A 30-year-old man comes to the office due to depression. He describes a 4-week history of severely depressed mood, loss of motivation, loss of interest, and sleeping 12 hours a day. The patient has difficulty concentrating and worries that it is interfering with his work. He is pessimistic about the future but has no suicidal thoughts. The patient had a previous depressive episode in his 20s that responded rapidly to sertraline. He felt "really good and energetic" after a few days of treatment but discontinued the antidepressant a week later as he did not feel that he needed it. He drinks 1 or 2 beers on social occasions. Physical examination is normal. Which of the following would be most important to assess prior to initiating pharmacologic treatment for this patient?

Question

A 30-year-old man comes to the office due to depression.  He describes a 4-week history of severely depressed mood, loss of motivation, loss of interest, and sleeping 12 hours a day.  The patient has difficulty concentrating and worries that it is interfering with his work.  He is pessimistic about the future but has no suicidal thoughts.  The patient had a previous depressive episode in his 20s that responded rapidly to sertraline.  He felt "really good and energetic" after a few days of treatment but discontinued the antidepressant a week later as he did not feel that he needed it.  He drinks 1 or 2 beers on social occasions.  Physical examination is normal.  Which of the following would be most important to assess prior to initiating pharmacologic treatment for this patient?

Quizplus · Accepted Answer

All patients with a major depressive episode should be screened for a past history of manic episodes to differentiate major depressive disorder (unipolar depression) from bipolar disorder. This is particularly relevant in this patient as his atypically rapid response to the selective serotonin reuptake inhibitor sertraline is suggestive of treatment-emergent mania. If further history substantiates a diagnosis of bipolar disorder, antidepressant monotherapy should be avoided, as all antidepressants carry a risk of inducing mania. Bipolar patients in the depressed phase may be misdiagnosed with unipolar major depressive disorder when either the physician neglects to ask about past manic symptoms or patients do not report them due to limited insight, difficulty recalling, or a tendency to minimize past manic episodes. Physicians should question patients regarding a history of distinct periods of elevated mood and increased energy, decreased need for sleep, hyperactivity, racing thoughts, and uncharacteristic risk-taking behavior. (Choices A, B, and F) A complete blood count, metabolic panel, and urine toxicology screen are not priorities for this patient with no new physical symptoms, normal physical examination, and minimal substance use. Selected laboratory tests should be performed in cases of treatment-resistant depression or in patients who experience new-onset physical symptoms along with depression (eg, thyroid function tests in a patient with signs of hypothyroidism). (Choice C) An ECG is not routinely performed prior to prescribing first-line antidepressants in an otherwise healthy, young patient. (Choice E) A history of sexual dysfunction would be helpful prior to selection and initiation of a specific antidepressant, as medications commonly cause sexual dysfunction. However, ensuring accurate diagnosis by screening for bipolar disorder takes precedence. Educational objective: Patients experiencing a major depressive episode should be carefully screened for past manic episodes to rule out bipolar disorder. Antidepressant monotherapy should be avoided in patients with bipolar disorder due to the risk of precipitating mania. __________ References: Differential diagnosis of bipolar disorder and major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25533909)

A 30-Year-Old Man Comes to the Office Due to Depression