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. Following discontinuation of fluoxetine, the patient continues to experience increased energy and decreased need for sleep. He is unable to focus on his research due to racing thoughts and stops attending classes because, "There is no need to study when you already know the truth." The patient is admitted to a psychiatric unit. Urine toxicology is negative, and routine laboratory values are within normal range. Lithium is started and titrated to a level of 1.1 mEq/L (therapeutic window: 0.6-1.2 mEq/L). Nursing reports indicate that the patient sleeps 2-3 hours a night and laughs inappropriately. He makes inappropriate sexual and threatening comments to the staff and does not respond to redirection. On mental status examination, he is pacing; has loud, pressured speech; and claims that he is on the verge of an important breakthrough that will revolutionize the Internet. Which of the following is the most appropriate next step in management of this patient?

Question

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.  Following discontinuation of fluoxetine, the patient continues to experience increased energy and decreased need for sleep.  He is unable to focus on his research due to racing thoughts and stops attending classes because, "There is no need to study when you already know the truth."  The patient is admitted to a psychiatric unit.  Urine toxicology is negative, and routine laboratory values are within normal range.  Lithium is started and titrated to a level of 1.1 mEq/L (therapeutic window: 0.6-1.2 mEq/L).  Nursing reports indicate that the patient sleeps 2-3 hours a night and laughs inappropriately.  He makes inappropriate sexual and threatening comments to the staff and does not respond to redirection.  On mental status examination, he is pacing; has loud, pressured speech; and claims that he is on the verge of an important breakthrough that will revolutionize the Internet.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: Despite a high normal therapeutic lithium level, this patient remains manic (decreased need for sleep, hypersexual, pressured speech, hyperactive, grandiose delusions) and exhibits threatening behavior. Patients with severe manic episodes (eg, aggression, psychotic symptoms, high-risk behaviors) frequently require combination therapy (lithium or valproate plus an antipsychotic). Adding an antipsychotic to the patient's lithium would be the next step in treating his acute manic symptoms. (Choice B) Lamotrigine is an anticonvulsant used in the depressed phase of bipolar illness and for maintenance therapy. It is not effective for treating mania. (Choice C) Combination treatment with a mood stabilizer and an antipsychotic is indicated for patients with severe mania. Lithium should not be discontinued as the patient is tolerating the medication and it can take several days to weeks to take full effect. (Choice D) Switching to an alternate monotherapy with the anticonvulsant mood stabilizer valproate would be unlikely to stabilize this acutely manic patient who requires more aggressive treatment. (Choice E) The patient's lithium level of 1.1 mEq/L is already in the high normal range that is typically targeted in acute mania. Increasing the dose would risk toxicity due to lithium's narrow therapeutic index. Educational objective: Combination therapy with a mood stabilizer (eg, lithium, valproate) and an antipsychotic is indicated in patients with severe mania or who do not respond to monotherapy. References: Combination therapy for manic phases: a critical review of a common practice. (http://www.ncbi.nlm.nih.gov/pubmed/23095277)

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