A 27-year-old woman is brought to the office by her boyfriend after locking herself in the bathroom and making a superficial cut to her forearm the night before. The patient states that she has been more down than usual for the past 2 weeks and has been contemplating suicide. She has been too tired to get out of bed and tends to sleep for hours after her alarm clock rings. The patient fears that her boyfriend will leave her because she is "completely useless." Her boyfriend says, "I'm not sure what changed-last month, she was looking forward to our first vacation together. She skipped work and spent a week straight figuring out all the details. She barely slept and couldn't stop talking about this trip because she was so excited." The patient has a history of 2 suicide attempts at age 18 and 21. She takes no medications. Temperature is 36.7 C (98.1 F), blood pressure is 119/78 mm Hg, pulse is 72/min, and respirations are 14/min. There is a 4-cm, superficial laceration on her left forearm. The patient is tearful and dysphoric. Which of the following is the most appropriate next step in treatment of this patient?

Question

A 27-year-old woman is brought to the office by her boyfriend after locking herself in the bathroom and making a superficial cut to her forearm the night before.  The patient states that she has been more down than usual for the past 2 weeks and has been contemplating suicide.  She has been too tired to get out of bed and tends to sleep for hours after her alarm clock rings.  The patient fears that her boyfriend will leave her because she is "completely useless."  Her boyfriend says, "I'm not sure what changed-last month, she was looking forward to our first vacation together.  She skipped work and spent a week straight figuring out all the details.  She barely slept and couldn't stop talking about this trip because she was so excited."  The patient has a history of 2 suicide attempts at age 18 and 21.  She takes no medications.  Temperature is 36.7 C (98.1 F), blood pressure is 119/78 mm Hg, pulse is 72/min, and respirations are 14/min.  There is a 4-cm, superficial laceration on her left forearm.  The patient is tearful and dysphoric.  Which of the following is the most appropriate next step in treatment of this patient?

Quizplus · Accepted Answer

11ec25c8_d7aa_6cba_bc81_5f80eb3ad89b_MD0003_00 This patient's 2-week episode of depression (ie, depressed mood, hypersomnia, low energy, feelings of worthlessness, suicidality) and history suggestive of a hypomanic episode (ie, ≥4 days of elevated mood, hyperactivity, hypertalkativeness, decreased sleep) are consistent with a diagnosis of bipolar II disorder. Patients with bipolar II disorder experience at least 1 episode of hypomania and ≥1 major depressive episodes; they do not experience the full-blown manic episodes that characterize bipolar I disorder (ie, severe symptoms with marked functional impairment). The depressive and hypomanic episodes in bipolar II disorder may resemble the mood instability seen in patients with borderline personality disorder. However, they can be differentiated as discrete periods lasting weeks, as in this patient, in contrast to the labile mood states in borderline personality disorder that typically last hours to days. Although this patient's multiple suicide attempts overlap with the suicidal/self-injurious behavior commonly seen in borderline personality disorder, there is insufficient evidence to diagnose borderline personality disorder (eg, lifelong pattern of identity disturbance, feelings of emptiness, intense anger, splitting) in this patient, and her decreased sleep is more consistent with bipolar disorder. Treatment of bipolar II major depression follows the same guidelines established for bipolar I major depression. First-line treatment of bipolar major depression includes lurasidone and quetiapine, which are second-generation antipsychotics with mood-stabilizing and antidepressant effects. Antidepressant monotherapy should generally be avoided in patients with bipolar disorder due to the risk of precipitating hypomania; bupropion, a norepinephrine-dopamine reuptake inhibitor, and escitalopram, a selective serotonin reuptake inhibitor, would be appropriate first-line treatments for unipolar major depression (Choices A and D). (Choice B) Adjunctive psychotherapy (eg, cognitive behavioral therapy) is helpful to educate patients with bipolar disorder about the illness, enhance medication adherence, manage psychosocial stressors, and promote a stable sleep schedule and routine. However, in a patient with acute bipolar disorder, pharmacotherapy is primary and would be the first step in management. (Choice C) Dialectical behavior therapy is a first-line treatment for borderline personality disorder (eg, lifelong pattern of identity disorder, labile mood states lasting hours to days), not bipolar disorder. Educational objective: Patients with bipolar II disorder experience at least 1 episode of hypomania and ≥1 major depressive episodes. First-line treatment of bipolar depressive episodes includes the antipsychotics lurasidone and quetiapine. References: Lurasidone in the treatment of bipolar depression: systematic review of systematic reviews. (http://www.ncbi.nlm.nih.gov/pubmed/28573138) The diagnosis and management of bipolar I and II disorders: clinical practice update. (http://www.ncbi.nlm.nih.gov/pubmed/28888714)

A 27-Year-Old Woman Is Brought to the Office by Her