A 27-year-old man is brought to the office by his wife due to her concern that "he has not been himself" for the past 3 weeks. She says that he seems sad and withdrawn and has difficulty sleeping, little desire for food, and no energy or interest in looking for work or participating in any activities. The patient was hospitalized 6 months ago after he became aggressive toward his wife. He tried to choke her when she confronted him about staying up all night, gambling away their savings, and investing a large sum of money in a start-up internet company that soon went bankrupt. At that time, the patient spoke very rapidly and was convinced that he had a brilliant plan to achieve world peace. He has experienced several similar episodes of elevated, irritable mood with increased energy over the past 2 years that responded to pharmacotherapy. Which combination of medications is the most appropriate maintenance therapy for this patient?

Question

A 27-year-old man is brought to the office by his wife due to her concern that "he has not been himself" for the past 3 weeks.  She says that he seems sad and withdrawn and has difficulty sleeping, little desire for food, and no energy or interest in looking for work or participating in any activities.  The patient was hospitalized 6 months ago after he became aggressive toward his wife.  He tried to choke her when she confronted him about staying up all night, gambling away their savings, and investing a large sum of money in a start-up internet company that soon went bankrupt.  At that time, the patient spoke very rapidly and was convinced that he had a brilliant plan to achieve world peace.  He has experienced several similar episodes of elevated, irritable mood with increased energy over the past 2 years that responded to pharmacotherapy.  Which combination of medications is the most appropriate maintenance therapy for this patient?

Quizplus · Accepted Answer

This patient's current major depressive episode and history of manic episodes meet the criteria for bipolar I disorder. Bipolar disorder is a lifelong and highly recurrent illness that requires maintenance treatment to delay or prevent recurrence of new mood episodes, reduce the risk of suicide, and improve psychosocial functioning. Evidence-based maintenance monotherapy options for bipolar disorder include lithium, valproate, quetiapine, and lamotrigine. However, those with severe illness, as seen in this patient (ie, psychosis, aggression, frequent episodes/hospitalization), often require combination therapy to maintain stability. Lithium or valproate combined with a second-generation antipsychotic (eg, quetiapine) is first-line combination therapy. (Choices A, C, and F) Antidepressants (eg, fluoxetine, sertraline, venlafaxine) should generally be avoided in the maintenance treatment of bipolar I disorder due to the risk of mood destabilization (ie, induction of mania or a mixed state). If an antidepressant is used to treat an acute depressive episode, it should be slowly tapered and discontinued during maintenance treatment. (Choice D) The combination of 2 second-generation antipsychotics is not first-line maintenance treatment for bipolar disorder. One antipsychotic in combination with lithium or valproate is preferred. (Choice E) First-generation antipsychotics such as haloperidol are not preferred for long-term maintenance due to the risk of extrapyramidal side effects. Educational objective: Bipolar disorder is a highly recurrent illness that requires maintenance pharmacotherapy. In patients with severe and frequent mood episodes, the combination of lithium or valproate and a second-generation antipsychotic is used as first-line combination pharmacotherapy. References: Treatment of bipolar disorder: review of evidence regarding quetiapine and lithium. (http://www.ncbi.nlm.nih.gov/pubmed/26688495) Effectiveness of psychotropic medications in the maintenance phase of bipolar disorder: a meta-analysis of randomized controlled trials. (http://www.ncbi.nlm.nih.gov/pubmed/21733231) Treatment of bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/23663953)

A 27-Year-Old Man Is Brought to the Office by His