Bipolar and Related Disorders

Match each clinical scenario describing an adverse pharmacological event in a patient being treated for bipolar disorder to the most accurate underlying mechanism of the interaction.

A psychiatric clinical pharmacist is reviewing the pharmacotherapy regimens of six patients being treated for various phases of bipolar disorder. Each scenario involves a critical drug-drug interaction, a specific administration requirement, or a major prescribing pitfall. Match each clinical scenario with the precise pharmacokinetic or pharmacodynamic rationale that governs its clinical management.

Match each clinical vignette describing a medication-specific complication, adverse effect, or pharmacokinetic requirement to the most likely offending psychotropic agent used in the context of bipolar disorder.

A 27-year-old male graphic designer is brought to the emergency department by his roommate. The patient has not left his bedroom for the past 3 weeks, has been eating very little, and sleeps up to 14 hours a day. The roommate notes that for the last 5 days, the patient has been repeatedly whispering to himself and claiming that "the authorities have hidden listening devices in the ceiling." Past psychiatric history is notable for an involuntary psychiatric admission 4 years ago due to severe agitation, grandiose beliefs of having superhuman abilities, and pressured speech; that episode lasted 12 days. The patient's medical history is significant for a recent ankle sprain, for which he is currently taking tramadol. Mental status examination reveals a disheveled appearance, poor eye contact, profound psychomotor retardation, and a restricted affect. He confirms hearing a male voice calling him a "traitor." Vital signs are within normal limits. Which of the following is the most appropriate management plan for this patient?

A 26-year-old female dental hygienist comes to the outpatient psychiatry clinic reporting two months of profound sadness, lack of motivation, and sleeping 12 to 14 hours a day. She states she has lost interest in her usual hobbies and feels intense, inappropriate guilt regarding a recent decline in her work performance. She has gained 5 kg (11 lb) over this period. Her medical history is unremarkable, and she currently takes no medications. Vital signs and physical examination are within normal limits. When specifically asked about past mood fluctuations, the patient recalls a distinct five-day period during her sophomore year of college when she felt "supercharged." During that time, she required only 3 hours of sleep per night, started multiple complex art projects, and felt highly productive. That period did not result in hospitalization or significant functional impairment. Mental status examination today reveals a cooperative woman with a blunted affect, psychomotor retardation, and slow speech. She denies suicidal ideation, auditory hallucinations, and paranoia. Which of the following is the most appropriate next step in pharmacotherapy?

A 28-year-old male fitness coach presents to the psychiatry clinic with a 5-week history of profound sadness, anhedonia, and sleeping up to 14 hours a day. He reports significant fatigue and difficulty concentrating on his clients' workout plans. Past psychiatric history reveals an episode 3 years ago characterized by 10 days of feeling "invincible," sleeping only 2 hours nightly, and maxing out several credit cards to start an ill-advised supplement company. His medical history is unremarkable. Vital signs are within normal limits. Mental status examination reveals psychomotor retardation, poor eye contact, and a constricted affect. Which of the following pharmacological interventions are appropriate for the acute management of this patient's current episode? (Select all that apply)

A 25-year-old woman is brought to the outpatient psychiatric clinic by her sister due to a 4-week history of profound sadness, lack of motivation, and sleeping up to 14 hours daily. For the past week, the patient has been hearing an unfamiliar voice repeatedly telling her she is "hopeless and already dead." Her past psychiatric history is notable for a 3-week hospitalization two years ago when she exhibited extremely rapid speech, required only two hours of sleep per night, and harbored grandiose delusions about being a spiritual prophet. Following her discharge from that hospitalization, she returned to her baseline functioning and experienced no mood or psychotic symptoms until the current episode. The patient currently takes no medications. Vital signs are within normal limits. Laboratory evaluation reveals a thyroid-stimulating hormone (TSH) level of $1.4 \mu U/mL$ (normal: $0.5-5.0 \mu U/mL$) and a free thyroxine (T4) level of $0.8 ng/dL$ (normal: $0.9-1.7 ng/dL$). Which of the following is the most appropriate next step in management?

A $26$-year-old woman comes to the psychiatric clinic for a follow-up evaluation regarding persistent low mood, hypersomnia, and severe fatigue. She has an established diagnosis of bipolar II disorder. Six weeks ago, she began taking lamotrigine for a major depressive episode. Her dosage was gradually increased according to standard protocols to a maintenance dose of $200 \text{ mg}$ daily, which she has been taking consistently for the past $2$ weeks. Despite medication adherence, the patient states she feels "just as depressed as before" and struggles to complete basic daily tasks. Her medical history is notable for polycystic ovary syndrome, which is well-controlled with a combined ethinyl estradiol and norgestimate oral contraceptive pill. Vital signs are within normal limits. Laboratory testing reveals a serum lamotrigine concentration of $1.2 \mu\text{g/mL}$ (therapeutic reference range: $3-15 \mu\text{g/mL}$).

