Maintenance therapy principles US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Maintenance therapy principles. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Maintenance therapy principles US Medical PG Question 1: 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
Maintenance therapy principles 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.
Maintenance therapy principles US Medical PG Question 2: A patient with a history of hypertension and bipolar disorder is seen in your clinic for new-onset tremor, increased urination, and mild dehydration symptoms. Her bipolar disorder has been well-controlled with her current medication regimen. She recently started a new medication for better management of her hypertension. Which of the following medications did she most likely start?
- A. Amlodipine
- B. Lisinopril
- C. Hydrochlorothiazide (Correct Answer)
- D. Furosemide
- E. Metoprolol
Maintenance therapy principles Explanation: ***Hydrochlorothiazide***
- **Thiazide diuretics** are first-line antihypertensive agents that promote **sodium and water excretion**.
- Volume depletion from thiazides **decreases renal lithium clearance**, increasing serum lithium levels and causing **lithium toxicity**.
- Classic lithium toxicity presents with **tremor, polyuria (nephrogenic diabetes insipidus), polydipsia**, and dehydration.
- This represents a critical **drug-drug interaction** between thiazides and lithium.
*Incorrect: Amlodipine*
- **Calcium channel blocker** (dihydropyridine class) commonly used for hypertension.
- Does **not affect lithium levels** or renal clearance.
- Side effects include peripheral edema and reflex tachycardia, not the symptoms described.
*Incorrect: Lisinopril*
- **ACE inhibitor** used as first-line therapy for hypertension.
- Does **not significantly affect lithium clearance** (though ACE inhibitors can have minor effects, they don't typically cause clinically significant lithium toxicity).
- Common side effects include dry cough and hyperkalemia, not tremor or polyuria.
*Incorrect: Furosemide*
- **Loop diuretic** that can cause dehydration and polyuria.
- Could potentially increase lithium levels through volume depletion, but **thiazides are more commonly implicated** in lithium toxicity.
- Furosemide is typically reserved for **resistant hypertension or heart failure**, not as initial therapy.
*Incorrect: Metoprolol*
- **Beta-blocker** used for hypertension management.
- Does **not affect lithium levels** or cause the described symptoms.
- Side effects include bradycardia, fatigue, and bronchospasm in susceptible patients.
Maintenance therapy principles US Medical PG Question 3: A 23-year-old woman is brought to the emergency department by emergency medical services. She was found trying to hang herself in her kitchen. The patient has a past medical history of drug abuse, alcoholism, anxiety, mania, irritable bowel syndrome, and hypertension. Her current medications include naltrexone, sodium docusate, and clonazepam as needed. Her temperature is 99.5°F (37.5°C), blood pressure is 100/65 mmHg, pulse is 90/min, respirations are 15/min, and oxygen saturation is 99% on room air. On physical exam, you note a teary young woman. There are multiple bilateral superficial cuts along her wrists. The patient's cardiac and pulmonary exams are within normal limits. Neurological exam reveals a patient who is alert and oriented. The patient claims that you cannot send her home because if you do she will kill herself. Laboratory values are ordered and return as below.
Hemoglobin: 15 g/dL
Hematocrit: 40%
Leukocyte count: 4,500 cells/mm^3 with normal differential
Platelet count: 197,500/mm^3
Serum:
Na+: 139 mEq/L
Cl-: 102 mEq/L
K+: 4.4 mEq/L
HCO3-: 24 mEq/L
BUN: 20 mg/dL
Glucose: 90 mg/dL
Creatinine: 1.0 mg/dL
Ca2+: 10.2 mg/dL
AST: 12 U/L
ALT: 10 U/L
The patient is transferred to the crisis intervention unit. Which of the following is the best next step in management?
- A. Haloperidol
- B. Escitalopram
- C. Diazepam
- D. Fluoxetine
- E. Lamotrigine (Correct Answer)
Maintenance therapy principles Explanation: ***Lamotrigine***
- The patient's history of **mania** and current **suicidal ideation** points towards a **bipolar disorder** presentation, for which **lamotrigine** is an excellent mood stabilizer.
- Lamotrigine is particularly effective in preventing the **depressive episodes** associated with bipolar disorder, which are often linked to suicidal thoughts and attempts.
*Haloperidol*
- **Haloperidol** is an **antipsychotic medication** primarily used for acute psychosis, agitation, or severe agitation in bipolar mania.
- While agitation might be present, the primary concern is the underlying mood dysregulation and suicidal risk, not acute psychosis.
