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Difficulty: MediumBipolar and Related Disorders

A 34-year-old man presents to the clinic with his partner due to a 1-month history of worsening sadness, anhedonia, and sleeping 12 to 14 hours a day. His partner reports that the patient has stopped going to his job as a software developer, barely eats, and has expressed feelings of worthlessness. Medical history is significant for a hospital admission 5 years ago when the patient was found wandering the streets, claiming he was a "prophet" who did not need to sleep, and talking so rapidly that he was difficult to understand. This previous episode resolved after a 2-week inpatient stay, and he eventually stopped taking his prescribed medications. The patient currently exhibits a flat affect and psychomotor retardation. Vital signs are within normal limits, and physical examination shows no abnormalities. Basic metabolic panel and thyroid-stimulating hormone levels are unremarkable. Which of the following pharmacologic therapies are appropriate for this patient's current episode? (Select all that apply)

  1. Initiate quetiapineAnswer
  2. Initiate lurasidoneAnswer
  3. C
    Initiate escitalopram
  4. D
    Initiate venlafaxine
  5. E
    Initiate amitriptyline

Answer

The appropriate pharmacologic therapies for this patient's acute bipolar depression are quetiapine and lurasidone.
This patient has a history of a severe manic episode (grandiosity, decreased need for sleep, pressured speech requiring hospitalization), which establishes the diagnosis of Bipolar I disorder. He is currently experiencing a major depressive episode. First-line, FDA-approved pharmacologic treatments for acute bipolar depression include specific second-generation antipsychotics such as quetiapine and lurasidone. These agents effectively target depressive symptoms without significantly increasing the risk of a manic switch.

Step-by-Step Solution

1
Analyze the patient's past psychiatric history.
The patient had a previous episode of grandiosity, decreased need for sleep, and rapid speech requiring hospitalization, which meets the criteria for a severe manic episode.
A single manic episode is sufficient to establish the diagnosis of Bipolar I disorder, regardless of current symptoms.
2
Evaluate the current clinical presentation.
The patient presents with sad mood, anhedonia, hypersomnia, decreased appetite, feelings of worthlessness, and psychomotor retardation lasting 1 month.
This constellation of symptoms confirms a current major depressive episode in the context of Bipolar I disorder.
3
Determine the appropriate pharmacotherapy for acute Bipolar I depression.
Appropriate first-line treatments include specific second-generation antipsychotics like quetiapine or lurasidone. Antidepressant monotherapy must be avoided.
Antidepressant monotherapy can precipitate a manic switch in patients with bipolar disorder. Mood stabilizers or specific atypical antipsychotics are indicated to treat the depression safely.

Key Concept

The treatment of acute bipolar depression requires specific agents such as quetiapine or lurasidone; antidepressant monotherapy is contraindicated due to the severe risk of inducing a manic episode.
Estimated Time:1m 15s
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Bipolar and Related Disorders

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