A 20-year-old woman is brought to the emergency department by police at 2:30 AM after she was caught attempting to scale a fence at the White House. The patient appears highly agitated and paces around the examination room. She has just flown in from out of state to "meet with the president about a foolproof plan for eliminating worldwide terrorism." The patient has barely slept for the past week due to her intensive work on this plan. She speaks rapidly but periodically stops to shout, "I'm going to sue all of you for interfering with my right to meet with the president." She refuses a cup of water offered by a nurse, flinging it across the room. The evaluation has to be stopped when the patient begins banging on the door and demanding to leave. Family history is significant for major depression in her mother. Temperature is 37 C (98.6 F), blood pressure is 148/84 mm Hg, pulse is 98/min, and respirations are 22/min. Urine drug screen is negative. Administration of which of the following medications is the most appropriate next step in management of this patient?

Question

A 20-year-old woman is brought to the emergency department by police at 2:30 AM after she was caught attempting to scale a fence at the White House.  The patient appears highly agitated and paces around the examination room.  She has just flown in from out of state to "meet with the president about a foolproof plan for eliminating worldwide terrorism."  The patient has barely slept for the past week due to her intensive work on this plan.  She speaks rapidly but periodically stops to shout, "I'm going to sue all of you for interfering with my right to meet with the president."  She refuses a cup of water offered by a nurse, flinging it across the room.  The evaluation has to be stopped when the patient begins banging on the door and demanding to leave.  Family history is significant for major depression in her mother.  Temperature is 37 C (98.6 F), blood pressure is 148/84 mm Hg, pulse is 98/min, and respirations are 22/min.  Urine drug screen is negative.  Administration of which of the following medications is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d7a0_a8b3_bc81_49763446c624_MD0003_00 This patient's grandiose delusions, decreased need for sleep, pressured speech, and psychomotor agitation causing marked impairment are consistent with a manic episode. In the absence of any substance or medical cause, the patient would be diagnosed with bipolar I disorder. First-line treatments for mania include antipsychotics (eg, olanzapine), lithium, and anticonvulsant mood stabilizers (eg, valproate). Because this patient exhibits acute psychosis (eg, grandiose delusions) and escalating agitation (eg, shouting, banging on the door, throwing a cup of water), an antipsychotic such as olanzapine would be the next step in management because it can be administered intramuscularly and has a rapid onset of action. Both first- and second-generation antipsychotics are effective in managing mania and associated acute behavioral agitation. Once this patient is calmer and willing to take oral medication, lithium or an anticonvulsant mood stabilizer could be given. Combination therapy with an antipsychotic plus lithium or valproate is often necessary to treat severe mania (eg, psychotic features, aggressive behavior, risk of harm to self or others). (Choices A and G) Although valproate or carbamazepine can be used in the management of bipolar disorder, they require oral administration (which the patient is currently unlikely to accept) and typically require gradual titration over several days to achieve therapeutic blood levels before they take effect. (Choice B) The antipsychotic clozapine requires mandatory monitoring of the complete blood count due to the risk of agranulocytosis; therefore, it is typically reserved for treatment of refractory psychosis. Olanzapine does not require this level of monitoring and would be a better initial choice for this patient. (Choices C and E) Escitalopram (selective serotonin reuptake inhibitor) and mirtazapine (alpha-2 receptor antagonist) are both antidepressants. The use of antidepressants in bipolar disorder is associated with a risk of precipitating or worsening manic episodes. Antidepressants should generally be discontinued if taken by a patient who has mania. (Choice D) The anticonvulsant lamotrigine has the greatest efficacy in treating bipolar depressive (not manic) episodes. The most significant adverse effect is rash, which can develop into a life-threatening mucocutaneous reaction (ie, Stevens-Johnson syndrome) in approximately 0.1% of patients. Educational objective: Management of patients who are agitated and have acute mania consists of antipsychotic medication (administered intramuscularly if needed) to control behavioral disturbances. Patients experiencing severe mania often require a combination of an antipsychotic and mood stabilizer to manage symptoms effectively. References: Comparative efficacy and acceptability of antimanic drugs in acute mania: a multiple-treatments meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/21851976) New treatment guidelines for acute bipolar mania: a critical review. (http://www.ncbi.nlm.nih.gov/pubmed/22100133) Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) collaborative update of CANMAT guidelines for the management of patients with bipolar disorder: update 2013. (http://www.ncbi.nlm.nih.gov/pubmed/23237061)

A 20-Year-Old Woman Is Brought to the Emergency Department by Police