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

A 29-year-old woman is brought to the psychiatrist by her sister due to worsening isolation and profound sadness over the past $5$ weeks. The patient sleeps $14$ hours daily and frequently hears voices stating, "You are a vessel of sin." Three years ago, she experienced a $10$-day period during which she slept only $3$ hours per night, spoke incessantly, and aggressively attempted to start a new company despite having no related experience. She has a history of primary hypothyroidism, for which she takes daily levothyroxine. Vital signs are normal. Laboratory results demonstrate a TSH of $2.2$ $\mu$ U/mL (normal: $0.4$-$4.0$ $\mu$ U/mL) and a free T4 of $1.3$ ng/dL (normal: $0.9$-$1.7$ ng/dL). Which of the following is the most appropriate next step in the management of this patient?

A 25-year-old male fitness instructor presents to a primary care clinic reporting a 6-week history of feeling 'completely drained of energy.' He states that he has lost interest in his usual workout routines, struggles to concentrate on his business, and has been sleeping up to 13 hours a day. His medical history is unremarkable, and he currently takes no medications. Upon further questioning about his past psychiatric history, he recalls a 5-week period approximately two years ago when he felt 'invincible.' During that time, he slept only 3 hours per night, spoke incredibly fast, and spontaneously purchased extremely expensive gym equipment that led to bankruptcy. He also harbored an intense belief that he possessed a telepathic ability to communicate with elite athletes worldwide; this belief entirely resolved when his energy levels returned to baseline. His vital signs are within normal limits. Mental status examination today reveals a blunted affect and psychomotor retardation, with no current delusional thought processes or suicidal ideation. Which of the following is the most appropriate next step in pharmacologic management?

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?

A 30-year-old male chef is brought to the emergency department by his husband due to worsening suicidal ideation. For the past month, the patient has experienced profound sadness, a 7-kg (15-lb) weight gain, hypersomnia, and a complete lack of energy. He has a history of major depressive disorder diagnosed in his early twenties. His husband reports that three years ago, the patient had a 3-week period where he slept only two hours per night, spoke so rapidly he was difficult to interrupt, and developed grandiose delusions that he had discovered the cure for aging. These delusions completely resolved when his mood returned to baseline. The patient is currently not taking any prescribed medications but consumes a high-dose St. John's wort supplement daily. Vital signs are within normal limits. Mental status examination reveals a cooperative patient with depressed mood, flattened affect, and psychomotor retardation. He denies current hallucinations or delusions. Which of the following is the most appropriate next step in management?

A 26-year-old female graduate student is brought to the emergency department by her roommate. For the past month, the patient has exhibited profound sadness, a 4.5-kg (10-lb) weight loss, and severe psychomotor retardation. She sleeps 14 hours a day and refuses to attend her classes. During the interview, she stares blankly and admits she has been hearing a persistent voice saying she is "a fraud who deserves to die." The roommate reports that two years ago, the patient had a distinct 3-week period where she barely slept, spoke incredibly fast, bought thousands of dollars of unneeded laboratory equipment on credit, and claimed she had independently deciphered the human genome. That prior episode culminated in a 5-day psychiatric hospitalization. Her urine toxicology screen is negative. Which of the following is the most accurate diagnosis and most appropriate initial pharmacotherapy for this patient?

A 48-year-old man is evaluated in the outpatient clinic for a 6-week history of persistently low mood, severe fatigue, anhedonia, and waking up at 3:00 AM every day without being able to return to sleep. He reports feeling "completely empty" and has unintentionally lost $4.5\text{ kg}$ ($10\text{ lb}$) over this period. His past medical history is significant for chronic lumbar radiculopathy, for which he takes daily tramadol. His past psychiatric history reveals a psychiatric hospitalization at age 32 for a 3-week episode of abnormally euphoric mood, hypersexuality, decreased need for sleep, and impulsive spending that led to significant debt. Vital signs are within normal limits. Physical examination is unremarkable. Mental status examination reveals a disheveled man with psychomotor retardation, restricted affect, and depressed mood. He denies active suicidal ideation. Laboratory studies show a thyroid-stimulating hormone (TSH) level of $1.8\text{ }\mu\text{U/mL}$ and a free thyroxine (T4) level of $1.2\text{ ng/dL}$. Which of the following is the most appropriate next step in management?

