First episode management US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for First episode management. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
First episode management US Medical PG Question 1: A 20-year-old woman is brought in by police for trying to break into a museum after hours. The patient states that she is a detective on the trail of a master collusion scheme and needs the artifacts from the museum to prove her case. Her family reports that she has been acting strangely for the past week. She has been up perusing the internet all night without taking breaks. Her husband states that she has had increased sexual interest for the past week; however, he did not report this to the physician when he first noticed it. The patient is unable to offer a history as she cannot be redirected from her current theory. Her temperature is 99.0°F (37.2°C), blood pressure is 122/81 mmHg, pulse is 97/min, respirations are 17/min, and oxygen saturation is 98% on room air. Physical exam is notable only for a highly-energized patient. Laboratory studies are ordered as seen below.
Urine:
Color: Yellow
Nitrite: Negative
Bacteria: Negative
Leukocytes: Negative
hCG: Positive
Benzodiazepines: Negative
Barbiturate: Negative
Cocaine: Negative
Acetaminophen: Negative
Which of the following is the most appropriate next step in management?
- A. Lithium
- B. Valproic acid
- C. Fluoxetine
- D. Haloperidol (Correct Answer)
- E. Electroconvulsive therapy
First episode management Explanation: ***Haloperidol***
- The patient is presenting with acute **mania** with psychotic features (delusions of being a detective) and behavioral disorganization (trying to break into a museum), requiring rapid tranquilization.
- **Haloperidol** is a potent **first-generation antipsychotic** effective for acute agitation and psychotic symptoms in mania, offering rapid symptom control.
- **Pregnancy consideration:** The patient's **positive hCG** is significant. Haloperidol is **relatively safe in pregnancy** (FDA Category C) and is appropriate for acute behavioral emergencies when immediate control is needed.
*Lithium*
- While **lithium** is a first-line mood stabilizer for bipolar disorder, it has a **slow onset of action** (weeks) and is not suitable for acute behavioral emergencies or rapid tranquilization.
- **Contraindicated in pregnancy** (especially first trimester) due to risk of **Ebstein's anomaly** and other cardiac malformations (FDA Category D).
*Valproic acid*
- **Valproic acid** is another effective mood stabilizer for bipolar disorder, but like lithium, it has a **relatively slow onset of action** and is not indicated for acute agitation or psychosis requiring immediate control.
- **Highly teratogenic and contraindicated in pregnancy**, with risks including neural tube defects, developmental delays, and reduced IQ (FDA Category D/X).
*Fluoxetine*
- **Fluoxetine** is an antidepressant and is generally **contraindicated as monotherapy** in bipolar disorder due to the risk of inducing or worsening manic episodes, especially in patients with acute mania.
- It could exacerbate the patient's current hyperactive, agitated state.
*Electroconvulsive therapy*
- **Electroconvulsive therapy (ECT)** is a highly effective treatment for severe mania and is considered **safe in pregnancy** with no teratogenic risk.
- While ECT is an excellent option for pregnant patients with severe bipolar disorder, it is typically reserved for cases that are **refractory to pharmacotherapy**, when rapid definitive response is needed due to life-threatening complications, or when severe symptoms persist despite medication.
- In this acute behavioral emergency, **pharmacologic rapid tranquilization with haloperidol is the more appropriate immediate next step**, with ECT considered if the patient does not respond to initial management.
First episode management US Medical PG Question 2: A 35-year-old man is brought to the emergency department by his wife. She was called by his coworkers to come and pick him up from work after he barged into the company’s board meeting and was being very disruptive as he ranted on about all the great ideas he had for the company. When they tried to reason with him, he became hostile and insisted that he should be the CEO as he knew what was best for the future of the company. The patient’s wife also noted that her husband has been up all night for the past few days but assumed that he was handling a big project at work. The patient has no significant past medical or psychiatric history. Which of the following treatments is most likely to benefit this patient’s condition?
- A. Antidepressants
- B. Valproic acid (Correct Answer)
- C. Haloperidol
- D. Psychotherapy
- E. Clozapine
First episode management Explanation: ***Valproic acid***
- This patient presents with symptoms highly suggestive of a **manic episode**, including grandiosity (believing he should be CEO), decreased need for sleep (up all night for days), pressured speech (ranting), and impulsivity with poor judgment (disruptive behavior at a board meeting).
