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Difficulty: HardBipolar and Related Disorders

A 35-year-old male teacher presents to the primary care clinic accompanied by his sister. He reports a 6-week history of profound sadness, excessive sleepiness, and a 6-kg (13.2-lb) weight gain. He states, "I am a terrible person. I am directly responsible for the recent earthquake in South America." His sister expresses deep concern about his withdrawal from family. When asked about his past psychiatric history, his sister notes that three years ago, he had a distinct 7-day period where he was extraordinarily energetic, spoke rapidly, slept only two hours a night, and wrote an entire 300-page manuscript in a few days. He was not hospitalized at that time. He has no other medical conditions and takes no medications. Vital signs are within normal limits. Mental status examination reveals a disheveled man with psychomotor retardation, downcast gaze, and restricted affect. His speech is slow but coherent. Which of the following is the most appropriate next step in management?

  1. Initiate quetiapineAnswer
  2. B
    Initiate sertraline
  3. C
    Diagnose brief psychotic disorder and initiate risperidone
  4. D
    Initiate fluoxetine and phenelzine
  5. E
    Notify the patient's employer regarding his condition due to safety concerns

Answer

The most appropriate next step is to initiate quetiapine, which will treat both the bipolar depression and the psychotic features.
The correct intervention is initiating quetiapine. The patient has Bipolar I Disorder, currently presenting with an acute major depressive episode with psychotic features (delusions of guilt). Quetiapine is an atypical antipsychotic that is FDA-approved as a first-line monotherapy for bipolar depression, and it simultaneously treats the psychotic symptoms.

Step-by-Step Solution

1
Identify the primary underlying psychiatric disorder from the patient's history.
The patient had a past 7-day episode of elevated energy, decreased need for sleep, rapid speech, and increased goal-directed activity. This meets the criteria for a manic episode, establishing a diagnosis of Bipolar I Disorder.
A single manic episode is sufficient to diagnose Bipolar I Disorder, regardless of whether the patient was hospitalized.
2
Characterize the current acute presentation.
The patient has a 6-week history of depressed mood, hypersomnia, and weight gain, accompanied by delusions of guilt (believing he caused an earthquake).
This constellation of symptoms indicates an acute major depressive episode with mood-congruent psychotic features.
3
Select the appropriate pharmacotherapy.
Treatment must target both severe bipolar depression and psychosis without risking a manic switch. Quetiapine is a first-line agent approved for bipolar depression that provides both mood-stabilizing and antipsychotic effects.
Standard antidepressants (SSRI/SNRI monotherapy) can induce mania in bipolar patients. Antipsychotic monotherapies like quetiapine, lurasidone, or cariprazine are the standard of care for this presentation.

Key Concept

Management of acute bipolar depression with psychotic features
Estimated Time:1m 30s
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Topics

Bipolar and Related Disorders

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