A 34-year-old man is brought to the emergency department by his wife after she found him running around the yard in his underwear shouting, "I am going to change the world." She reports that he has a lot of energy despite hardly sleeping for the past 7 days, and that he recently quit his job to write a 500-page novel that he says "explains everything about the universe." The patient's history is significant for epilepsy with generalized seizures since childhood and a psychiatric hospitalization a year ago for a major depressive episode. Family history is significant for alcoholism and hypertension in his father and schizophrenia in his grandmother. Which of the following medications would be most helpful for long-term treatment of this patient's psychiatric condition as well as his seizure disorder?

Question

A 34-year-old man is brought to the emergency department by his wife after she found him running around the yard in his underwear shouting, "I am going to change the world."  She reports that he has a lot of energy despite hardly sleeping for the past 7 days, and that he recently quit his job to write a 500-page novel that he says "explains everything about the universe."  The patient's history is significant for epilepsy with generalized seizures since childhood and a psychiatric hospitalization a year ago for a major depressive episode.  Family history is significant for alcoholism and hypertension in his father and schizophrenia in his grandmother.  Which of the following medications would be most helpful for long-term treatment of this patient's psychiatric condition as well as his seizure disorder?

Quizplus · Accepted Answer

11ec160b_3c50_c478_9249_25de8f281238_MD0001_00 This patient's history of major depression along with his current manic symptoms (ie, decreased need for sleep, grandiosity, goal-directed activity) indicate a diagnosis of bipolar disorder. Valproate (valproic acid) is used as an anticonvulsant and mood stabilizer. It blocks voltage-gated sodium channels and enhances the availability of GABA. As a mood stabilizer, it is used in acute mania and maintenance treatment of bipolar disorder. As an anticonvulsant, it effectively treats absence, myoclonic, and generalized tonic-clonic seizures. It is the drug of choice for myoclonic seizures and a second-line agent for absence seizures (for which ethosuximide is preferred). Other anticonvulsants used as mood stabilizers in bipolar disorder include carbamazepine and lamotrigine. Carbamazepine is a CYP450 inducer that can cause lower levels of concomitant medications. Lamotrigine is associated with skin rash, which rarely can progress to life-threatening mucocutaneous reactions (eg, Stevens-Johnson syndrome). (Choice A) Aripiprazole is a second-generation antipsychotic used to treat psychotic and mood disorders. Antipsychotics are not indicated for seizures and may lower the seizure threshold. (Choice B) Citalopram is a selective serotonin reuptake inhibitor (SSRI) antidepressant. SSRI monotherapy is avoided in bipolar disorder due to the risk of inducing mania. SSRIs have no role in the treatment of seizures. (Choices C and F) Levetiracetam and phenytoin are anticonvulsants used in the treatment of epilepsy but they are not useful for treating bipolar disorder. (Choice D) Lithium is a mood stabilizer that is effective for the treatment of bipolar disorder. Lithium is thought to modify second messenger signal transduction (eg, adenylyl cyclase and phospho-inositol pathways) at several levels, resulting in decreased excitatory neurotransmission. Lithium is not an anticonvulsant. (Choice E) Lorazepam is a benzodiazepine that enhances the affinity of GABA for its receptor (increases frequency of chloride channel openings), thereby increasing its inhibitory potential. Lorazepam is a first-line medication for the treatment of active seizures, acute anxiety, and alcohol withdrawal. Educational objective: Lithium and the anticonvulsants valproate, carbamazepine, and lamotrigine are mood-stabilizing agents used in bipolar disorder. Valproate is commonly used in the treatment of generalized as well as myoclonic seizures. __________ References: Anticonvulsants in bipolar disorders: current research and practice and future directions. (http://www.ncbi.nlm.nih.gov/pubmed/19538683) Management of adverse effects of mood stabilizers. (http://www.ncbi.nlm.nih.gov/pubmed/26084665)

A 34-Year-Old Man Is Brought to the Emergency Department by His