glucose and lipid panel, and monitoring these parameters regularly during treatment.

Step-by-Step Solution

1
Analyze the patient's psychiatric history.
The patient had a 10-day episode of elevated mood, pressured speech, decreased sleep, and grandiose delusions requiring hospitalization.
To establish a baseline diagnosis of Bipolar I disorder, which requires at least one manic episode.
2
Evaluate the current clinical presentation.
The patient is experiencing a 4-week period of severe depressed mood, hypersomnia, weight gain, and inability to work.
To diagnose an acute major depressive episode, which, in the context of his history, confirms the current phase is acute bipolar depression.
3
Determine the appropriate pharmacological interventions and necessary diagnostic workup.
First-line treatment for bipolar depression includes specific second-generation antipsychotics (e.g., quetiapine, lurasidone). Initiation of these medications requires baseline and ongoing metabolic monitoring. Antidepressant monotherapy must be avoided.
To formulate a safe and effective management plan while avoiding interventions that could precipitate a manic switch or cause severe drug interactions.

Key Concept

Diagnosis of Bipolar I Disorder and appropriate management of acute bipolar depression, including avoiding antidepressant monotherapy and ensuring metabolic monitoring for second-generation antipsychotics.
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Topics

Bipolar and Related Disorders

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