A researcher is investigating whether there is an association between the use of social media in teenagers and bipolar disorder. In order to study this potential relationship, she collects data from people who have bipolar disorder and matched controls without the disorder. She then asks how much on average these individuals used social media in the 3 years prior to their diagnosis. This continuous data is divided into 2 groups: those who used more than 2 hours per day and those who used less than 2 hours per day. She finds that out of 1000 subjects, 500 had bipolar disorder of which 300 used social media more than 2 hours per day. She also finds that 400 subjects who did not have the disorder also did not use social media more than 2 hours per day. Which of the following is the odds ratio for development of bipolar disorder after being exposed to more social media?
Q2
A 19-year-old woman is brought to the physician by her parents because of irritable mood that started 5 days ago. Since then, she has been staying up late at night working on a secret project. She is energetic despite sleeping less than 4 hours per day. Her parents report that she seems easily distracted. She is usually very responsible, but this week she spent her paycheck on supplies for her project. She has never had similar symptoms before. In the past, she has had episodes where she felt too fatigued to go to school and slept until 2 pm every day for 2 weeks at a time. During those times, her parents noticed that she cried excessively, was very indecisive, and expressed feelings of worthlessness. Two months ago, she had an asthma exacerbation and was treated with bronchodilators and steroids. She tried cocaine once in high school but has not used it since. Vital signs are within normal limits. On mental status examination, she is irritable but cooperative. Her speech is pressured and her thought process is linear. Which of the following is the most likely diagnosis?
Q3
A 33-year-old woman is brought to the physician by her husband because of persistent sadness for the past 2 months. During this period, she also has had difficulty sleeping and an increased appetite. She had similar episodes that occurred 2 years ago and 9 months ago that each lasted for 4 months. Between these episodes, she reported feeling very energetic and rested after 3 hours of sleep. She often went for long periods of time without eating. She works as a stock market trader and received a promotion 5 months ago. She regularly attends yoga classes on the weekends with her friends. On mental status examination, she has a blunted affect. She denies suicidal thoughts and illicit drug use. Which of the following is the most likely diagnosis?
Q4
A mental health volunteer is interviewing locals as part of a community outreach program. A 46-year-old man discloses that he has felt sad for as long as he can remember. He feels as though his life is cursed and if something terrible can happen to him, it usually will. He has difficulty making decisions and feels hopeless. He also feels that he has had worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration over the past 2 weeks. He is otherwise getting enough sleep and able to hold a job. Which of the following statement best describes this patient's condition?
Q5
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?
Q6
A 24-year-old male comes into the psychiatric clinic complaining of consistent sadness. He endorses feelings of worthlessness, anxiety, and anhedonia for the past couple months but denies feeling suicidal. He further denies any past episodes of feeling overly energetic with racing thoughts. Confident of the diagnosis, you recommend frequent talk therapy along with a long-term prescription of a known first-line medication for this disorder. What is the drug and what are some of the most frequently encountered side effects?
Q7
A 34-year-old woman comes to the physician because of a 6-week history of depressed mood, loss of interest, and difficulty sleeping. She also has had a 4.5-kg (10-lb) weight loss during this period. She has not been as productive as before at work due to difficulty concentrating. There is no evidence of suicidal ideation. Laboratory studies including thyroid-stimulating hormone are within the reference range. The physician prescribes treatment with escitalopram. This drug targets a neurotransmitter that is produced in which of the following brain structures?
Q8
A 40-year-old man is brought to the emergency department by police officers due to inappropriate public behavior. He was at a pharmacy demanding to speak with the manager so he could discuss a business deal. Two weeks ago, he left his wife of 10 years and moved from another city in order to pursue his dreams of being an entrepreneur. He has not slept for more than 3-4 hours a night in the last 2 weeks. He has a history of bipolar disorder and diabetes. He has been hospitalized three times in the last year for mood instability. Current medications include lithium and insulin. Mental status examination shows accelerated speech with flight of ideas. His serum creatinine concentration is 2.5 mg/dL. Which of the following is the most appropriate next step in management with respect to his behavior?