- **Valproic acid** is a **first-line, guideline-recommended mood stabilizer** for acute mania. It is particularly effective for managing the core symptoms of mania including mood elevation, irritability, and impulsivity.
- It has a relatively rapid onset of action and a favorable side effect profile compared to typical antipsychotics, making it an excellent choice for initial management of acute mania in the emergency setting.
*Antidepressants*
- Administering **antidepressants** during a manic or hypomanic episode can exacerbate symptoms, potentially leading to a rapid cycling pattern or worsening mania.
- Antidepressants are primarily used for depressive episodes in bipolar disorder, typically in conjunction with a mood stabilizer, never as monotherapy in a patient presenting with mania.
*Haloperidol*
- **Haloperidol** is a typical antipsychotic that can be used for acute agitation in mania, but it does not address the underlying mood dysregulation.
- While it may help with immediate behavioral control, mood stabilizers like valproic acid or lithium are preferred as primary treatments because they target the core pathophysiology of bipolar disorder.
- Haloperidol also has a higher risk of extrapyramidal symptoms and does not prevent future mood episodes.
*Psychotherapy*
- **Psychotherapy** is a crucial component of long-term management for bipolar disorder but is not effective as a sole treatment for acute mania.
- Patients in acute mania are often too agitated, impulsive, and lack sufficient insight to meaningfully engage in therapeutic interventions.
- Psychotherapy should be initiated after mood stabilization with pharmacotherapy.
*Clozapine*
- **Clozapine** is an atypical antipsychotic reserved for treatment-resistant schizophrenia or treatment-resistant bipolar disorder, particularly with prominent psychotic features that have not responded to multiple other medications.
- Given its significant side effect profile, including agranulocytosis requiring regular blood monitoring, it is not a first-line or even second-line treatment for an initial presentation of mania.
- This patient has no psychiatric history and requires standard first-line treatment, not a medication reserved for refractory cases.
First episode management US Medical PG Question 3: A 22-year-old woman is brought to the emergency department 20 minutes after being detained by campus police for attempting to steal from the bookstore. Her roommate says that the patient has been acting strangely over the last 2 weeks. She has not slept in 4 days and has painted her room twice in that time span. She has also spent all of her savings on online shopping and lottery tickets. She has no history of psychiatric illness or substance abuse, and takes no medications. During the examination, she is uncooperative, combative, and refusing care. She screams, “Let me go, God has a plan for me and I must go finish it!”. Her temperature is 37.2°C (99°F), pulse is 75/min, respirations are 16/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, she describes her mood as “amazing.” She has a labile affect, speaks rapidly, and her thought process is tangential. She denies having any hallucinations. Which of the following is the most appropriate initial pharmacotherapy?
- A. Clozapine
- B. Sertraline
- C. Lithium
- D. Valproate
- E. Haloperidol (Correct Answer)
First episode management Explanation: ***Haloperidol***
- The patient presents with acute agitation, **psychomotor agitation**, flight of ideas, pressured speech, and potentially **psychotic features** (grandiosity, combative behavior) within the context of a likely manic episode.
- **Haloperidol**, a first-generation antipsychotic, is highly effective for rapidly controlling severe agitation and psychotic symptoms in such emergency settings due to its potent dopamine D2 antagonism.
*Clozapine*
- **Clozapine** is an atypical antipsychotic primarily reserved for **treatment-resistant schizophrenia** or bipolar disorder due to its superior efficacy but higher risk of severe side effects like agranulocytosis.
- It is not an appropriate first-line agent for acute agitation or initial treatment of a manic episode given its side effect profile and the need for frequent monitoring.
*Sertraline*
- **Sertraline** is a selective serotonin reuptake inhibitor (SSRI) used to treat depression, anxiety disorders, and other conditions involving serotonin dysregulation.
- Administering an antidepressant like sertraline during an acute manic episode can **worsen mania** or induce rapid cycling, making it contraindicated in this acute presentation.
*Lithium*
- **Lithium** is a mood stabilizer and a cornerstone treatment for bipolar disorder, particularly for chronic management and prevention of manic and depressive episodes.
- While effective, lithium has a **slow onset of action** (days to weeks) and is not suitable for rapid control of acute agitation and psychosis in the emergency setting.
*Valproate*
- **Valproate** (valproic acid) is an anticonvulsant that also functions as a mood stabilizer, commonly used for acute mania and maintenance treatment of bipolar disorder.
