A 35-year-old businesswoman comes to the office due to poor energy. She says, "Although I have no energy, I still can't sleep and am up most of the night. I drag myself to work but barely get anything done because I have no motivation and can hardly concentrate. I'm a horrible wife and mother. I don't want to go out anymore or do anything. All I want to do is hide in my room and get into bed." The patient has a history of 3 prior episodes of depression beginning at age 18. She was also hospitalized 3 years ago for aggressive behavior following an arrest for unauthorized use of her company's funds to finance a personal business venture. At that time, she had excessive energy, slept 2 hours a night, and believed that she had a brilliant idea that would revolutionize the computer industry. The patient has no history of drug or alcohol abuse. There is a family history of depression in her mother, who responded well to tricyclic antidepressants. Mental status examination is remarkable for psychomotor retardation, frequent tearfulness, depressed mood, and suicidal ideation. Which of the following is the most appropriate pharmacotherapy?

Question

A 35-year-old businesswoman comes to the office due to poor energy.  She says, "Although I have no energy, I still can't sleep and am up most of the night.  I drag myself to work but barely get anything done because I have no motivation and can hardly concentrate.  I'm a horrible wife and mother.  I don't want to go out anymore or do anything.  All I want to do is hide in my room and get into bed."  The patient has a history of 3 prior episodes of depression beginning at age 18.  She was also hospitalized 3 years ago for aggressive behavior following an arrest for unauthorized use of her company's funds to finance a personal business venture.  At that time, she had excessive energy, slept 2 hours a night, and believed that she had a brilliant idea that would revolutionize the computer industry.  The patient has no history of drug or alcohol abuse.  There is a family history of depression in her mother, who responded well to tricyclic antidepressants.  Mental status examination is remarkable for psychomotor retardation, frequent tearfulness, depressed mood, and suicidal ideation.  Which of the following is the most appropriate pharmacotherapy?

Quizplus · Accepted Answer

This patient is currently experiencing a major depressive episode. She meets the criteria for bipolar I disorder as she has a history of a manic episode (eg, increased energy, decreased need for sleep, risky spending, grandiose delusions). Medications commonly used in the treatment of acute bipolar depression include the second-generation antipsychotics quetiapine and lurasidone and the anticonvulsant lamotrigine. Lithium, valproate, and the combination of olanzapine and fluoxetine have also demonstrated efficacy. manic episode Antidepressant monotherapy should generally be avoided in patients with bipolar I disorder due to the risk of precipitating mania. If necessary, antidepressants should be used in combination with mood stabilizers (eg, lithium, valproate, second-generation antipsychotics) as these appear to decrease the risk of an antidepressant-induced switch from depression to mania. Other risks of using antidepressants in patients with bipolar depression include the development of rapid cycling (≥4 mood episodes/year) and increased mood cycle frequency. (Choices A, B, and F) These drugs are first-line antidepressants but should be avoided in this patient due to the risk of precipitating mania. Bupropion is a norepinephrine-dopamine reuptake inhibitor, citalopram is a selective serotonin reuptake inhibitor, and venlafaxine is a serotonin-norepinephrine reuptake inhibitor. (Choice C) Haloperidol is a first-generation antipsychotic that has not shown efficacy in the treatment of bipolar depression. It is associated with extrapyramidal side effects due to its potent D2 antagonism. (Choice D) The patient has a family history of response to tricyclic antidepressants (eg, imipramine). However, like all antidepressants, these would be contraindicated as monotherapy for a patient with bipolar I disorder. Educational objective: Second-generation antipsychotics (eg, quetiapine, lurasidone) are effective in the depressed phase of bipolar illness. Antidepressant monotherapy should be avoided in patients with bipolar I disorder. References: Treatment of bipolar depression: making sensible decisions. (http://www.ncbi.nlm.nih.gov/pubmed/25407667)

A 35-Year-Old Businesswoman Comes to the Office Due to Poor