Q9
A 55-year-old man presents to his primary care physician with complaints of fluctuating mood for the past 2 years. He feels great and full of energy for some months when he is very creative with tons of ideas just racing through his mind. He is noted to be very talkative and distracted by his different ideas. During these times, he is very productive and able to accomplish much at work and home. However, these periods are frequently followed by a prolonged depressed mood. During this time, he has low energy, poor concentration, and low self-esteem. The accompanying feeling of hopelessness from these cycling “ups” and “downs” have him eating and sleeping more during the “downs.” He does not remember a period within the last 2 years where he felt “normal.” What is the most likely diagnosis?
Q10
A 19-year-old female college student is brought into the emergency department by her boyfriend. The boyfriend reports that the patient got caught stealing from the company she works for and subsequently got fired. The boyfriend received a text that evening saying “I’ll miss you.” When he arrived at her dorm room, the patient was slumped in the shower covered in blood. The patient agreed to be driven to the emergency room. When asked about what happened, the patient replies “I just want out of this life.” The patient has bipolar disorder, and takes lithium as prescribed. She has a psychiatrist she sees every week, which the boyfriend confirms. She has never had a prior suicide attempt nor has she ever been hospitalized for a psychiatric disorder. The patient’s vitals are stable. Upon physical examination, a 4 centimeter vertical incision is noted on the patient’s left forearm. During the patient’s laceration repair, she asks if she will be admitted. She states, “these ups and downs are common for me, but I feel better now.” She verbalizes that she understands that she overreacted. She asks to go home, and her boyfriend insists that he will stay with her. They both confirm that neither of them have guns or know any peers with access to guns. Which of the following is the most appropriate management for the patient?
Rapid cycling bipolar disorder US Medical PG Practice Questions and MCQs
Question 1: A researcher is investigating whether there is an association between the use of social media in teenagers and bipolar disorder. In order to study this potential relationship, she collects data from people who have bipolar disorder and matched controls without the disorder. She then asks how much on average these individuals used social media in the 3 years prior to their diagnosis. This continuous data is divided into 2 groups: those who used more than 2 hours per day and those who used less than 2 hours per day. She finds that out of 1000 subjects, 500 had bipolar disorder of which 300 used social media more than 2 hours per day. She also finds that 400 subjects who did not have the disorder also did not use social media more than 2 hours per day. Which of the following is the odds ratio for development of bipolar disorder after being exposed to more social media?
A. 1.5
B. 6 (Correct Answer)
C. 0.17
D. 0.67
Explanation: ***6***
- To calculate the odds ratio, we first construct a 2x2 table [1]:
- Bipolar Disorder (Cases): 500
- No Bipolar Disorder (Controls): 500 (1000 total subjects - 500 cases)
- Cases exposed to more social media (>2 hrs/day): 300
- Cases not exposed to more social media (≤2 hrs/day): 200 (500 - 300)
- Controls not exposed to more social media (≤2 hrs/day): 400
- Controls exposed to more social media (>2 hrs/day): 100 (500 - 400)
- The odds ratio (OR) is calculated as (odds of exposure in cases) / (odds of exposure in controls) = (300/200) / (100/400) = 1.5 / 0.25 = **6** [1].
*1.5*
- This value represents the **odds of exposure** (more than 2 hours of social media) in individuals with bipolar disorder (300 cases exposed / 200 cases unexposed = 1.5).
- It is not the odds ratio, which compares these odds to the odds of exposure in the control group.
*0.17*
- This value is close to the reciprocal of 6 (1/6 ≈ 0.166), suggesting a potential miscalculation or an inverted odds ratio.
- An odds ratio of 0.17 would imply a protective effect (lower odds of bipolar disorder with more social media), which is contrary to the calculation and typical interpretation in this context.
*0.67*
- This value is the reciprocal of 1.5 (1/1.5 ≈ 0.67) which represents the odds of *not* being exposed in cases (200/300).
- It does not represent the correct odds ratio, which compares the odds of exposure in cases to the odds of exposure in controls.
Question 2: A 19-year-old woman is brought to the physician by her parents because of irritable mood that started 5 days ago. Since then, she has been staying up late at night working on a secret project. She is energetic despite sleeping less than 4 hours per day. Her parents report that she seems easily distracted. She is usually very responsible, but this week she spent her paycheck on supplies for her project. She has never had similar symptoms before. In the past, she has had episodes where she felt too fatigued to go to school and slept until 2 pm every day for 2 weeks at a time. During those times, her parents noticed that she cried excessively, was very indecisive, and expressed feelings of worthlessness. Two months ago, she had an asthma exacerbation and was treated with bronchodilators and steroids. She tried cocaine once in high school but has not used it since. Vital signs are within normal limits. On mental status examination, she is irritable but cooperative. Her speech is pressured and her thought process is linear. Which of the following is the most likely diagnosis?