- Though effective for mania, like lithium, its onset of action is not as rapid as antipsychotics in controlling severe agitation and acute behavioral disturbances in an emergency.
First episode management US Medical PG Question 4: A 24-year-old man is brought to your emergency department under arrest by the local police. The patient was found naked at a busy intersection jumping up and down on top of a car. Interviewing the patient, you discover that he has not slept in 2 days because he does not feel tired. He reports hearing voices. The patient was previously hospitalized 1 year ago with auditory hallucinations, paranoia, and a normal mood. What is the most likely diagnosis?
- A. Schizophrenia
- B. Bipolar disorder
- C. Brief psychotic disorder
- D. Schizotypal disorder
- E. Schizoaffective disorder (Correct Answer)
First episode management Explanation: ***Schizoaffective disorder***
- This patient demonstrates the **hallmark feature** of schizoaffective disorder: **psychotic symptoms occurring both during AND independent of mood episodes**.
- **Current presentation**: Clear **manic episode** (decreased need for sleep, grandiose/disinhibited behavior, psychomotor agitation) with psychotic features (auditory hallucinations).
- **Previous hospitalization**: **Psychotic symptoms (hallucinations, paranoia) in the absence of a mood episode** ("normal mood"), requiring hospitalization for at least 2 weeks - this is the **key diagnostic criterion** for schizoaffective disorder.
- The diagnosis requires an **uninterrupted period of illness** with both psychotic symptoms (meeting Criterion A for schizophrenia) and a major mood episode, PLUS psychotic symptoms for **≥2 weeks without prominent mood symptoms**.
*Bipolar disorder*
- In bipolar disorder with psychotic features, psychotic symptoms occur **exclusively during mood episodes** (manic, hypomanic, or depressive).
- This patient's previous hospitalization with psychosis but **"normal mood"** indicates psychotic symptoms independent of mood episodes, which **rules out** bipolar disorder and points to schizoaffective disorder.
- While the current presentation shows mania with psychosis, the longitudinal course is critical for diagnosis.
*Schizophrenia*
- Schizophrenia involves **continuous psychotic symptoms** without prominent mood episodes dominating the clinical picture.
- This patient has **prominent manic symptoms** (decreased sleep, grandiose behavior, agitation) that are central to the current presentation, making schizophrenia less likely.
- The presence of full mood episodes that occupy a **substantial portion** of the illness duration favors schizoaffective disorder over schizophrenia.
*Brief psychotic disorder*
- Brief psychotic disorder involves psychotic symptoms lasting **<1 month** with full return to baseline functioning.
- This patient has a **recurrent course** with hospitalization 1 year ago, indicating a chronic/recurring condition rather than a brief, self-limited episode.
*Schizotypal disorder*
- This is a **personality disorder** characterized by social deficits, cognitive/perceptual distortions, and eccentric behavior, but **NOT overt psychotic episodes**.
- Does not involve acute psychotic breaks with severe symptoms like hallucinations requiring hospitalization or manic episodes.
First episode management US Medical PG Question 5: A 27-year-old woman presents to the psychiatrist due to feelings of sadness for the past 3 weeks. She was let go from her job 1 month ago, and she feels as though her whole life is coming to an end. She is unable to sleep well at night and also finds herself crying at times during the day. She has not been able to eat well and has been losing weight as a result. She has no will to go out and meet with her friends, who have been extremely supportive during this time. Her doctor gives her an antidepressant which blocks the reuptake of both serotonin and norepinephrine to help with these symptoms. One week later, she is brought to the emergency room by her friends who say that she was found to be in a state of euphoria. They mention bizarre behavior, one of which is booking a plane ticket to New York, even though she has 3 interviews lined up the same week. Her words cannot be understood as she is speaking very fast, and she is unable to sit in one place for the examination. Which of the following was most likely prescribed by her psychiatrist?
- A. Bupropion
- B. Venlafaxine (Correct Answer)
- C. Sertraline
- D. Fluvoxamine
- E. Lithium
First episode management Explanation: ***Venlafaxine***
- The patient's presentation of depression followed by a rapid shift to **euphoria**, **bizarre behavior**, **rapid speech**, and **psychomotor agitation** after starting an antidepressant strongly suggests **antidepressant-induced mania**.
