A 25-year-old woman is brought to the emergency department by her parents for evaluation of agitated and bizarre behavior over the past week. The patient abruptly stopped attending college classes a week ago. She has gotten into several loud arguments with strangers on the street. She has not slept for several days but has "tons of energy." The patient demands to leave the hospital, explaining that she must work on her novel, which "will be the greatest book of the century." The patient experienced depression at age 17 and 20 but was never treated. Physical examination is unremarkable, and a urine drug screen is negative. In the emergency department, the patient starts to pace and becomes increasingly agitated when told she cannot leave. She shouts, pounds her fists, and refuses medication. Administration of which of the following medications is the most appropriate next step in management?

Question

A 25-year-old woman is brought to the emergency department by her parents for evaluation of agitated and bizarre behavior over the past week.  The patient abruptly stopped attending college classes a week ago.  She has gotten into several loud arguments with strangers on the street.  She has not slept for several days but has "tons of energy."  The patient demands to leave the hospital, explaining that she must work on her novel, which "will be the greatest book of the century."  The patient experienced depression at age 17 and 20 but was never treated.  Physical examination is unremarkable, and a urine drug screen is negative.  In the emergency department, the patient starts to pace and becomes increasingly agitated when told she cannot leave.  She shouts, pounds her fists, and refuses medication.  Administration of which of the following medications is the most appropriate next step in management?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c04a_54cd_8f63_37c2297e8e6d_MD0005_00 This patient's agitated behavior, irritable mood, increased energy, decreased need for sleep, pressured speech, and grandiose delusions are consistent with an acute manic episode of bipolar I disorder. Her history of recurrent depressive episodes is also characteristic of the disorder. Although lithium and valproate (an anticonvulsant mood stabilizer) are first-line treatments for bipolar I disorder, immediate management of the acutely manic patient with escalating agitation and psychosis requires an antipsychotic medication. Antipsychotics (eg, risperidone) have a more rapid onset of action and can be administered intramuscularly if necessary. Lithium and valproate are not effective in managing agitation acutely because they are taken orally, necessitate gradual titration to achieve therapeutic blood levels, and require days to weeks to take effect (Choices B and E). (Choices A and D) Fluoxetine, a selective serotonin reuptake inhibitor, is commonly used in the treatment of unipolar major depressive disorder. Trazodone is an antidepressant that is commonly used off-label for treatment of insomnia due to its sedating properties. Antidepressants are contraindicated in acute mania because they worsen manic symptoms. Educational objective: Antipsychotic medication is used in the immediate management of agitated patients with acute mania and can be administered intramuscularly if necessary. Lithium and valproate are first-line treatments but require titration and have a slower onset of effect. References: Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21851976) Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29536616)

A 25-Year-Old Woman Is Brought to the Emergency Department by Her