A. Major depressive disorder
B. Bipolar I disorder
C. Bipolar II disorder (Correct Answer)
D. Schizoaffective disorder
E. Substance abuse
Explanation: ***Bipolar II disorder***
- This patient exhibits symptoms consistent with both **hypomania** (increased energy, decreased need for sleep, irritability, distractibility, spending sprees) and past episodes of **major depression** (fatigue, hypersomnia, crying, indecisiveness, worthlessness). The key distinction for Bipolar II is the presence of at least one hypomanic episode and one major depressive episode, without a full manic episode.
- The current symptoms of increased energy and decreased need for sleep for 5 days, along with a significant change in behavior (spending paycheck on a "secret project"), indicate a level of impairment consistent with hypomania, rather than a full-blown mania as the thought process is described as linear.
*Major depressive disorder*
- While the patient has a history of depressive episodes, the current presentation with **elevated mood, increased energy, and decreased need for sleep** is inconsistent with a unipolar depressive episode.
- Major depressive disorder does not involve periods of elevated or irritable mood or increased activity.
*Bipolar I disorder*
- Bipolar I disorder requires the occurrence of at least one **manic episode**. While the patient's current symptoms are suggestive of a mood elevation, they do not meet the criteria for full mania, which typically involves severe impairment, psychotic features, or hospitalization.
- The patient's speech is pressured but her thought process is described as **linear**, which is less typical for a full manic episode where **flight of ideas** or **tangential/disorganized thinking** might be present.
*Schizoaffective disorder*
- Schizoaffective disorder involves a period of uninterrupted illness during which there is a **major mood episode (depressive or manic) concurrent with symptoms of schizophrenia**, such as delusions or hallucinations.
- The patient's symptoms are primarily mood-related, and there is no mention of psychotic symptoms independent of the mood disturbance.
*Substance abuse*
- Although the patient used cocaine once in high school, there is no evidence of recent substance use that would explain the current symptoms. The symptoms are sustained over days and include a history of recurrent mood disturbances.
- While the patient received steroid treatment 2 months ago (which can precipitate mood episodes), the timing and clinical presentation are more consistent with a primary mood disorder rather than a substance/medication-induced disorder.
Question 3: A 33-year-old woman is brought to the physician by her husband because of persistent sadness for the past 2 months. During this period, she also has had difficulty sleeping and an increased appetite. She had similar episodes that occurred 2 years ago and 9 months ago that each lasted for 4 months. Between these episodes, she reported feeling very energetic and rested after 3 hours of sleep. She often went for long periods of time without eating. She works as a stock market trader and received a promotion 5 months ago. She regularly attends yoga classes on the weekends with her friends. On mental status examination, she has a blunted affect. She denies suicidal thoughts and illicit drug use. Which of the following is the most likely diagnosis?
A. Major depressive disorder with seasonal pattern
B. Persistent depressive disorder
C. Bipolar II disorder (Correct Answer)
D. Major depressive disorder with atypical features
E. Cyclothymic disorder
Explanation: ***Bipolar II disorder***
- The patient exhibits recurrent episodes of **major depression** (sadness, sleep difficulties, increased appetite) interspersed with periods of **hypomania** (energetic, reduced need for sleep, long periods without eating, successful work performance with promotion)
- This pattern is characteristic of **Bipolar II disorder**: major depressive episodes plus at least one hypomanic episode
- No evidence of **frank mania** (e.g., psychosis, severe impairment requiring hospitalization) is present, which distinguishes this from Bipolar I disorder
*Major depressive disorder with seasonal pattern*
- While the patient presents with depressive symptoms, the episodes of **hypomania** (increased energy, decreased need for sleep) rule out unipolar depression
- The history of episodes at various times (2 years ago, 9 months ago, current) does not fit a **seasonal pattern**
- The **hypomanic phases** between depressive episodes are inconsistent with any form of major depressive disorder
*Persistent depressive disorder*
- This condition involves **chronic depressive symptoms** lasting at least 2 years, but typically less severe than major depressive episodes
- The presence of distinct, severe **major depressive episodes** and recurrent **hypomanic periods** contradicts this diagnosis
- Persistent depressive disorder does not include hypomania or mood elevation
*Major depressive disorder with atypical features*
- Atypical features include **increased appetite**, **hypersomnia**, leaden paralysis, interpersonal rejection sensitivity, and mood reactivity
- While increased appetite is present during depressive phases, the alternating periods of **hypomania** exclude this from being major depressive disorder
- Any form of major depressive disorder is ruled out by the presence of hypomanic episodes
*Cyclothymic disorder*
- Cyclothymic disorder involves numerous periods of **hypomanic symptoms** and **depressive symptoms** for at least 2 years, but symptoms do not meet full criteria for major depressive or hypomanic episodes
- This patient explicitly experiences **major depressive episodes** (persistent sadness, neurovegetative symptoms lasting 4 months), which exceed the threshold for cyclothymia
- The severity and duration of depressive episodes make Bipolar II disorder the correct diagnosis
Question 4: A mental health volunteer is interviewing locals as part of a community outreach program. A 46-year-old man discloses that he has felt sad for as long as he can remember. He feels as though his life is cursed and if something terrible can happen to him, it usually will. He has difficulty making decisions and feels hopeless. He also feels that he has had worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration over the past 2 weeks. He is otherwise getting enough sleep and able to hold a job. Which of the following statement best describes this patient's condition?