- This response is characteristic of an underlying **bipolar disorder** unmasked by an antidepressant, particularly a **serotonin-norepinephrine reuptake inhibitor (SNRI)** like venlafaxine.
*Bupropion*
- Bupropion is a **norepinephrine-dopamine reuptake inhibitor (NDRI)**, not an SNRI, and is less commonly associated with inducing mania compared to SNRIs or SSRIs in vulnerable individuals.
- While it can be activating, its specific mechanism primarily targets dopamine and norepinephrine, with less direct serotonin reuptake blockade.
*Sertraline*
- Sertraline is a **selective serotonin reuptake inhibitor (SSRI)**, which primarily blocks serotonin reuptake.
- While SSRIs can induce mania in patients with undiagnosed bipolar disorder, the question specifically states the doctor prescribed an antidepressant that blocks the reuptake of **both serotonin and norepinephrine**.
*Fluvoxamine*
- Fluvoxamine is also a **selective serotonin reuptake inhibitor (SSRI)**, primarily targeting serotonin, not both serotonin and norepinephrine.
- As with other SSRIs, it can induce manic episodes in vulnerable individuals, but it does not fit the description of the prescribed drug's mechanism of action.
*Lithium*
- Lithium is a **mood stabilizer** primarily used for the treatment of bipolar disorder and prevention of manic/depressive episodes, not an antidepressant.
- It would be contraindicated as a first-line treatment for what initially presented as unipolar depression and is used to *treat* rather than *induce* mania.
First episode management US Medical PG Question 6: A 45-year-old man is brought to the physician by his wife for the evaluation of abnormal sleep patterns that began 10 days ago. She reports that he has only been sleeping 2–3 hours nightly during this time and has been jogging for long periods of the night on the treadmill. The patient has also been excessively talkative and has missed work on several occasions to write emails to his friends and relatives to convince them to invest in a new business idea that he has had. He has chronic kidney disease requiring hemodialysis, but he has refused to take his medications because he believes that he is cured. Eight months ago, he had a 3-week long period of persistent sadness and was diagnosed with major depressive disorder. Mental status examination shows psychomotor agitation and pressured speech. Treatment of this patient's condition should include which of the following drugs?
- A. Triazolam
- B. Valproate (Correct Answer)
- C. Mirtazapine
- D. Fluoxetine
- E. Bupropion
First episode management Explanation: ***Valproate***
- This patient presents with classic features of a **manic episode** (decreased need for sleep, psychomotor agitation, pressured speech, grandiosity, increased goal-directed activity, impaired judgment) occurring after a prior depressive episode, indicating **bipolar I disorder**.
- **Mood stabilizers** are first-line treatment for acute mania. While **lithium** is traditionally considered the gold standard, this patient has **chronic kidney disease requiring hemodialysis**, making lithium relatively **contraindicated** due to its renal excretion and narrow therapeutic index.
- **Valproate** is an excellent alternative mood stabilizer for acute mania and maintenance therapy in bipolar disorder, and it is **hepatically metabolized**, making it safer in patients with **renal impairment**.
- Other options include atypical antipsychotics (e.g., olanzapine, quetiapine, aripiprazole), but valproate is the appropriate mood stabilizer choice given this clinical context.
*Triazolam*
- **Triazolam** is a short-acting benzodiazepine used for **insomnia**.
- While it may provide symptomatic relief for sleep disturbance, it does **not treat the underlying manic episode** and is not indicated as primary therapy for bipolar mania.
- Benzodiazepines may be used as adjunctive agents for acute agitation but are not definitive treatment.
*Mirtazapine*
- **Mirtazapine** is a tetracyclic antidepressant used for **major depressive disorder**.
- Antidepressant monotherapy in bipolar disorder can **precipitate or worsen manic episodes** and is contraindicated during an acute manic phase.
- If antidepressants are needed for bipolar depression, they should be combined with mood stabilizers.
*Fluoxetine*
- **Fluoxetine** is a selective serotonin reuptake inhibitor (SSRI) antidepressant.
- Like other antidepressants, using fluoxetine as monotherapy in a patient with bipolar disorder can **induce or exacerbate manic episodes**.
- It is inappropriate for treating acute mania.
*Bupropion*
- **Bupropion** is an atypical antidepressant (norepinephrine-dopamine reuptake inhibitor) used for depression and smoking cessation.
