A 32-year-old woman comes to the office for a follow-up. She has a history of mild asthma, migraine headaches, and bipolar I disorder. The patient was hospitalized for a depressive episode 8 months ago and was started on quetiapine. She responded well to the medication and was feeling fine, so she discontinued it 3 months ago. The patient tells the psychiatrist, "The depression lifted after a few months on the medication, which was such a relief. I was so down before and couldn't enjoy anything, but now I am really doing great. I just applied for 2 new jobs. Also, I met a fantastic new guy 2 weeks ago, and we've been together ever since. He is literally the man of my dreams." She also says, "We are engaged, and we're getting married in 3 weeks; I'm so excited. I really don't want to take medicine because I feel terrific and we plan to start a family right away." The patient's mood, quality of sleep, and appetite are good, and she continues to maintain her job at a real estate office. On mental status examination, she is neatly dressed and groomed; she has a bright affect and mildly pressured speech. Which of the following is the most appropriate intervention for this patient?

Question

A 32-year-old woman comes to the office for a follow-up.  She has a history of mild asthma, migraine headaches, and bipolar I disorder.  The patient was hospitalized for a depressive episode 8 months ago and was started on quetiapine.  She responded well to the medication and was feeling fine, so she discontinued it 3 months ago.  The patient tells the psychiatrist, "The depression lifted after a few months on the medication, which was such a relief.  I was so down before and couldn't enjoy anything, but now I am really doing great.  I just applied for 2 new jobs.  Also, I met a fantastic new guy 2 weeks ago, and we've been together ever since.  He is literally the man of my dreams."  She also says, "We are engaged, and we're getting married in 3 weeks; I'm so excited.  I really don't want to take medicine because I feel terrific and we plan to start a family right away."  The patient's mood, quality of sleep, and appetite are good, and she continues to maintain her job at a real estate office.  On mental status examination, she is neatly dressed and groomed; she has a bright affect and mildly pressured speech.  Which of the following is the most appropriate intervention for this patient?

Quizplus · Accepted Answer

Explanation: This patient, who has a history of bipolar illness that is currently untreated, exhibits symptoms concerning for possible hypomania (eg, elevated mood, slightly pressured speech, increased sociability and work activities, excessive optimism, impulsivity). It is the physician's duty to ask further questions and ascertain if the patient's desire to marry could be influenced by the impulsivity and poor judgment that accompany hypomanic episodes. If this patient's decision seems to be influenced by her illness, then the best approach would be to provide gentle feedback about the physician' concerns and encourage her to delay life-altering decisions until the psychiatric condition is stabilized. (Choices A and E) This patient does not believe she is ill and is unlikely to accept medication without further discussion. In addition, the patient plans to have children, making valproic acid a poor choice due to its teratogenic effects (neural tube defects). (Choice C) If the physician is concerned about a patient's judgment, the issue should be explored further and the patient encouraged to delay making decisions if necessary. However, directly advising the patient against marrying at this point is unlikely to be well received and may damage the physician-patient relationship. (Choice D) Offering congratulations before ascertaining if the decision is being influenced by the patient's illness is inappropriate. Educational objective: Hypomania is frequently associated with impulsivity, poor judgment, and risky behavior. Early recognition of hypomanic states and a gentle exploration of these patients' motives may be necessary to help them avoid making impulsive decisions they may later regret. References: High-risk behaviour in hypomanic states. (http://www.ncbi.nlm.nih.gov/pubmed/23489397)

A 32-Year-Old Woman Comes to the Office for a Follow-Up