A. The patient may have symptoms of mania or psychosis.
B. The patient is likely to show anhedonia.
C. The patient likely has paranoid personality disorder.
D. The patient has double depression. (Correct Answer)
E. The patient should be started on an SSRI.
Explanation: ***The patient has double depression.***
- The patient describes **chronic low-grade depressive symptoms** ("felt sad for as long as he can remember," "life is cursed," "difficulty making decisions," "hopeless") consistent with **persistent depressive disorder (dysthymia)**, which requires at least 2 years of symptoms.
- The recent worsening of symptoms over the past two weeks, including "worsening suicidal ideations, guilt from past problems, decreased energy, and poor concentration," indicates an additional **major depressive episode (MDE) superimposed on dysthymia**, a condition known as **double depression**.
- This patient currently meets criteria for both conditions simultaneously, not just at risk for developing them.
*The patient may have symptoms of mania or psychosis.*
- There are no symptoms mentioned that suggest **mania**, such as elevated mood, increased energy, decreased need for sleep, grandiosity, or racing thoughts.
- While suicidal ideation is present, there is no evidence of **psychotic features** like hallucinations or delusions.
*The patient is likely to show anhedonia.*
- **Anhedonia** (inability to feel pleasure) is a common symptom of depression and may well be present in this patient.
- However, the patient's presentation specifically highlights the pattern of **chronic dysthymia with a superimposed major depressive episode**, making **double depression** a more precise, comprehensive, and diagnostically specific description of his current condition.
- While anhedonia might be present, it is a symptom rather than a diagnostic formulation.
*The patient likely has paranoid personality disorder.*
- **Paranoid personality disorder** is characterized by pervasive distrust and suspicion of others, interpreting their motives as malevolent, without sufficient basis.
- The patient's feelings of being "cursed" and that "something terrible can happen" reflect **depressive pessimism and negative cognitive distortions**, not paranoid ideation about others' intentions.
- This is consistent with the hopelessness seen in depression.
*The patient should be started on an SSRI.*
- While an **SSRI (selective serotonin reuptake inhibitor)** combined with psychotherapy would likely be appropriate treatment for double depression, making a specific treatment recommendation is premature without comprehensive clinical assessment.
- The question asks for the **best statement describing the patient's condition** (diagnosis), not for treatment recommendations.
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
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.
Question 6: A 24-year-old male comes into the psychiatric clinic complaining of consistent sadness. He endorses feelings of worthlessness, anxiety, and anhedonia for the past couple months but denies feeling suicidal. He further denies any past episodes of feeling overly energetic with racing thoughts. Confident of the diagnosis, you recommend frequent talk therapy along with a long-term prescription of a known first-line medication for this disorder. What is the drug and what are some of the most frequently encountered side effects?
A. Selective serotonin reuptake inhibitor; hypomania, suicidal thoughts
B. Tricyclic antidepressants; hypomania, suicidal thoughts
C. Selective serotonin reuptake inhibitor; anorgasmia, insomnia (Correct Answer)
D. Monoamine oxidase inhibitors; Orthostatic hypotension, weight gain
E. Tricyclic antidepressants; Orthostatic hypotension, anticholinergic effects
Explanation: ***Selective serotonin reuptake inhibitor; anorgasmia, insomnia***
- The patient presents with classic symptoms of **major depressive disorder**, including persistent sadness, worthlessness, anxiety, and anhedonia, without any history of manic or hypomanic episodes. **SSRIs** are considered first-line pharmacotherapy for this condition.