- It carries a **higher risk of inducing mania** compared to other antidepressants due to its dopaminergic activity.
- It is not appropriate for acute mania treatment and could worsen the patient's current symptoms.
First episode management US Medical PG Question 7: A 24-year-old woman is brought to the emergency department by her roommate because of bizarre behavior and incoherent talkativeness for the past week. Her roommate reports that the patient has been rearranging the furniture in her room at night and has ordered a variety of expensive clothes online. The patient says she feels “better than ever” and has a lot of energy. She had absence seizures as a child and remembers that valproate had to be discontinued because it damaged her liver. She has been otherwise healthy and is not taking any medication. She is sexually active with her boyfriend. She does not smoke, drink alcohol, or use illicit drugs. Physical and neurologic examinations show no abnormalities. Her pulse is 78/min, respirations are 13/min, and blood pressure is 122/60 mm Hg. Mental status examination shows pressured and disorganized speech, flight of ideas, lack of insight, and affective lability. Which of the following is the best initial step before deciding on a therapy for this patient's condition?
- A. Obtain CBC, liver function studies, and beta-HCG
- B. Obtain TSH, β-hCG, and serum creatinine concentration (Correct Answer)
- C. Obtain BMI, HbA1c, lipid levels, and prolactin levels
- D. Perform urine drug testing and begin cognitive behavior therapy
- E. Assess for suicidal ideation and obtain echocardiography
First episode management Explanation: ***Obtain TSH, β-hCG, and serum creatinine concentration***
- This patient presents with symptoms highly suggestive of **mania** (bizarre behavior, incoherent talkativeness, grandiosity, increased energy, pressured speech, flight of ideas). Before initiating treatment, it's crucial to rule out other medical conditions that can **mimic mania**, such as **hyperthyroidism** (TSH), **pregnancy** (β-hCG), or **kidney dysfunction** (creatinine), which can impact medication choice and dosage.
- TSH levels are essential as **hyperthyroidism** can cause symptoms like agitation, rapid speech, and increased energy, mimicking mania. A **pregnancy test (β-hCG)** is critical for women of childbearing age to ensure that any potential psychiatric medications are safe for both the mother and fetus. **Serum creatinine** helps assess kidney function, which is important for dosing many psychotropic medications eliminated by the kidneys.
*Obtain CBC, liver function studies, and beta-HCG*
- While a **β-hCG** is appropriate, **CBC** and **liver function studies (LFTs)** are typically obtained if there are specific concerns for anemia, infection, or liver damage (which the patient mentions about valproate in childhood, but there's no immediate indication for current LFTs before diagnosis confirmation).
- Although LFTs are important for certain antidepressant or mood stabilizer monitoring (e.g., valproate, carbamazepine), they are not the most immediate initial screen for ruling out medical mimics of mania in this context as **TSH** and **renal function** are more critical.
*Obtain BMI, HbA1c, lipid levels, and prolactin levels*
- These tests are important for **monitoring long-term metabolic side effects** of certain antipsychotics and mood stabilizers, but they are not the best initial steps for ruling out acute medical causes of manic symptoms.
- **BMI, HbA1c, and lipid levels** are typically assessed *after* diagnosis and initiation of treatment to establish a baseline for future metabolic monitoring. **Prolactin levels** might be checked if there is concern for hyperprolactinemia, which is a side effect of some antipsychotics, but not usually a cause of acute mania.
*Perform urine drug testing and begin cognitive behavior therapy*
- While **urine drug testing** is often performed in acute psychiatric presentations to rule out substance-induced mania, it is not listed as the *best initial step* alone, as other medical conditions also need to be ruled out concurrently.
- **Cognitive behavioral therapy (CBT)** is not an appropriate initial treatment for acute mania due to the patient's severe symptoms, lack of insight, and disorganized thought processes. **Pharmacotherapy** is the cornerstone of acute mania management.
*Assess for suicidal ideation and obtain echocardiography*
- Assessing for **suicidal ideation** is crucial in every psychiatric evaluation, but it is a mental status component rather than a diagnostic lab test. While important for patient safety, it doesn't rule out medical mimics of mania.
- **Echocardiography** is not indicated in the initial work-up of acute mania unless there are specific cardiac symptoms or a history that suggests underlying heart disease.
