A 26-Year-Old Male Graduate Student Under Treatment for Depression Comes

A 26-year-old male graduate student under treatment for depression comes to the office for follow-up.  Two weeks earlier, he was evaluated for symptoms of depressed and irritable mood, loss of appetite, low energy, and impaired concentration.  He had no motivation to work on his thesis and was sleeping 12-14 hours a day.  Physical examination and laboratory studies were unremarkable.  The patient was agreeable to a trial of medication and was started on fluoxetine 20 mg.  At today's visit, he reports feeling irritable and anxious, but notes that his energy is much improved.  He is now staying up almost all night to work on his thesis and says, "I've had some fascinating insights into my research that I never thought of before."  The patient has been adherent with his medication and has no other medical problems.  He denies substance use apart from 2 beers he drank at a party 3 nights ago.  Mental status examination shows mildly pressured speech and tense affect.  The patient interrupts the physician several times to ask inappropriate questions about the physician's personal life.  No delusions or hallucinations are elicited.  He has no suicidal ideation. Item 1 of 2 Which of the following is the most appropriate next step in management of this patient?

A) Add a benzodiazepine at bedtime
B) Add lithium
C) Add risperidone
D) Continue fluoxetine and follow up in 1 week
E) Discontinue fluoxetine