- Common side effects of SSRIs include **sexual dysfunction** (e.g., anorgasmia, decreased libido) and **insomnia** or agitation, especially during the initial weeks of treatment.
*Selective serotonin reuptake inhibitor; hypomania, suicidal thoughts*
- While SSRIs are the correct drug class, **hypomania** is not a frequent side effect in patients without bipolar disorder. For patients with bipolar disorder, antidepressant monotherapy can induce hypomania or mania, but this patient denies such episodes.
- **Suicidal thoughts** can occur, particularly in young adults, during the initial phase of antidepressant treatment, but it is less common to frame it as a *frequently encountered side effect* in the general population compared to sexual dysfunction or sleep disturbances.
*Tricyclic antidepressants; hypomania, suicidal thoughts*
- **Tricyclic antidepressants (TCAs)** are generally not first-line due to their less favorable side effect profile compared to SSRIs, including significant anticholinergic effects and cardiovascular risks.
- As with SSRIs, **hypomania** is not a typical frequent side effect in unipolar depression, and while **suicidal thoughts** are a concern with antidepressants, TCAs carry a higher risk of lethality in overdose, making them less preferred initially.
*Monoamine oxidase inhibitors; Orthostatic hypotension, weight gain*
- **Monoamine oxidase inhibitors (MAOIs)** are effective but are typically reserved for **refractory depression** due to their significant drug and food interactions (e.g., tyramine-induced hypertensive crisis).
- While **orthostatic hypotension** and **weight gain** are known side effects of MAOIs, this class is not considered a first-line treatment for major depressive disorder.
*Tricyclic antidepressants; Orthostatic hypotension, anticholinergic effects*
- **TCAs** are indeed associated with side effects such as **orthostatic hypotension** and prominent **anticholinergic effects** (e.g., dry mouth, constipation, blurred vision, urinary retention).
- However, because of these more burdensome side effects and higher toxicity in overdose, TCAs are not generally considered the first-line medication choice, especially when SSRIs are available and safer.
Question 7: A 34-year-old woman comes to the physician because of a 6-week history of depressed mood, loss of interest, and difficulty sleeping. She also has had a 4.5-kg (10-lb) weight loss during this period. She has not been as productive as before at work due to difficulty concentrating. There is no evidence of suicidal ideation. Laboratory studies including thyroid-stimulating hormone are within the reference range. The physician prescribes treatment with escitalopram. This drug targets a neurotransmitter that is produced in which of the following brain structures?
A. Substantia nigra
B. Raphe nucleus (Correct Answer)
C. Nucleus accumbens
D. Basal nucleus of Meynert
E. Locus coeruleus
Explanation: ***Raphe nucleus***
- **Escitalopram** is a **selective serotonin reuptake inhibitor (SSRI)**, and the **raphe nuclei** are the primary source of serotonin production in the brain.
- Serotonergic neurons originating from the raphe nuclei project widely throughout the brain, influencing mood, sleep, appetite, and cognition.
*Substantia nigra*
- The **substantia nigra** is primarily associated with **dopamine production**, particularly in the nigrostriatal pathway, which is crucial for motor control.
- Dysfunction in this area is a hallmark of **Parkinson's disease**, not directly targeted by SSRIs for depression.
*Nucleus accumbens*
- The **nucleus accumbens** is a key component of the **reward pathway** and is primarily involved in dopamine and pleasure, not the primary site of serotonin production.
- While dopamine dysfunction can contribute to mood disorders, SSRIs do not directly target dopamine production in this area.
*Basal nucleus of Meynert*
- The **basal nucleus of Meynert** is a major source of **acetylcholine** in the brain, playing a critical role in memory and learning.
- Degeneration of these neurons is associated with **Alzheimer's disease**, and it is not involved in serotonin synthesis.
*Locus coeruleus*
- The **locus coeruleus** is the primary site of **norepinephrine production** in the brain, involved in arousal, attention, and stress responses.