*Escitalopram*
- **Escitalopram** is an **SSRI antidepressant**, generally avoided as monotherapy in bipolar disorder as it can precipitate **mania** or **rapid cycling**.
- Using an antidepressant alone in a patient with a history of mania can worsen their underlying mood instability.
*Diazepam*
- **Diazepam** is a **benzodiazepine** used for acute anxiety or sedation.
- While it could help with immediate anxiety, it does not address the underlying mood disorder or reduce long-term suicidal risk; its use would be symptomatic and temporary.
*Fluoxetine*
- **Fluoxetine** is another **SSRI antidepressant** that, like escitalopram, can induce or exacerbate manic episodes in patients with bipolar disorder if not co-administered with a mood stabilizer.
- While it treats depression, it is not suitable as a monotherapy for bipolar depression due to the risk of mood destabilization.
Maintenance therapy principles US Medical PG Question 4: A 22-year-old woman with a history of bipolar disorder presents to her psychiatrist’s office for a follow-up appointment. She says she is doing better on the new drug she was prescribed. However, she recently noticed that she is drinking a lot of water and urinates more frequently throughout the day. She also says there are moments recently when she feels confused and agitated. Her vitals include: blood pressure 122/89 mm Hg, temperature 36.7°C (98.0°F), pulse 88/min and respirations 18/min. Her physical examination is within normal limits. Which of the following drugs was she most likely prescribed?
- A. Chlorpromazine
- B. Carbamazepine
- C. Lithium (Correct Answer)
- D. Amitriptyline
- E. Valproic acid
Maintenance therapy principles Explanation: ***Lithium***
- The patient's symptoms of **polyuria**, **polydipsia**, **confusion**, and **agitation** are consistent with **lithium-induced nephrogenic diabetes insipidus** and potential early neurotoxicity.
- **Lithium** is a common mood stabilizer for bipolar disorder but has a narrow therapeutic window. **Nephrogenic diabetes insipidus** occurs in up to 40% of patients on chronic lithium therapy due to impaired renal response to ADH.
- The CNS symptoms (confusion, agitation) may indicate lithium levels approaching or in the toxic range, warranting serum level monitoring.
*Chlorpromazine*
- This is a first-generation antipsychotic often used for psychosis and mania, but it is more commonly associated with **extrapyramidal symptoms**, **sedation**, and **orthostatic hypotension**.
- It does not typically cause the triad of polyuria, polydipsia, and confusion suggestive of the patient's presentation.
*Carbamazepine*
- An anticonvulsant used as a mood stabilizer, it is known for adverse effects such as **drowsiness**, **dizziness**, **ataxia**, and **hyponatremia** (due to SIADH).
- While it can cause neurological symptoms, the described polyuria and polydipsia are not typical side effects.
*Amitriptyline*
- This is a tricyclic antidepressant (TCA) and is not a first-line treatment for bipolar disorder due to the risk of inducing **mania**.
- Its side effects include **anticholinergic effects** (dry mouth, constipation, urinary retention), **sedation**, and **cardiac arrhythmias**, which differ from the patient's symptoms.
*Valproic acid*
- An anticonvulsant and mood stabilizer, it can cause **gastrointestinal upset**, **tremor**, **sedation**, and **hepatic dysfunction**.
- While therapeutic monitoring is important, **polyuria** and **polydipsia** are not characteristic side effects, differentiating it from the patient's presentation.
Maintenance therapy principles US Medical PG Question 5: 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
Maintenance therapy principles 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.
Maintenance therapy principles US Medical PG Question 6: A 34-year-old man is brought to a psychiatric hospital by friends for erratic behavior. He has been up for the past several nights painting his apartment walls purple and reading the Bible out loud, as well as talking fast and making sexually provocative comments. Collateral information from family reveals 2 similar episodes last year. Mental status exam is notable for labile affect and grandiose delusions. Urine toxicology is negative. The patient is admitted and started on lithium for mania. His symptoms resolve within 2 weeks. How should this patient’s lithium be managed in anticipation of discharge?
- A. Continue lithium until a therapeutic serum lithium level is reached, then taper it
- B. Cross-taper lithium to valproic acid for maintenance therapy
- C. Continue lithium lifelong (Correct Answer)
- D. Discontinue lithium, but re-start in the future if the patient has another manic episode
- E. Cross-taper lithium to aripiprazole for maintenance therapy
Maintenance therapy principles Explanation: ***Continue lithium lifelong***
- This patient presents with clear symptoms of **bipolar I disorder**, characterized by recurrent episodes of **mania** (as evidenced by the current presentation and two similar episodes in the past year).
