A 30-year-old woman is brought to the office by her husband. He says that over the past 2 months, the patient has become increasingly depressed to the point that she rarely gets out of bed. She has called in sick to work, does not answer the phone when her friends call, and has lost 4.5 kg (10 lb). The patient has a history of 2 psychiatric hospitalizations. She was first hospitalized at age 27 for a period of extreme irritability and agitation that lasted a week. At that time, she spoke so rapidly that she was difficult to understand and stayed up for nights dictating letters to government officials about her solution to world hunger. Last year, the patient was hospitalized for severe depression and a suicide attempt. She responded within days to venlafaxine but discontinued the medication shortly after discharge because she "felt fine." On mental status examination, the patient shows a depressed and tearful affect. She admits to "hearing the devil saying I'm a useless waste of time." Which of the following medications would be most appropriate for the long-term treatment of this patient's condition?

Question

A 30-year-old woman is brought to the office by her husband.  He says that over the past 2 months, the patient has become increasingly depressed to the point that she rarely gets out of bed.  She has called in sick to work, does not answer the phone when her friends call, and has lost 4.5 kg (10 lb).  The patient has a history of 2 psychiatric hospitalizations.  She was first hospitalized at age 27 for a period of extreme irritability and agitation that lasted a week.  At that time, she spoke so rapidly that she was difficult to understand and stayed up for nights dictating letters to government officials about her solution to world hunger.  Last year, the patient was hospitalized for severe depression and a suicide attempt.  She responded within days to venlafaxine but discontinued the medication shortly after discharge because she "felt fine."  On mental status examination, the patient shows a depressed and tearful affect.  She admits to "hearing the devil saying I'm a useless waste of time."  Which of the following medications would be most appropriate for the long-term treatment of this patient's condition?

Quizplus · Accepted Answer

This patient is currently experiencing symptoms of depression with psychotic features. Her history of mania, suggested by an episode of increased irritability, agitation, pressured speech, decreased need for sleep, and grandiosity, makes bipolar I disorder the most likely diagnosis. Common options for maintenance treatment of bipolar disorder include lithium and valproate. The second-generation antipsychotic quetiapine and the anticonvulsant lamotrigine have also demonstrated efficacy. Lithium would be particularly helpful in this patient because it would reduce the risk of suicide. (Choice A) Clozapine is reserved for use in treatment-resistant schizophrenia due to the potential for life-threatening agranulocytosis. (Choices B, E, and F) Antidepressant monotherapy should be avoided in patients with bipolar I disorder due to the risk of mood destabilization. Fluoxetine, mirtazapine, and venlafaxine would be appropriate maintenance treatments for patients with recurrent, unipolar major depressive disorder but would risk inducing mania in this patient with bipolar I disorder. Her uncharacteristically rapid response to venlafaxine within a few days (typical time to response is 2-4 weeks) is another clue that she has bipolar disorder. (Choice C) Although haloperidol has a role in treating acute mania, particularly with psychotic features, it is not used for long-term management due to its side effect profile. Educational objective: Lithium, valproate, quetiapine, and lamotrigine are first-line maintenance treatments for bipolar disorder. References: Prophylactic efficacy of lithium, valproic acid, and carbamazepine in the maintenance phase of bipolar disorder: a naturalistic study. (http://www.ncbi.nlm.nih.gov/pubmed/26523730) Recent advances in the understanding and management of bipolar disorder in adults. (http://www.ncbi.nlm.nih.gov/pubmed/29188027)

A 30-Year-Old Woman Is Brought to the Office by Her