- While norepinephrine is implicated in mood disorders, escitalopram specifically targets **serotonin reuptake**, not norepinephrine synthesis, which occurs in the locus coeruleus.
Question 8: A 40-year-old man is brought to the emergency department by police officers due to inappropriate public behavior. He was at a pharmacy demanding to speak with the manager so he could discuss a business deal. Two weeks ago, he left his wife of 10 years and moved from another city in order to pursue his dreams of being an entrepreneur. He has not slept for more than 3-4 hours a night in the last 2 weeks. He has a history of bipolar disorder and diabetes. He has been hospitalized three times in the last year for mood instability. Current medications include lithium and insulin. Mental status examination shows accelerated speech with flight of ideas. His serum creatinine concentration is 2.5 mg/dL. Which of the following is the most appropriate next step in management with respect to his behavior?
A. Lithium and olanzapine
B. Valproic acid and quetiapine (Correct Answer)
C. Carbamazepine only
D. Clozapine only
E. Lithium and valproic acid
Explanation: ***Valproic acid and quetiapine***
- This patient presents with symptoms of **acute mania**, including **grandiosity**, **decreased need for sleep**, accelerated speech, and flight of ideas, in the context of bipolar disorder. His **elevated serum creatinine (2.5 mg/dL) indicates significant renal impairment**, which necessitates **lithium discontinuation**.
- The renal impairment may be due to **lithium-induced nephrotoxicity** (a known complication of chronic lithium therapy), making continuation of lithium both ineffective and potentially dangerous.
- **Valproic acid** is an effective mood stabilizer for acute mania and can be safely used in patients with renal impairment (hepatically metabolized), while **quetiapine**, an atypical antipsychotic, targets the psychotic symptoms and helps with **agitation and sleep disturbances**.
- This combination provides both mood stabilization and rapid control of acute manic symptoms.
*Lithium and olanzapine*
- The patient's **serum creatinine of 2.5 mg/dL indicates significant renal impairment**, making lithium, which is renally cleared and can be nephrotoxic, **contraindicated**.
- Continuing lithium in the setting of renal dysfunction increases risk of **lithium toxicity** and further renal damage.
- While olanzapine is effective for acute mania, continuing lithium would be unsafe given the patient's kidney function.
*Carbamazepine only*
- **Carbamazepine** is an alternative mood stabilizer for bipolar disorder, but **monotherapy with carbamazepine is insufficient** for managing severe acute mania with psychotic features and significant agitation.
- This patient requires both a mood stabilizer and an antipsychotic for rapid stabilization.
- Additionally, carbamazepine requires monitoring for **hematologic and hepatic side effects**.
*Clozapine only*
- **Clozapine** is reserved for **treatment-resistant cases** of bipolar disorder or schizophrenia that have failed multiple other agents.
- It requires intensive monitoring for life-threatening side effects including **agranulocytosis** (weekly/biweekly CBC monitoring) and myocarditis.
- It is **not appropriate as a first-line agent** for acute manic stabilization in the emergency setting.
*Lithium and valproic acid*
- **Lithium is contraindicated** in this patient due to his **elevated serum creatinine (2.5 mg/dL)**, which indicates significant renal impairment.
- While valproic acid would be appropriate, combining it with lithium would pose serious safety risks given the renal dysfunction.
Question 9: A 55-year-old man presents to his primary care physician with complaints of fluctuating mood for the past 2 years. He feels great and full of energy for some months when he is very creative with tons of ideas just racing through his mind. He is noted to be very talkative and distracted by his different ideas. During these times, he is very productive and able to accomplish much at work and home. However, these periods are frequently followed by a prolonged depressed mood. During this time, he has low energy, poor concentration, and low self-esteem. The accompanying feeling of hopelessness from these cycling “ups” and “downs” have him eating and sleeping more during the “downs.” He does not remember a period within the last 2 years where he felt “normal.” What is the most likely diagnosis?
A. Dysthymic disorder
B. Bipolar II disorder
C. Persistent depressive disorder
D. Bipolar I disorder
E. Cyclothymic disorder (Correct Answer)
Explanation: ***Cyclothymic disorder***
- The patient experiences chronic **fluctuating moods**, with numerous periods of **hypomanic symptoms** (elevated energy, racing thoughts, increased productivity) and numerous periods of **depressive symptoms** (low energy, poor concentration, hopelessness) over at least 2 years.
