A 36-year-old woman with a history of recurrent major depressive episodes comes to the office due to a 1-month history of severely depressed mood, social isolation, decreased libido, low energy, sleeping 14 hours a day, and weight gain. The patient works as a real estate agent but recently took a leave of absence as she has no motivation and is unable to concentrate. She has had 4 prior episodes of severe depression, starting in her mid-20s after the birth of her first child. The patient's first episode responded to sertraline within several days. She also responded well to venlafaxine, but her husband recalls that she was instructed to stop the medication after 2 weeks due to severe insomnia. The patient has no significant medical history. She has a family history of opioid use disorder. She drinks 1 or 2 glasses of wine a day and does not use illicit drugs.
Temperature is 36 C (96.8 F), blood pressure is 118/75 mm Hg, and pulse is 68/min. Physical examination is normal.
Which of the following would be most important to obtain prior to initiating antidepressant treatment?

Question

A 36-year-old woman with a history of recurrent major depressive episodes comes to the office due to a 1-month history of severely depressed mood, social isolation, decreased libido, low energy, sleeping 14 hours a day, and weight gain.  The patient works as a real estate agent but recently took a leave of absence as she has no motivation and is unable to concentrate.  She has had 4 prior episodes of severe depression, starting in her mid-20s after the birth of her first child.  The patient's first episode responded to sertraline within several days.  She also responded well to venlafaxine, but her husband recalls that she was instructed to stop the medication after 2 weeks due to severe insomnia.  The patient has no significant medical history.  She has a family history of opioid use disorder.  She drinks 1 or 2 glasses of wine a day and does not use illicit drugs.
Temperature is 36 C (96.8 F), blood pressure is 118/75 mm Hg, and pulse is 68/min.  Physical examination is normal.
Which of the following would be most important to obtain prior to initiating antidepressant treatment?

Quizplus · Accepted Answer

Patients with bipolar disorder may be misdiagnosed with unipolar major depressive disorder when the physician fails to assess for history of manic or hypomanic episodes. This patient's atypically rapid antidepressant response and adverse event of intolerable insomnia on venlafaxine are suggestive of treatment-emergent mania, raising concern for bipolar disorder. Other clues to possible bipolarity include early onset of severe or psychotic depression, family history of bipolar disorder, and depressive episodes characterized by lethargy and hypersomnia. Prior to beginning antidepressant therapy, all patients with a major depressive episode should be screened for history of manic or hypomanic episodes to rule out bipolar disorder. Questions regarding periods of elevated mood, decreased need for sleep, racing thoughts, and uncharacteristic risk-taking behavior should be explored. Involving a family member is often helpful as patients may have limited insight, difficulty recalling, or a tendency to minimize past manic or hypomanic episodes. If further history substantiates a diagnosis of bipolar disorder, antidepressant monotherapy should be avoided due to the risk of inducing hypomania/mania. (Choice A) Routine screening laboratory tests (eg, complete blood count, metabolic panel) are not indicated for this patient with a history of depression, no significant medical history, and a normal physical examination. Selected laboratory tests should be performed in cases of new-onset or treatment-resistant depression or in patients who experience new-onset physical symptoms along with depression. (Choice B) The extent of this patient's alcohol use is unlikely to result in complications or be a primary cause of her depression. She should be advised that alcohol use can exacerbate her depressed mood, but it would not affect the decision to prescribe an antidepressant. (Choice C) Assessing for comorbid illness such as anxiety is necessary to gain a deeper understanding of the patient's symptoms. However, first-line pharmacotherapy for both depression and anxiety is antidepressant medications. Ruling out bipolar disorder would take priority due to the risk of inducing mania. (Choice E) This patient denies illicit drug use and shows no signs of substance abuse. Educational objective: Prior to initiating antidepressants, physicians should carefully screen patients with depression for past hypomanic and manic episodes to rule out bipolar disorder. Antidepressant monotherapy should be avoided in patients with bipolar disorder. __________ References: Misdiagnosis of bipolar depression in primary care practices. (http://www.ncbi.nlm.nih.gov/pubmed/24717386) Consequences of misdiagnosis: inaccurate treatment and poor patient outcomes in bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/26528666)

A 36-Year-Old Woman with a History of Recurrent Major Depressive