A 26-year-old woman comes to the office for treatment of depression. She was prescribed fluoxetine a month ago due to symptoms of depressed mood, lack of motivation, poor sleep, fatigue, and poor concentration at work. The patient reports that she is tolerating the medication without difficulty and began improving 2 days after starting it. She says, "I've never felt better. I instantly clicked with this guy I went on a date with yesterday, and I started a second part-time job." The patient is sleeping 3 or 4 hours a night but reports that her energy is "excellent." She tells the physician she is figuring out how to invest her savings in the stock market and offers to share her tips. The patient does not use alcohol or illicit drugs. Physical examination is normal. Mental status examination is remarkable for moderately loud and rapid speech. Which of the following is the most appropriate initial step in management of this patient?

Question

A 26-year-old woman comes to the office for treatment of depression.  She was prescribed fluoxetine a month ago due to symptoms of depressed mood, lack of motivation, poor sleep, fatigue, and poor concentration at work.  The patient reports that she is tolerating the medication without difficulty and began improving 2 days after starting it.  She says, "I've never felt better.  I instantly clicked with this guy I went on a date with yesterday, and I started a second part-time job."  The patient is sleeping 3 or 4 hours a night but reports that her energy is "excellent."  She tells the physician she is figuring out how to invest her savings in the stock market and offers to share her tips.  The patient does not use alcohol or illicit drugs.  Physical examination is normal.  Mental status examination is remarkable for moderately loud and rapid speech.  Which of the following is the most appropriate initial step in management of this patient?

Quizplus · Accepted Answer

This patient's elevated mood, decreased need for sleep, pressured speech, and increased activity and energy following exposure to the selective serotonin reuptake inhibitor fluoxetine are consistent with antidepressant-induced hypomania/mania. All antidepressants carry the risk of inducing mania in susceptible patients; many patients who experience this are ultimately diagnosed with a bipolar spectrum disorder. In addition to her symptoms suggestive of hypomania/mania, this patient's atypically rapid improvement in depression after 2 days of antidepressant treatment (typical time to onset of effect is 2 weeks) is an additional clue that she may be in the bipolar spectrum. The most appropriate initial step in management of antidepressant-induced hypomania is to discontinue the antidepressant to prevent further worsening of mania. If manic symptoms persist despite discontinuing the antidepressant, treatment with a mood stabilizer (eg, lithium, valproate) or an antipsychotic (eg, quetiapine) should be considered (Choices A, B, and C). (Choice D) An antidepressant serum level test would not assist in the management of this patient. The emergence of clinically significant manic symptoms is reason to discontinue the medication, regardless of level. (Choice F) Switching from fluoxetine to bupropion is not appropriate because all antidepressants carry the risk of inducing mania. Educational objective: All antidepressants are associated with a risk of inducing mania in susceptible patients. The first step in management is discontinuation of the offending medication. References: Do antidepressants increase the risk of mania and bipolar disorder in people with depression? A retrospective electronic case register cohort study. (http://www.ncbi.nlm.nih.gov/pubmed/26667012) The risk of switch to mania in patients with bipolar disorder during treatment with an antidepressant alone and in combination with a mood stabilizer. (http://www.ncbi.nlm.nih.gov/pubmed/24935197) Antidepressant-induced hypomania/mania in patients with major depression: evidence from the BRIDGE-II-MIX study. (http://www.ncbi.nlm.nih.gov/pubmed/28558366)

A 26-Year-Old Woman Comes to the Office for Treatment of Depression