An 18-year-old woman comes to the office due to low energy, decreased appetite, insomnia, poor concentration, and decreased interest in her daily activities. She has lost 3.6 kg (8 lb) over the last month. The patient has no psychiatric history and has no current or significant medical illnesses. Physical examination and laboratory evaluation are unremarkable. Treatment with medication is initiated. Three weeks later, the patient is brought to the emergency department by her mother for not sleeping at all for 3 nights. The patient reports that she does not feel tired despite lack of sleep. She spent a large amount of money on plane tickets and plans to travel around the world to promote world peace. Her mother adds that she herself has suffered from severe mood swings in the past. This patient was most likely started on which of the following medications 3 weeks ago?

Question

An 18-year-old woman comes to the office due to low energy, decreased appetite, insomnia, poor concentration, and decreased interest in her daily activities.  She has lost 3.6 kg (8 lb) over the last month.  The patient has no psychiatric history and has no current or significant medical illnesses.  Physical examination and laboratory evaluation are unremarkable.  Treatment with medication is initiated.  Three weeks later, the patient is brought to the emergency department by her mother for not sleeping at all for 3 nights.  The patient reports that she does not feel tired despite lack of sleep.  She spent a large amount of money on plane tickets and plans to travel around the world to promote world peace.  Her mother adds that she herself has suffered from severe mood swings in the past.  This patient was most likely started on which of the following medications 3 weeks ago?

Quizplus · Accepted Answer

This patient initially had symptoms of major depressive disorder (ie, loss of interest, low energy, weight loss, insomnia, impaired concentration) and was most likely prescribed an antidepressant (eg, sertraline) as first-line therapy. Three weeks later in the emergency department, she exhibits symptoms of mania (ie, decreased need for sleep, increased energy, reckless spending, and grandiosity). All antidepressants carry a risk of inducing mania in susceptible patients. Antidepressant-induced mania can occur early in the first few days or weeks of starting the medication (even before the time frame normally expected for an antidepressant to take effect). In this case, the mother's history of severe mood swings suggests a family history of bipolar disorder that places the patient at increased risk for developing this disorder. If a patient becomes manic or hypomanic on antidepressant therapy, the antidepressant should be stopped. (Choices A, C, and F) Carbamazepine, lithium, and valproate are mood stabilizers used in acute episodes and maintenance treatment of bipolar disorder. This patient presented with depression, with no known history of bipolar disorder at that time. A mood stabilizer would not have been the initial first-line treatment. (Choice B) Lamotrigine, an anticonvulsant mood stabilizer, is effective in the depressed phase of bipolar disorder and is also used in the maintenance phase. Its use would have been appropriate if the patient had a known bipolar disorder at initial presentation. Lamotrigine is associated with a risk of benign rash that can progress to serious rash (including Stevens-Johnson syndrome) in rare cases. (Choice D) Olanzapine is a second-generation antipsychotic with mood-stabilizing properties that can be used in bipolar disorder. It is associated with weight gain and metabolic side effects. Educational objective: Antidepressant monotherapy can induce mania in susceptible patients, especially those with unrecognized bipolar disorder. __________ References: Antidepressant-associated mood-switching and transition from unipolar major depression to bipolar disorder: a review. (http://www.ncbi.nlm.nih.gov/pubmed/23219059) Risk of manic switch associated with antidepressant therapy in pediatric bipolar depression. (http://www.ncbi.nlm.nih.gov/pubmed/25470655)

An 18-Year-Old Woman Comes to the Office Due to Low