A 22-year-old man comes to the emergency department with his roommate due to depression and thoughts of killing himself. The patient says, "I've been struggling for weeks, but my roommate convinced me to finally get help." The patient has not attended classes the past 2 weeks because he feels exhausted and has been sleeping throughout the day. He has no appetite and must force himself to eat at least 1 meal a day. The roommate says, "The whole week before he got depressed, he was doing great. He was reading ahead for class and working in the lab with almost no sleep. He was so excited about his research and would talk about it nonstop to anyone who would listen." The patient takes no medication. Physical examination and laboratory studies are unremarkable; urine drug screen is negative. He appears tearful and has suicidal ideation. The patient is admitted for inpatient psychiatric treatment. Which of the following is the most appropriate pharmacotherapy at present?

Question

A 22-year-old man comes to the emergency department with his roommate due to depression and thoughts of killing himself.  The patient says, "I've been struggling for weeks, but my roommate convinced me to finally get help."  The patient has not attended classes the past 2 weeks because he feels exhausted and has been sleeping throughout the day.  He has no appetite and must force himself to eat at least 1 meal a day.  The roommate says, "The whole week before he got depressed, he was doing great.  He was reading ahead for class and working in the lab with almost no sleep.  He was so excited about his research and would talk about it nonstop to anyone who would listen."  The patient takes no medication.  Physical examination and laboratory studies are unremarkable; urine drug screen is negative.  He appears tearful and has suicidal ideation.  The patient is admitted for inpatient psychiatric treatment.  Which of the following is the most appropriate pharmacotherapy at present?

Quizplus · Accepted Answer

Patients with depressive symptoms should be carefully assessed for a history of manic or hypomanic episodes to differentiate unipolar (depressive episodes only) from bipolar disorders (hypomanic/manic and depressive episodes). This patient's course of illness is consistent with bipolar disorder as he experienced a one-week episode of hypomanic symptoms (eg, decreased need for sleep, hyperactivity, pressured speech with increased productivity) followed by a ≥2-week period of depressive symptoms (eg, depressed mood, suicidal ideation, low energy, hypersomnia, decreased appetite). Treatment of bipolar depression differs from treatment of unipolar depression. Antidepressant monotherapy should generally be avoided with bipolar disorder due to the risk of inducing mania; it would be particularly risky in this patient who was recently in a hypomanic episode. First-line medications for treatment of acute bipolar depression include the second-generation antipsychotics quetiapine and lurasidone. Lamotrigine, lithium, valproate, and the combination of olanzapine and fluoxetine have also demonstrated efficacy. (Choices A, B, and E) Bupropion, fluoxetine, and mirtazapine are first-line antidepressants that would be appropriate in unipolar major depressive disorder. They should be avoided in this patient with bipolar disorder due to the risk of inducing hypomania or mania. In general, antidepressant use in bipolar disorder should be limited to use as an adjunct in combination with an antimanic drug. (Choice C) Gabapentin is an anticonvulsant with no evidence to support its use in treating acute bipolar depression. (Choice D) The first-generation antipsychotic haloperidol has not shown efficacy in the treatment of bipolar depression. It has a high risk of extrapyramidal side effects due to its potent D2 antagonism. Educational objective: The second-generation antipsychotics quetiapine and lurasidone are first-line medications for the treatment of acute bipolar depression. Antidepressant monotherapy should be avoided due to the risk of inducing mania. References: Treatment of bipolar depression: evolving recommendations. (http://www.ncbi.nlm.nih.gov/pubmed/26876316) Treatment of acute bipolar depression. (http://www.ncbi.nlm.nih.gov/pubmed/30069121) Quetiapine for acute bipolar depression: a systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25028535)

A 22-Year-Old Man Comes to the Emergency Department with His