- **Lithium** is a highly effective **mood stabilizer** for bipolar I disorder and is crucial for preventing future manic and depressive episodes. Lifelong maintenance therapy is recommended to reduce recurrence rates.
*Continue lithium until a therapeutic serum lithium level is reached, then taper it*
- While achieving a **therapeutic serum lithium level** is essential for acute management, tapering it after symptom resolution would increase the risk of **relapse**, as bipolar disorder requires long-term mood stabilization.
- Tapering off lithium prematurely contradicts evidence-based guidelines for preventing recurrent mood episodes in bipolar disorder.
*Cross-taper lithium to valproic acid for maintenance therapy*
- Although **valproic acid** is another effective mood stabilizer for bipolar disorder, there's no indication to switch from lithium if it's effective and tolerated. Both can be used for maintenance.
- Unnecessarily changing an effective medication increases the risk of destabilization during the cross-taper and requires re-establishing therapeutic levels of a new medication.
*Discontinue lithium, but re-start in the future if the patient has another manic episode*
- Discontinuing lithium and waiting for another manic episode is associated with a significantly **higher risk of relapse** and potential worsening of subsequent episodes over time.
- The goal of treating bipolar disorder is to **prevent episodes** rather than waiting for them to occur, which is why long-term prophylactic treatment is critical.
*Cross-taper lithium to aripiprazole for maintenance therapy*
- **Aripiprazole** is an atypical antipsychotic that can be used as a mood stabilizer, particularly for treating acute mania and sometimes for maintenance in bipolar disorder.
- However, similar to valproic acid, there is no compelling reason to switch from lithium if it is effective and well-tolerated. Lithium remains a first-line long-term treatment.
Maintenance therapy principles US Medical PG Question 7: A 34-year-old woman presents with recurrent panic attacks that have been worsening over the past 5 weeks. She also says she has been seeing things that are not present in reality and is significantly bothered by a short attention span which has badly affected her job in the past 6 months. No significant past medical history. No current medications. The patient is afebrile and vital signs are within normal limits. Her BMI is 34 kg/m2. Physical examination is unremarkable. The patient is prescribed antipsychotic medication. She expresses concerns about any effects of the new medication on her weight. Which of the following medications would be the best course of treatment in this patient?
- A. Ziprasidone (Correct Answer)
- B. Clozapine
- C. Chlorpromazine
- D. Olanzapine
- E. Clonazepam
Maintenance therapy principles Explanation: ***Ziprasidone***
- **Ziprasidone** causes minimal **weight gain** and has a lower risk of metabolic side effects compared to other antipsychotics, making it a good choice for a patient concerned about weight, especially with a BMI of 34 kg/m2.
- It treats psychotic symptoms like hallucinations and can help manage anxiety associated with panic attacks.
*Clozapine*
- **Clozapine** is known for causing significant **weight gain** and metabolic disturbances, which would be a concern for this patient.
- It is typically reserved for treatment-resistant schizophrenia due to its potential for serious side effects like **agranulocytosis**.
*Chlorpromazine*
- **Chlorpromazine** is a first-generation antipsychotic associated with a high risk of **extrapyramidal symptoms** (EPS) and sedation.
- It can also lead to moderate **weight gain** and is generally not preferred as a first-line treatment if metabolic concerns are present.
*Olanzapine*
- **Olanzapine** is associated with a high risk of **weight gain** and metabolic syndrome, which would exacerbate the patient's existing weight concerns.
- While effective for psychosis, its metabolic side effect profile makes it a less suitable choice in this scenario.
*Clonazepam*
- **Clonazepam** is a **benzodiazepine** primarily used for anxiety and panic attacks, but it is not an antipsychotic.
- It would not address the patient's psychotic symptoms (seeing things not present in reality), which require an antipsychotic medication.
Maintenance therapy principles US Medical PG Question 8: A 37-year-old African American man is brought to the emergency department by police. The patient refused to leave a petting zoo after closing. He states that he has unique ideas to revolutionize the petting zoo experience. The patient has a past medical history of multiple suicide attempts. His temperature is 99.5°F (37.5°C), blood pressure is 130/85 mmHg, pulse is 100/min, respirations are 16/min, and oxygen saturation is 99% on room air. The patient's cardiac and pulmonary exams are within normal limits. He denies any nausea, vomiting, shortness of breath, or systemic symptoms. The patient struggles to answer questions, as he is constantly changing the subject and speaking at a very rapid rate. The patient is kept in the emergency department overnight and is observed to not sleep and is very talkative with the nurses. Which of the following is the best long-term therapy for this patient?
