A 28-year-old fourth-year medical student is brought to the emergency department by 3 hospital security officers after causing a disturbance in the medical director's office. On questioning, the student says that he has developed a "simple cure for cancer." He is extremely excited about this discovery but is perplexed that the medical director does not take him seriously. He says that this discovery will be praised in the medical and scientific communities and will result in a Nobel Prize. The patient has "endless energy" and "a million ideas" in his head. He has difficulty focusing on answering questions at times and becomes irritable and hostile when efforts are made to redirect him. Medical history is significant for depression at age 19. Family history is significant for adult polycystic kidney disease in his father. Temperature is 37 C (98.6 F), blood pressure is 142/82 mm Hg, pulse is 104/min, and respirations are 20/min. Review of systems and physical examination are otherwise unremarkable. Laboratory results are as follows: Urine drug screen is negative. Which of the following medications is most appropriate for long-term management of this patient's illness?

Question

A 28-year-old fourth-year medical student is brought to the emergency department by 3 hospital security officers after causing a disturbance in the medical director's office.  On questioning, the student says that he has developed a "simple cure for cancer."  He is extremely excited about this discovery but is perplexed that the medical director does not take him seriously.  He says that this discovery will be praised in the medical and scientific communities and will result in a Nobel Prize.  The patient has "endless energy" and "a million ideas" in his head.  He has difficulty focusing on answering questions at times and becomes irritable and hostile when efforts are made to redirect him.  Medical history is significant for depression at age 19.  Family history is significant for adult polycystic kidney disease in his father.  Temperature is 37 C (98.6 F), blood pressure is 142/82 mm Hg, pulse is 104/min, and respirations are 20/min.  Review of systems and physical examination are otherwise unremarkable.  Laboratory results are as follows:  Urine drug screen is negative.  Which of the following medications is most appropriate for long-term management of this patient's illness?

Quizplus · Accepted Answer

This patient's grandiose delusions, racing thoughts, distractibility, increased energy, and irritability are highly suggestive of a manic episode. His history of depression at age 19 and now manic symptoms, with apparent good functioning between episodes, support a diagnosis of bipolar I disorder. Bipolar disorder is a highly recurrent illness. Following stabilization of acute symptoms, this patient will require maintenance treatment to delay or prevent recurrence of new mood episodes. Commonly used first-line mood stabilizers for bipolar maintenance include lithium and valproate. The second-generation antipsychotic quetiapine and the anticonvulsant lamotrigine have also demonstrated efficacy. This patient's elevated creatinine level suggests possible renal dysfunction, making valproate the preferred treatment over lithium (Choice C). Lithium is excreted unchanged by the kidneys and may build up to toxic levels when used in patients with renal dysfunction. Long-term use of lithium has been associated with nephrogenic diabetes insipidus and chronic tubulointerstitial nephropathy, which in rare cases can progress to end-stage renal disease. Valproate, in contrast, is not nephrotoxic, although periodic monitoring of liver function tests and platelets is necessary due to the medication's rare association with hepatotoxicity and thrombocytopenia. (Choice A) Bupropion is a norepinephrine and dopamine reuptake inhibitor. Like all antidepressants, it may induce mania and therefore is not an appropriate choice for maintenance treatment. (Choice B) The first-generation antipsychotic haloperidol can be used for acute stabilization of manic episodes, but it is not preferred for maintenance treatment due to the associated risk of extrapyramidal symptoms. (Choice D) Topiramate is an anticonvulsant that has not demonstrated efficacy in acute or maintenance treatment of bipolar disorder. Educational objective: Lithium and valproate are first-line options for bipolar disorder maintenance treatment. Lithium is excreted unchanged by the kidneys and should generally be avoided in patients with renal dysfunction due to the risk of systemic toxicity and long-term nephrotoxic effects. References: Lithium nephrotoxicity. (http://www.ncbi.nlm.nih.gov/pubmed/26043842)

A 28-Year-Old Fourth-Year Medical Student Is Brought to the Emergency