First episode management US Medical PG Question 8: A 23-year-old woman is brought to the physician by her father because of irritability, mood swings, and difficulty sleeping over the past 10 days. A few days ago, she quit her job and spent all of her savings on supplies for a “genius business plan.” She has been energetic despite sleeping only 1–2 hours each night. She was diagnosed with major depressive disorder 2 years ago. Mental status examination shows pressured speech, a labile affect, and flight of ideas. Throughout the examination, she repeatedly states “I feel great, I don't need to be here.” Urine toxicology screening is negative. Which of the following is the most likely diagnosis?
- A. Schizoaffective disorder
- B. Bipolar disorder type II
- C. Bipolar disorder type I (Correct Answer)
- D. Delusional disorder
- E. Attention-deficit hyperactivity disorder
First episode management Explanation: ***Bipolar disorder type I***
- The patient's presentation of lasting **elevated mood**, decreased need for sleep, increased energy, pressured speech, flight of ideas, and impulsive behavior (quitting job, spending savings) are hallmark symptoms of a **manic episode**.
- A diagnosis of **Bipolar I Disorder** requires the occurrence of at least one manic episode, which is clearly evident here and distinguishes it from other mood disorders, especially given her prior history of major depressive disorder.
*Schizoaffective disorder*
- This disorder involves a period of illness during which there is an uninterrupted period of major mood episode (depressive or manic) concurrent with symptoms of **schizophrenia**, such as delusions or hallucinations, for at least 2 weeks in the absence of a major mood episode.
- The patient's symptoms are primarily mood-driven and do not include the characteristic psychotic features that persist independently of mood disturbances.
*Bipolar disorder type II*
- Bipolar II Disorder is characterized by at least one major depressive episode and at least one **hypomanic episode**.
- The patient's current symptoms, including significant impairment in social/occupational functioning, are indicative of a **manic episode**, not a hypomanic episode, which by definition does not cause marked impairment or require hospitalization.
*Delusional disorder*
- This disorder is characterized by the presence of **non-bizarre delusions** that last for at least one month, without other prominent psychotic symptoms or significant impairment in functioning.
- While the patient's "genius business plan" might seem delusional, her pervasive mood disturbance, flight of ideas, and significant functional impairment are not consistent with the primary features of delusional disorder.
*Attention-deficit hyperactivity disorder*
- ADHD is characterized by a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning or development, often presenting in childhood.
- While there is some overlap in symptoms like impulsivity and difficulty sleeping, the episodic nature, the extent of **mood disturbance**, grandiosity, and **pressured speech** are more characteristic of a manic episode than ADHD.
First episode management US Medical PG Question 9: A 25-year-old woman is brought to the emergency department by EMS after being found naked in a busy downtown square. The patient stated that she is liberating people from material desires and was found destroying objects. Her temperature is 99.5°F (37.5°C), blood pressure is 127/68 mmHg, pulse is 120/min, respirations are 22/min, and oxygen saturation is 98% on room air. Physical exam is deferred due to patient combativeness. The patient is given diphenhydramine and haloperidol and transferred to the psychiatric ward. On day 1 on the ward, the patient is no longer aggressive or agitated and has calmed down. She states that she feels severely depressed and wants to kill herself. The patient is started on a medication and monitored closely. On day 3 of the patient's stay in the hospital she is found in her room drawing up plans and states that she has major plans to revamp the current energy problems in the country. Which of the following is the most likely medication that was started in this patient?
- A. Quetiapine
- B. Olanzapine
- C. Lamotrigine
- D. Sertraline (Correct Answer)
- E. Lithium
First episode management Explanation: ***Sertraline***
- This patient exhibits classic **bipolar I disorder** with rapid mood cycling from **mania** (naked in public, grandiose delusions, destroying objects) to **severe depression** (suicidal ideation on Day 1) and back to **mania** (grandiose plans on Day 3).
- The key clinical clue is the **rapid return to mania by Day 3** after starting medication during the depressive phase. This suggests **antidepressant-induced mania/mood switch**, a well-known complication of using **SSRI antidepressants** (like sertraline) **without adequate mood stabilization** in bipolar disorder.
- **Antidepressants can precipitate manic episodes** within days in bipolar patients, which is why they should be avoided or used only with concomitant mood stabilizers. This question tests recognition of this critical psychiatric principle.
*Lithium*
- Lithium is a first-line **mood stabilizer** for bipolar disorder and would be appropriate for long-term management. However, lithium **prevents manic episodes** rather than causing them.
