Examkin

Question

Difficulty: MediumBipolar and Related Disorders

A 29-year-old male presents to the outpatient clinic reporting a 4-week history of persistently depressed mood, anhedonia, severe fatigue, sleeping 12 to 14 hours a day, and a 4-kg (9-lb) weight gain. He states that he is struggling to concentrate at his job as a data analyst. He denies any suicidal ideation. His past medical history is notable for an episode three years ago during which he experienced a 10-day period of decreased need for sleep (sleeping only 2 hours per night), remarkably elevated mood, grandiosity, and impulsive behavior that resulted in significant credit card debt. He did not seek medical attention at that time, and the symptoms eventually resolved. Vital signs are normal. Physical examination is unremarkable. Laboratory studies show a thyroid-stimulating hormone (TSH) level of 1.4 mU/L and a free thyroxine (T4) level of 1.2 ng/dL. Which of the following is the most appropriate next step in management?

  1. Begin quetiapine therapyAnswer
  2. B
    Begin sertraline therapy
  3. C
    Begin venlafaxine therapy
  4. D
    Begin amitriptyline therapy
  5. E
    Begin levothyroxine therapy

Answer

The most appropriate next step in management is to prescribe an atypical antipsychotic approved for bipolar depression, such as quetiapine.
The correct approach is to begin quetiapine therapy. This patient is currently experiencing a major depressive episode but has a history of a distinct manic episode (10 days of elevated mood, decreased need for sleep, and severe functional impairment in the form of significant debt). This clinical picture is diagnostic of Bipolar I Disorder, currently in a depressed episode. The standard of care for acute bipolar depression includes specific atypical antipsychotics (such as quetiapine, lurasidone, or cariprazine) or established mood stabilizers (such as lithium or valproate). Quetiapine has well-demonstrated efficacy for bipolar depression and does not carry the risk of precipitating mania.

Step-by-Step Solution

1
Analyze the patient's current symptoms.
The patient presents with depressed mood, anhedonia, hypersomnia, fatigue, and weight gain for 4 weeks.
To determine the current clinical syndrome, which meets the criteria for a major depressive episode.
2
Evaluate the patient's past psychiatric history.
The patient had a 10-day episode of decreased sleep, grandiosity, and impulsive behavior leading to severe impairment (significant debt).
To differentiate between unipolar major depressive disorder and bipolar disorder. The past episode meets the criteria for a manic episode, establishing a diagnosis of Bipolar I Disorder.
3
Select the appropriate pharmacotherapy for acute bipolar depression.
Quetiapine therapy is selected.
Quetiapine, lurasidone, and cariprazine are first-line, FDA-approved monotherapies for bipolar depression. Antidepressant monotherapy must be avoided due to the risk of inducing a manic switch.

Key Concept

Patients presenting with depressive episodes must be carefully screened for a history of mania or hypomania. Treatment of bipolar depression requires mood stabilizers or specific atypical antipsychotics (e.g., quetiapine, lurasidone); antidepressant monotherapy is contraindicated due to the high risk of precipitating a manic switch.
Rate this question

Topics

Bipolar and Related Disorders

More questions from this topic