- The symptoms are not severe enough to meet full criteria for a **manic episode**, **hypomanic episode**, or **major depressive episode**, and there has been no period longer than 2 months without symptoms.
*Dysthymic disorder*
- This is the **DSM-IV term** for what is now called **persistent depressive disorder** in DSM-5, involving a **chronic depressed mood** that lasts for at least 2 years.
- It does not include periods of significant elevated mood or hypomania.
- The patient's presentation includes distinct periods of **elevated mood and energy**, which are not characteristic of dysthymic disorder.
*Bipolar II disorder*
- Bipolar II disorder requires at least one **major depressive episode** and at least one **hypomanic episode**.
- While the patient exhibits hypomanic and depressive symptoms, the periods of depression do not meet the full criteria for a **major depressive episode** (e.g., duration, number of symptoms) and the hypomanic symptoms are subsyndromal.
*Persistent depressive disorder*
- This is the **DSM-5 term** for chronic low-grade depression (formerly called dysthymic disorder), characterized by depressed mood for at least 2 years without manic or hypomanic symptoms.
- The patient's history of elevated mood and energy precludes this diagnosis.
*Bipolar I disorder*
- Bipolar I disorder requires at least one **manic episode**, which is characterized by a distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and causing significant impairment.
- The patient's "ups" are described as productive and not causing significant impairment or involving psychotic features, indicating **hypomanic symptoms** rather than full mania.
Question 10: A 19-year-old female college student is brought into the emergency department by her boyfriend. The boyfriend reports that the patient got caught stealing from the company she works for and subsequently got fired. The boyfriend received a text that evening saying “I’ll miss you.” When he arrived at her dorm room, the patient was slumped in the shower covered in blood. The patient agreed to be driven to the emergency room. When asked about what happened, the patient replies “I just want out of this life.” The patient has bipolar disorder, and takes lithium as prescribed. She has a psychiatrist she sees every week, which the boyfriend confirms. She has never had a prior suicide attempt nor has she ever been hospitalized for a psychiatric disorder. The patient’s vitals are stable. Upon physical examination, a 4 centimeter vertical incision is noted on the patient’s left forearm. During the patient’s laceration repair, she asks if she will be admitted. She states, “these ups and downs are common for me, but I feel better now.” She verbalizes that she understands that she overreacted. She asks to go home, and her boyfriend insists that he will stay with her. They both confirm that neither of them have guns or know any peers with access to guns. Which of the following is the most appropriate management for the patient?
A. Have the patient sign a suicide contract before discharge
B. Set up a next-day appointment with the patient’s psychiatrist
C. Involuntarily admit the patient (Correct Answer)
D. Call the patient’s parents
E. Discontinue lithium and start valproate
Explanation: ***Involuntarily admit the patient***
- The patient's statement "I just want out of this life" combined with the **suicide attempt** (cutting her forearm after a text expressing suicidal ideation) indicates a high risk of self-harm. Despite her current verbalizations of feeling better, the **impulsivity** and severity of the attempt warrant involuntary admission for safety.
- The sudden shift in mood and desire to go home after a serious suicide attempt, stating "these ups and downs are common for me, but I feel better now," suggests potential **lability** and a continued risk that cannot be safely managed with outpatient follow-up alone.
*Have the patient sign a suicide contract before discharge*
- **Suicide contracts** have not been consistently shown to be effective in preventing suicide and can create a false sense of security.
- Given the **actual suicide attempt** and the patient's underlying psychiatric condition, a contract is insufficient to ensure her safety.
*Set up a next-day appointment with the patient’s psychiatrist*
- While follow-up with her psychiatrist is crucial, relying solely on a **next-day appointment** is inadequate given the acute and severe nature of the suicide attempt.
- There is a significant risk of another attempt before the appointment, and the patient needs the **structured environment and constant observation** of an inpatient setting.
*Call the patient’s parents*
- While involving the patient's support system is generally helpful, this action does not directly address the immediate **safety risk** posed by the recent suicide attempt.
- Parental involvement should be considered, but it is not the primary or most appropriate immediate management for a patient at **high risk of self-harm**.
*Discontinue lithium and start valproate*
- Modifying psychotropic medication is a decision made by a psychiatrist after a thorough evaluation, often over time, and is not the immediate or most appropriate "management" in the **emergency setting** for an acute suicide attempt.
- The priority is **safety and stabilization**, not an immediate medication change, especially given that she is already on a mood stabilizer.
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