- Lithium takes **1-2 weeks to reach therapeutic levels**, so it would not explain the rapid mood switch to mania by Day 3. If lithium had been started, we would expect **stabilization or improvement**, not a return to mania.
*Quetiapine*
- Quetiapine is an **atypical antipsychotic** effective for both acute mania and bipolar depression. It can provide rapid mood stabilization.
- If quetiapine was started on Day 1, we would expect **mood stabilization or sedation**, not a switch back to mania. Quetiapine does **not precipitate manic episodes**.
*Olanzapine*
- Olanzapine is another **atypical antipsychotic** used for acute mania and maintenance in bipolar disorder.
- Like quetiapine, olanzapine would **stabilize mood** and reduce manic symptoms, not trigger them. It would not explain the return to mania on Day 3.
*Lamotrigine*
- Lamotrigine is a mood stabilizer particularly effective for **preventing depressive episodes** in bipolar disorder, though less effective for acute mania.
- Lamotrigine **does not precipitate manic episodes** and takes weeks to titrate to therapeutic doses due to risk of Stevens-Johnson syndrome. It would not explain the rapid mood switch observed here.
First episode management US Medical PG Question 10: A 28-year-old woman is brought to the emergency department by her friends. She is naked except for a blanket and speaking rapidly and incoherently. Her friends say that she was found watering her garden naked and refused to put on any clothes when they tried to make her do so, saying that she has accepted how beautiful she is inside and out. Her friends say she has also purchased a new car she can not afford. They are concerned about her, as they have never seen her behave this way before. For the past week, she has not shown up at work and has been acting ‘strangely’. They say she was extremely excited and has been calling them at odd hours of the night to tell them about her future plans. Which of the following drug mechanisms will help with the long-term management this patient’s symptoms?
- A. Inhibition of inositol monophosphatase and inositol polyphosphate 1-phosphatase (Correct Answer)
- B. Increase the concentration of dopamine and norepinephrine at the synaptic cleft
- C. Modulate the activity of gamma-aminobutyric acid receptors
- D. Acts as an antagonist at the dopamine, serotonin and adrenergic receptors
- E. Inhibit the reuptake of norepinephrine and serotonin from the presynaptic cleft
First episode management Explanation: ***Inhibition of inositol monophosphatase and inositol polyphosphate 1-phosphatase***
- The patient's symptoms (euphoria, grandiosity, reduced need for sleep, impulsivity, rapid speech, and unusual behavior) are classic for a **manic episode**, strongly suggesting **bipolar disorder**.
- **Lithium** is a mood stabilizer used for long-term management of bipolar disorder, and its primary molecular action is thought to involve the **inhibition of inositol phosphatases**, thereby depleting inositol and modulating intracellular signaling.
*Increase the concentration of dopamine and norepinephrine at the synaptic cleft*
- This mechanism describes the action of **stimulants** or some **antidepressants** (like TCAs or SNRIs), which could exacerbate manic symptoms in bipolar disorder.
- Increasing dopamine and norepinephrine would likely worsen the current patient's **hyperactivity**, **agitation**, and **psychosis**.
*Inhibit the reuptake norepinephrine and serotonin from the presynaptic cleft*
- This mechanism is characteristic of **antidepressants** (e.g., SSRIs, SNRIs) used to treat depression.
- Administering such drugs during a manic episode can precipitate or worsen **mania** or induce **rapid cycling** in bipolar patients.
*Modulate the activity of Ƴ-aminobutyric acid receptors*
- This describes the action of **benzodiazepines** or some **antiepileptic drugs** (e.g., valproate, lamotrigine).
- While some antiepileptic drugs (like valproate) are used as mood stabilizers, the direct modulation of GABA receptors to **increase GABAergic activity** (as with benzodiazepines) is typically for acute agitation and anxiety, not the primary long-term mood stabilization for bipolar disorder.
*Acts as an antagonist at the dopamine, serotonin, and adrenergic receptors*
- This mechanism generally describes the action of **antipsychotic medications** (e.g., olanzapine, quetiapine, risperidone).
- While antipsychotics are effective for acute mania and some are used in long-term maintenance of bipolar disorder, the question asks for the primary drug mechanism for long-term management which is **Lithium's mechanism of action**, targeting intracellular signaling rather than broad receptor antagonism.
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