A 26\text{-year-old} female graduate student presents to the outpatient psychiatry clinic … — USMLE Step 2 CK

A $26\text{-year-old}$ female graduate student presents to the outpatient psychiatry clinic accompanied by her roommate due to worsening isolation and depression. For the past $3 \text{ weeks}$ , the patient has stayed in her room, slept up to $14 \text{ hours}$ a day, and consumed large amounts of junk food, leading to a $4 \text{ kg}$ ( $8.8 \text{ lb}$ ) weight gain. She tells the physician, "I am a failure and I hear a voice whispering that I should just give up." Her roommate mentions that the patient has been taking an over-the-counter herbal supplement, St. John's wort, for the past $2 \text{ months}$ to "help with her mood," but it has not provided any relief.

Review of her psychiatric history reveals that $2 \text{ years}$ ago, she had a distinct $6\text{-day}$ period where she felt "incredibly energized," slept only $3 \text{ hours}$ per night, and simultaneously wrote three term papers while serving as the president of a student club. She did not require hospitalization during that time, and her overall functioning was arguably enhanced.

Her vital signs and physical examination are normal. Laboratory studies, including a TSH of $4.5 \text{ \mu U/mL}$ (normal: $0.5 - 5.0 \text{ \mu U/mL}$ ) and a free T4 of $0.9 \text{ ng/dL}$ (normal: $0.8 - 1.8 \text{ ng/dL}$ ), are unremarkable.

Which of the following is the most appropriate next step in management?

A
Diagnose schizophreniform disorder and initiate risperidone
B
Discontinue St. John's wort and initiate sertraline
Discontinue St. John's wort and initiate quetiapineCevap
D
Initiate levothyroxine
E
Add phenelzine to the current regimen

Cevap

Discontinue St. John's wort and initiate quetiapine

The correct action is to discontinue St. John's wort and initiate quetiapine. This patient presents with a major depressive episode (hypersomnia, weight gain, depressed mood) accompanied by mood-congruent psychotic features (hearing a whispering voice). However, her history of a 6-day episode of elevated energy, decreased need for sleep, and hyper-productivity that did not cause severe impairment represents a past hypomanic episode. Therefore, her correct diagnosis is Bipolar II disorder. The first-line treatment for bipolar depression includes atypical antipsychotics such as quetiapine or lurasidone, which effectively target both the depressive and psychotic symptoms. St. John's wort should be discontinued because it is ineffective for severe bipolar depression and acts as a potent CYP3A4 inducer, which would decrease the serum concentration of quetiapine.

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Synthesize the patient's current presentation.

The patient is experiencing a major depressive episode (depressed mood, hypersomnia, weight gain) with mood-congruent psychotic features (auditory hallucinations) lasting 3 weeks.

Establishing the current syndrome is necessary to guide acute management.

Evaluate the patient's psychiatric history for previous mood episodes.

The patient has a history of a distinct 6-day period of elevated energy, decreased need for sleep, and hyper-productivity without severe impairment.

A past hypomanic episode changes the diagnosis from Major Depressive Disorder to Bipolar II Disorder, fundamentally altering the treatment algorithm.

Review laboratory results to rule out secondary causes.

TSH and Free T4 are within normal limits.

Medical etiologies such as hypothyroidism must be excluded before finalizing a primary psychiatric diagnosis.

Select the appropriate pharmacotherapy and manage current medications.

Initiate quetiapine to treat the bipolar depression and psychosis, and discontinue St. John's wort.

Antidepressant monotherapy is contraindicated in bipolar disorder. Quetiapine treats both the mood and psychotic symptoms. St. John's wort is a CYP3A4 inducer (which lowers quetiapine levels) and carries serotonergic risks.

Anahtar Kavram

Bipolar depression with psychotic features requires treatment with agents that target both mood and psychosis (e.g., quetiapine, lurasidone), while avoiding antidepressant monotherapy due to the risk of a manic switch.

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