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Difficulty: HardBipolar and Related Disorders

A 28-year-old woman is brought to the outpatient psychiatric clinic by her partner due to a one-month history of worsening depression. The patient reports profound sadness, anhedonia, extreme fatigue, and sleeping up to 14 hours a day. She has gained 4 kg (8.8 lb) over the past month. She mentions feeling completely worthless but denies any active suicidal plans. Two years ago, the patient was hospitalized for 3 weeks after an episode characterized by a decreased need for sleep, pressured speech, and grandiose delusions of being a divine messenger. She was treated with medication at that time but discontinued it a year ago because she felt her symptoms were cured. Vital signs are within normal limits. Mental status examination reveals a depressed mood, flat affect, and psychomotor retardation. Her laboratory results, including a comprehensive metabolic panel, thyroid-stimulating hormone, and complete blood count, are within normal limits. 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 fluoxetine and phenelzine
  5. E
    Diagnose schizophreniform disorder and initiate risperidone

Answer

Initiate quetiapine
The patient's history of a manic episode (decreased sleep, pressured speech, grandiosity) combined with a current major depressive episode establishes the diagnosis of bipolar I disorder, currently in a depressed phase. The treatment of choice for acute bipolar depression includes quetiapine, lurasidone, or lithium. Quetiapine is a second-generation antipsychotic that effectively treats bipolar depression without the risk of precipitating a manic switch, making it the most appropriate next step.

Step-by-Step Solution

1
Analyze the patient's past psychiatric history.
The patient had a 3-week episode of decreased sleep, pressured speech, and grandiose delusions requiring hospitalization.
This establishes a history of at least one manic episode, fulfilling the diagnostic criteria for bipolar I disorder.
2
Evaluate the patient's current clinical presentation.
The patient exhibits profound sadness, hypersomnia, hyperphagia, and psychomotor retardation lasting for one month.
This presentation confirms an acute major depressive episode occurring in the context of bipolar I disorder (bipolar depression).
3
Determine the appropriate pharmacotherapy for acute bipolar depression.
Select a medication approved for bipolar depression that does not risk a manic switch, such as quetiapine.
Antidepressant monotherapy can precipitate mania in bipolar patients; therefore, specific second-generation antipsychotics or mood stabilizers are the preferred first-line treatments.

Key Concept

The first-line treatment for acute bipolar depression includes specific second-generation antipsychotics (e.g., quetiapine, lurasidone) or mood stabilizers (e.g., lithium), while strictly avoiding antidepressant monotherapy due to the risk of inducing a manic switch.
Estimated Time:1m 30s
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Topics

Bipolar and Related Disorders

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