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?
Q2
A 28-year-old woman is brought into the clinic by her husband with concerns that she might be depressed. She delivered a healthy newborn a week and a half ago without any complications. Since then, she has been having trouble sleeping, eating poorly, and has stopped playing with the baby. The patient says she feels like she is drained all the time and feels guilty for not doing more for the baby. Which of the following is the best course of treatment for this patient?
Q3
A 31-year-old G1P0 woman is brought into the emergency room by the police after a failed suicide attempt. She jumped off a nearby bridge but was quickly rescued by some nearby locals. The height of the bridge was not significant, so the patient did not sustain any injuries. For the 3 weeks before this incident, the patient says she had been particularly down, lacking energy and unable to focus at home or work. She says she no longer enjoys her usual hobbies or favorite meals and is not getting enough sleep. Which of the following is the best course of treatment for this patient?
Q4
A 26-year-old man being treated for major depressive disorder returns to his psychiatrist complaining that he has grown weary of the sexual side effects. Which other medication used to treat major depressive disorder may be appropriate as a stand-alone or add-on therapy?
Q5
A 27-year old gentleman presents to the primary care physician with the chief complaint of "feeling down" for the last 6 weeks. He describes trouble falling asleep at night, decreased appetite, and recent feelings of intense guilt regarding the state of his personal relationships. He says that everything "feels slower" than it used to. He endorses having a similar four-week period of feeling this way last year. He denies thoughts of self-harm or harm of others. He also denies racing thoughts or delusions of grandeur. Which of the following would be an INAPPROPRIATE first line treatment for him?
Q6
A 22-year-old man comes to the physician because of generalized fatigue for the past 3 months. During this time, his grades have declined in his college courses because he has had difficulty focusing on assignments and sometimes sleeps in class. He no longer plays the drums for his band and has stopped attending family events. His temperature is 37°C (98.6°F), pulse is 60/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he describes his mood as “ok.” He has a flat affect. There is no evidence of suicidal ideation. His speech is slow in rate and monotone in rhythm, and his thought process is organized. He has no delusions or hallucinations. Which of the following is the most appropriate next step in treatment?
Q7
A 29-year-old man is being monitored at the hospital after cutting open his left wrist. He has a long-standing history of unipolar depressive disorder and multiple trials of antidepressants. The patient expresses thoughts of self-harm and does not deny suicidal intent. A course of electroconvulsive therapy is suggested. His medical history is not significant for other organic illness. Which of the following complications of this therapy is this patient at greatest risk for?
Q8
A 26-year-old man is brought to the emergency room by his roommate after he was found attempting to commit suicide. His roommate says that he stopped him before he was about to jump off the balcony. He has been receiving treatment for depression for about a year. 6 months ago, he had come to the hospital reporting decreased interest in his daily activities and inability to concentrate on his work. He had stopped going out or accepting invitations for any social events. He spent several nights tossing and turning in bed. He also expressed guilt for being unable to live up to his parents’ expectations. His psychiatrist started him on fluoxetine. He says that none of the medications have helped even though the dose of his medication was increased on several occasions, and he was also switched to other medications over the course of the past year. He has mentioned having suicidal thoughts due to his inability to cope with daily activities, but this is the first time he has ever attempted it. Which of the following would this patient be a suitable candidate for?
Q9
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?
Q10
A 17-year-old white female with a history of depression is brought to your office by her parents because they are concerned that she is acting differently. She is quiet and denies any changes in her personality or drug use. After the parents step out so that you can speak alone, she begins crying. She states that school has been very difficult and has been very depressed for the past 2 months. She feels a lot of pressure from her parents and coaches and says she cannot handle it anymore. She says that she has been cutting her wrists for the past week and is planning to commit suicide. She instantly regrets telling you and begs you not to tell her parents. What is the most appropriate course of action?
Treatment-resistant depression US Medical PG Practice Questions and MCQs
Question 1: 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 2: A 28-year-old woman is brought into the clinic by her husband with concerns that she might be depressed. She delivered a healthy newborn a week and a half ago without any complications. Since then, she has been having trouble sleeping, eating poorly, and has stopped playing with the baby. The patient says she feels like she is drained all the time and feels guilty for not doing more for the baby. Which of the following is the best course of treatment for this patient?
A. Reassurance
B. Fluoxetine (Correct Answer)
C. Risperidone
D. Amitriptyline
E. No treatment
Explanation: ***Fluoxetine***
- This patient's symptoms (trouble sleeping, poor appetite, guilt, and anhedonia towards the baby) occurring 10 days postpartum are highly suggestive of **postpartum depression**. **SSRIs** like fluoxetine are first-line pharmacological treatments for this condition.
