A 32-year-old man comes to the office due to severely depressed mood. He says, "For the past month I have had no energy. I could sleep all day and have missed several days at work because I can't motivate myself to get out of bed." The patient is sleeping 12 hours a day and his appetite is poor. He has suicidal ideation but no intent or plan. He has no delusions or hallucinations. The patient has a history of depression in his 20s that responded poorly to fluoxetine. He was hospitalized briefly 2 years ago after being arrested for aggressive behavior when police attempted to restrain him as he entered a government building without authorization. At the time, the patient wanted to explain his "strategy for world peace at the United Nations." Following discharge, he did not follow up with treatment and currently takes no medication. The patient has a history of childhood asthma and knee pain from a motorcycle accident. He drinks beer on weekends and does not use illicit drugs. Family history is significant for depression in his maternal grandfather, who was treated with nortriptyline.
Blood pressure is 122/78 mm Hg, pulse is 72/min, and respirations are 16/min. Physical examination is unremarkable.
Which of the following is the most appropriate pharmacotherapy?

Question

A 32-year-old man comes to the office due to severely depressed mood.  He says, "For the past month I have had no energy.  I could sleep all day and have missed several days at work because I can't motivate myself to get out of bed."  The patient is sleeping 12 hours a day and his appetite is poor.  He has suicidal ideation but no intent or plan.  He has no delusions or hallucinations.  The patient has a history of depression in his 20s that responded poorly to fluoxetine.  He was hospitalized briefly 2 years ago after being arrested for aggressive behavior when police attempted to restrain him as he entered a government building without authorization.  At the time, the patient wanted to explain his "strategy for world peace at the United Nations."  Following discharge, he did not follow up with treatment and currently takes no medication.  The patient has a history of childhood asthma and knee pain from a motorcycle accident.  He drinks beer on weekends and does not use illicit drugs.  Family history is significant for depression in his maternal grandfather, who was treated with nortriptyline.
Blood pressure is 122/78 mm Hg, pulse is 72/min, and respirations are 16/min.  Physical examination is unremarkable.
Which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

This patient currently meets the criteria for a major depressive episode. However, his history of hospitalization for impulsive, aggressive behavior and probable grandiose delusions suggests a prior manic episode, supporting a diagnosis of bipolar I disorder. Quetiapine is a second-generation antipsychotic with established efficacy in treating bipolar depression and is effective in patients with or without psychotic features. Other FDA-approved treatments for bipolar depression include the second-generation antipsychotic lurasidone and the combination of olanzapine and fluoxetine. There is also evidence for the efficacy of the mood stabilizer lithium and the anticonvulsants lamotrigine and valproate. Antidepressants in the absence of mood stabilizers have not been shown to be effective in bipolar depression (Choices A, C, and E). In general, antidepressant monotherapy should be avoided in bipolar depression due to the risk of precipitating mania and inducing rapid cycling (>4 mood episodes per year). In patients who do not improve with first-line treatment of bipolar depression, antidepressants can be added cautiously to mood stabilizers (eg, lithium, valproate) or second-generation antipsychotics (eg, quetiapine, olanzapine) as this appears to decrease the risk of antidepressant-induced switching from depression to mania. (Choice B) Although this patient has a family history of response to the tricyclic antidepressant nortriptyline, like all antidepressants, it would be contraindicated as monotherapy for a patient with bipolar I disorder. Educational objective: The second-generation antipsychotic quetiapine is a first-line treatment for bipolar depression. Antidepressant monotherapy should be avoided in patients with bipolar I disorder due to the risk of switching to mania or inducing rapid cycling. __________ References: The diagnosis and treatment of bipolar disorder: decision-making in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/25317368) Improving outcomes in patients with bipolar depression: a comprehensive review. (http://www.ncbi.nlm.nih.gov/pubmed/25830453)

A 32-Year-Old Man Comes to the Office Due to Severely