Examkin

Question

Difficulty: MediumDepressive Disorders

A 2828-year-old software engineer presents to the clinic with a 44-week history of profound sadness, poor concentration, and a 55-kg (1111-lb) weight gain. She reports sleeping up to 1414 hours a day and feeling a "heavy sensation" in her arms and legs. She has stopped attending social events and is struggling to meet her project deadlines. Her medical history is unremarkable, and she takes no medications. When asked about past psychiatric symptoms, she recalls a 66-day period during college when she felt "unstoppable," slept only 22 to 33 hours a night without feeling tired, and wrote an entire novel. During that time, friends noted she was speaking much faster than usual, though her behavior did not result in hospitalization or academic failure. Vital signs are within normal limits. Laboratory results show a thyroid-stimulating hormone level of 1.8μU/mL1.8 \mu U/mL (normal: 0.50.5 to 5.0μU/mL5.0 \mu U/mL) and a negative urine toxicology screen. Which of the following is the most appropriate next step in pharmacotherapy for this patient?

  1. Initiate lurasidone therapyAnswer
  2. B
    Initiate escitalopram therapy
  3. C
    Initiate escitalopram and tranylcypromine therapy
  4. D
    Initiate levothyroxine therapy
  5. E
    Initiate risperidone therapy

Answer

Initiate lurasidone therapy
The patient is presenting with a major depressive episode characterized by atypical features (hypersomnia, hyperphagia, leaden paralysis). Crucially, her history of a distinct 66-day period of abnormally elevated mood, decreased need for sleep, and increased goal-directed activity (writing a novel) without severe impairment or hospitalization meets the criteria for a hypomanic episode. Therefore, her correct diagnosis is bipolar II disorder, currently in a depressive episode. First-line pharmacotherapy for bipolar depression includes mood stabilizers or specific second-generation antipsychotics such as lurasidone, quetiapine, or cariprazine. Lurasidone is an appropriate and effective choice that targets her depressive symptoms without risking mood destabilization.

Step-by-Step Solution

1
Identify the current syndrome from the clinical presentation.
The patient exhibits depressed mood, weight gain, hypersomnia, and leaden paralysis for 44 weeks.
These symptoms fulfill the criteria for a major depressive episode with atypical features.
2
Evaluate the patient's psychiatric history for prior mood episodes.
The patient reports a distinct 66-day period of elevated mood, decreased need for sleep, and increased goal-directed activity.
Because this episode lasted at least 44 days and did not cause severe functional impairment or require hospitalization, it meets the criteria for a hypomanic episode.
3
Synthesize the diagnosis.
Major depressive episode plus a history of a hypomanic episode confirms the diagnosis of Bipolar II disorder.
Differentiating unipolar major depressive disorder from bipolar depression is a critical diagnostic step before initiating pharmacotherapy.
4
Determine the appropriate evidence-based pharmacotherapy.
Select a medication approved for bipolar depression, such as lurasidone.
Standard antidepressants (SSRIs) must be avoided as monotherapy in bipolar disorder to prevent mood destabilization.

Key Concept

Patients presenting with a depressive episode must be screened for a history of mania or hypomania to accurately differentiate between major depressive disorder and bipolar disorder, which dictates the choice of pharmacotherapy.
Rate this question

Topics

Depressive Disorders

More questions from this topic