A 53-year-old man comes to the office due to depressed mood, low energy, and poor sleep for the past 2 months. Although he spends up to 12 hours a day lying in bed, he gets only 4-5 hours of sleep and never feels rested. He is isolating himself from his family and says, "I eat only because I have to." The patient has had several previous periods of depression but was never diagnosed or treated. He also has had periods lasting 5-6 days at a time in which he gets a burst of energy, has "tons of new ideas in my head," and feels great. During these times, he likes to work extra-long hours to take on additional projects at work, and he feels well rested despite sleeping only 4 hours a night. Now the patient fears that his depression is having a major impact on his work and family life. He has been uncharacteristically procrastinating on several projects and is frequently late to work. He has no motivation to spend time with his children or friends. The patient has increased his daily caffeine consumption to 6 cups of coffee and has an energy drink to counteract his fatigue, and he recently started using marijuana at bedtime to escape from his depression and help him fall asleep. Mental status examination shows slow speech, a sad affect, and no suicidal ideation. Which of the following is the most likely diagnosis?

Question

A 53-year-old man comes to the office due to depressed mood, low energy, and poor sleep for the past 2 months.  Although he spends up to 12 hours a day lying in bed, he gets only 4-5 hours of sleep and never feels rested.  He is isolating himself from his family and says, "I eat only because I have to."  The patient has had several previous periods of depression but was never diagnosed or treated.  He also has had periods lasting 5-6 days at a time in which he gets a burst of energy, has "tons of new ideas in my head," and feels great.  During these times, he likes to work extra-long hours to take on additional projects at work, and he feels well rested despite sleeping only 4 hours a night.  Now the patient fears that his depression is having a major impact on his work and family life.  He has been uncharacteristically procrastinating on several projects and is frequently late to work.  He has no motivation to spend time with his children or friends.  The patient has increased his daily caffeine consumption to 6 cups of coffee and has an energy drink to counteract his fatigue, and he recently started using marijuana at bedtime to escape from his depression and help him fall asleep.  Mental status examination shows slow speech, a sad affect, and no suicidal ideation.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7a5_d8d5_bc81_4734de772cb5_MD0003_00 The differential diagnosis of mood disorders requires screening for hypomanic and manic symptoms. This patient is currently in a major depressive episode (eg, ≥2 weeks, depressed mood, decreased interest, low energy, sleep and appetite disturbance) but also describes a history consistent with hypomania (eg, elevated mood, increased energy and productivity at work, flight of ideas, decreased need for sleep lasting ≥4 days). Occupational functioning in hypomania is either improved, as in this patient, or only mildly impaired. Mania, in contrast, is characterized by more severe symptoms resulting in markedly impaired functioning (eg, unable to work, grossly disorganized behavior), psychosis, or need for psychiatric hospitalization. Patients with a history of ≥1 major depressive episode, ≥1 hypomanic episode, and no manic episodes are diagnosed with bipolar II disorder. Patients diagnosed with bipolar I disorder must have a history of ≥1 manic episode and frequently experience major depressive episodes, although these are not required for diagnosis (Choice A). Major depressive disorder is a unipolar disorder that requires no history of mania or hypomania (Choice D). Correct diagnosis is important to help guide pharmacological treatment. (Choice C) Cyclothymic disorder is characterized by numerous periods of hypomanic and depressive symptoms that do not meet the full criteria for hypomanic or depressive episodes over the course of ≥2 years. (Choice E) This patient is using caffeine and marijuana to self-medicate his fatigue, depression, and insomnia. His substance use is a consequence, not a cause, of his mood disorder. Educational objective: Bipolar II disorder is characterized by hypomanic and major depressive episodes with no history of manic episodes. Hypomania is distinguished from mania by less severity, no psychotic features, and no need for hospitalization. Functioning in hypomania is either improved or only mildly impaired. References: Differential diagnosis of bipolar disorder and major depressive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25533909) The presentation, recognition and management of bipolar depression in primary care. (http://www.ncbi.nlm.nih.gov/pubmed/23835789)

A 53-Year-Old Man Comes to the Office Due to Depressed