- A. Haloperidol
- B. Lithium (Correct Answer)
- C. Diphenhydramine
- D. Valproic acid
- E. Risperidone
Maintenance therapy principles Explanation: ***Lithium***
- The patient exhibits classic symptoms of **mania**, including grandiosity, decreased need for sleep, pressured speech, and flight of ideas, suggesting **bipolar I disorder**.
- **Lithium** is considered a first-line agent and the best long-term maintenance therapy for **bipolar I disorder**, effective in reducing both manic and depressive episodes and decreasing suicide risk.
*Haloperidol*
- **Haloperidol** is a potent typical antipsychotic primarily used for acute management of severe agitation, psychosis, or manic episodes due to its rapid tranquilizing effects.
- While it could be used for immediate symptom control, it is not the **best long-term therapy** for mood stabilization in bipolar disorder and carries a high risk of **extrapyramidal side effects**.
*Diphenhydramine*
- **Diphenhydramine** is an antihistamine with sedative properties, sometimes used for mild insomnia or allergic reactions, but it has no role in the treatment of acute mania or the long-term management of bipolar disorder.
- It would not address the underlying mood dysregulation and behavioral symptoms seen in this patient's presentation.
*Valproic acid*
- **Valproic acid** (divalproex) is an effective mood stabilizer used for bipolar disorder, particularly in patients who cannot tolerate lithium or have rapid cycling.
- However, for long-term therapy and overall efficacy, especially considering lithium's proven benefits in reducing suicidality, **lithium** is generally considered the preferred first-line agent, although valproic acid is a strong alternative.
*Risperidone*
- **Risperidone** is an atypical antipsychotic, primarily used for acute mania or as an adjunct in bipolar depression, and in schizophrenia.
- While useful for acute symptom management of psychosis and agitation in bipolar disorder, it is not typically the sole **best long-term maintenance monotherapy** compared to mood stabilizers like lithium, which directly target the mood swings.
Maintenance therapy principles US Medical PG Question 9: A 27-year-old man comes to the physician for a follow-up examination. Paroxetine therapy was initiated 6 weeks ago for a major depressive episode. He now feels much better and says he is delighted with his newfound energy. He gets around 8 hours of sleep nightly. His appetite has increased. Last year, he had two episodes of depressed mood, insomnia, and low energy during which he had interrupted his job training and stopped going to the gym. Now, he has been able to resume his job at a local bank. He also goes to the gym three times a week to work out and enjoys reading books again. His temperature is 36.5°C (97.7°F), pulse is 70/min, and blood pressure is 128/66 mm Hg. Physical and neurologic examinations show no abnormalities. On mental status examination, he describes his mood as "good." Which of the following is the most appropriate next step in management?
- A. Discontinue paroxetine
- B. Switch from paroxetine to venlafaxine therapy
- C. Continue paroxetine therapy for 6 months
- D. Continue paroxetine therapy for 2 years (Correct Answer)
- E. Switch from paroxetine to lithium therapy
Maintenance therapy principles Explanation: **Continue paroxetine therapy for 2 years**
- This patient has experienced **recurrent major depressive episodes**, with two episodes in the past year. Guidelines recommend continuing antidepressant therapy for **1-3 years or indefinitely** after a second or third episode to prevent relapse.
- Given his significant improvement and history of recurrent depression, long-term maintenance with paroxetine is the most appropriate strategy.
*Discontinue paroxetine*
- Discontinuing the antidepressant now would significantly increase the risk of a rapid **relapse** of major depressive disorder, especially given his history of multiple episodes.
- Antidepressants should not be abruptly stopped once symptoms resolve, particularly in patients with recurrent depression.
*Switch from paroxetine to venlafaxine therapy*
- There is no indication to switch to venlafaxine, as the patient has responded well to paroxetine and is currently in **remission**.
- Switching medications carries the risk of new side effects or a recurrence of depressive symptoms.
*Continue paroxetine therapy for 6 months*
- While 6 months of continuation therapy is standard after a **first episode** of major depressive disorder, it is insufficient for patients with **recurrent episodes**.
- Continuing for only 6 months heightens the risk of relapse for this patient given his history.
*Switch from paroxetine to lithium therapy*
- Lithium is typically used as a mood stabilizer for **bipolar disorder** or as an augmentation strategy for refractory depression.
- There is no evidence in the vignette to suggest bipolar disorder, and the patient has responded well to monotherapy with paroxetine.
Maintenance therapy principles US Medical PG Question 10: 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
Maintenance therapy principles 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.
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