A 34-year-old woman comes to the outpatient psychiatry clinic reporting that she "cannot get out of bed" and feels completely hopeless. Over the past 6 weeks, she has experienced a persistently depressed mood, slept 14 hours a day, gained 4.5 kg (10 lb), and suffered from profound fatigue. She admits to passive suicidal ideation but denies any active plan. Her past psychiatric history is notable for a major depressive episode at age 22, for which she was prescribed paroxetine. Three weeks after starting paroxetine, she developed a severely elevated mood, rapid and pressured speech, decreased need for sleep (2 hours per night), and grandiose delusions resulting in psychiatric hospitalization. She was stabilized on a medication that she discontinued 5 years ago because she "felt fine." Her medical history includes type 2 diabetes mellitus, hypertension, and osteoarthritis. Current medications are metformin, lisinopril, hydrochlorothiazide, and daily ibuprofen. Her vital signs show a blood pressure of 145/90 mmHg. Her BMI is 38 kg/m². Laboratory studies reveal a hemoglobin A1c of 9.2%. Mental status examination shows marked psychomotor retardation, a flattened affect, and a depressed mood. Which of the following is the most appropriate next step in pharmacotherapy for this patient's current psychiatric symptoms?

A 34-year-old man presents via telehealth for a follow-up visit. Over the past four weeks, he has experienced persistent low mood, hypersomnia, extreme fatigue, and a loss of interest in his usual activities. Five years ago, he was hospitalized for an episode characterized by grandiosity, pressured speech, and a significantly decreased need for sleep. He has not taken any medications for the past six months. Which of the following are appropriate pharmacological treatments for this patient's current condition? (Select all that apply)

An emergency department physician evaluates a 31-year-old man who presents with a 4-week history of severe depressed mood, hypersomnia, and a 6-kg (13.2-lb) weight gain. He recently took a leave of absence from his job as an accountant because he "lacks the mental energy to look at spreadsheets." Review of his electronic medical record reveals a prior hospitalization one year ago for acute agitation, pressured speech, and decreased need for sleep lasting 10 days; during that admission, he was convinced he had discovered a secret formula for infinite energy. He currently takes no medications and has no other medical conditions. Vital signs are within normal limits. Laboratory evaluation shows a normal comprehensive metabolic panel, negative urine toxicology screen, and a normal thyroid-stimulating hormone (TSH) level. The physician is formulating a comprehensive management plan. Which of the following statements regarding the diagnosis and management of this patient are correct? (Select all that apply)

A 46-year-old woman is evaluated in the psychiatric clinic for an acute bipolar depressive episode. She has a history of bipolar I disorder with multiple past hospitalizations for severe mania. Her medical history includes hypertension, chronic lower back pain, and Hashimoto thyroiditis. Her current medications are lisinopril, naproxen (taken daily), and levothyroxine. Laboratory studies show a normal serum creatinine with an estimated glomerular filtration rate (eGFR) of 95 mL/min/1.73m² and a normal thyroid-stimulating hormone (TSH) level. The psychiatrist plans to initiate lithium carbonate for her current depressive episode and for long-term maintenance.

Which of the following are appropriate steps in the management of this patient prior to or during the initiation of lithium therapy? (Select all that apply)

A 23-year-old woman comes to the clinic reporting profound sadness, low energy, and poor concentration over the past 6 weeks. She sleeps up to 12 hours a day and has lost interest in her usual hobbies. Her medical history is notable for a psychiatric hospitalization three years ago. At that time, she experienced a two-week period of feeling 'invincible,' requiring only 2 to 3 hours of sleep per night, and impulsively spending her entire savings on luxury handbags. Her current vital signs and physical examination are unremarkable. Laboratory results, including a complete blood count, comprehensive metabolic panel, and thyroid-stimulating hormone (TSH) level, are within normal limits. Which of the following is the most appropriate initial medication for this patient's current symptoms?

A 21-year-old male university student is evaluated in the student health center for worsening fatigue, hypersomnia, and feelings of worthlessness over the past month. He states that he is failing his classes and feels "it would be better if I just went to sleep and never woke up." Review of his medical record reveals a prior psychiatric hospitalization at age 19 for a week-long episode of decreased need for sleep, grandiosity, and reckless spending. He currently takes no medications and uses no illicit substances. The physician is formulating a comprehensive management plan. Which of the following statements regarding his diagnosis and pharmacological management are correct? Select all that apply.