- Fluoxetine is a **selective serotonin reuptake inhibitor (SSRI)** that helps regulate mood by increasing serotonin levels in the brain. It is generally considered safe during breastfeeding, with a relatively low infant exposure compared to other antidepressants.
*Reassurance*
- Reassurance alone may be appropriate for **postpartum blues**, which are milder and self-limiting, typically resolving within two weeks.
- This patient's symptoms are more severe and persistent, lasting beyond typical postpartum blues and significantly impacting her functioning, indicating a need for more substantial intervention.
*Risperidone*
- Risperidone is an **atypical antipsychotic** primarily used to treat conditions like schizophrenia or bipolar disorder, or as an adjunct for severe refractory depression with psychotic features.
- There is no indication of psychosis in this patient's presentation, and the use of an antipsychotic would be disproportionate and carry unnecessary side effects.
*Amitriptyline*
- Amitriptyline is a **tricyclic antidepressant (TCA)**. While effective for depression, TCAs are generally not first-line due to a less favorable side effect profile (e.g., anticholinergic effects, cardiac conductivity issues) compared to SSRIs.
- SSRIs like fluoxetine are preferred for initial treatment of postpartum depression due to their better tolerability and safety profile.
*No treatment*
- This patient exhibits clear symptoms of **postpartum depression**, which is a serious condition that can worsen without intervention and impact both the mother's and infant's well-being.
- Untreated depression can lead to significant functional impairment, chronic suffering, and in severe cases, harm to oneself or the baby.
Question 3: A 31-year-old G1P0 woman is brought into the emergency room by the police after a failed suicide attempt. She jumped off a nearby bridge but was quickly rescued by some nearby locals. The height of the bridge was not significant, so the patient did not sustain any injuries. For the 3 weeks before this incident, the patient says she had been particularly down, lacking energy and unable to focus at home or work. She says she no longer enjoys her usual hobbies or favorite meals and is not getting enough sleep. Which of the following is the best course of treatment for this patient?
A. Bupropion
B. Paroxetine
C. Combination of SSRI and SNRI
D. Phenelzine
E. Electroconvulsive therapy (Correct Answer)
Explanation: ***Electroconvulsive therapy***
- This patient presents with **severe depression with suicidal ideation** (a failed suicide attempt), which warrants urgent intervention. **ECT** is highly effective for severe depression, especially when there is an acute suicide risk or psychotic features.
- ECT has a **rapid onset of action** compared to antidepressants, which is crucial for patients at high risk of self-harm, and is considered **safe in pregnancy**.
*Bupropion*
- **Bupropion** is an antidepressant that primarily inhibits the reuptake of norepinephrine and dopamine. While effective for depression, it has a slower onset of action than ECT and may not be sufficient for severe, acute suicidal ideation.
- It is often used for depression with atypical features or for patients who experience sexual side effects with SSRIs, but it is **contraindicated in patients with a history of seizures or eating disorders**.
*Paroxetine*
- **Paroxetine** is an SSRI commonly used for depression and anxiety disorders. Like other antidepressants, it has a delayed onset of action (several weeks) and may not be appropriate for the immediate management of a patient with recent, severe suicidal ideation.
- One of the major concerns with paroxetine in this patient population is that it has a **higher rate of teratogenicity and neonatal complications** compared to other SSRIs, which is relevant given the patient is G1P0.
*Combination of SSRI and SNRI*
- Combining an **SSRI and an SNRI** (e.g., fluoxetine and venlafaxine) is a strategy sometimes used for treatment-resistant depression. However, like monotherapy with these agents, it still has a delayed onset of action.
- The combination also carries a **higher risk of side effects** compared to monotherapy.
*Phenelzine*
- **Phenelzine** is a monoamine oxidase inhibitor (MAOI). MAOIs are effective antidepressants but are typically reserved for **treatment-resistant depression** due to their significant drug-drug and drug-food interactions (e.g., **hypertensive crisis with tyramine-rich foods or sympathomimetics**).
- Given the patient's acute suicidal risk, a treatment with a more rapid and safer profile, such as ECT, would be preferred over initiating an MAOI.
Question 4: A 26-year-old man being treated for major depressive disorder returns to his psychiatrist complaining that he has grown weary of the sexual side effects. Which other medication used to treat major depressive disorder may be appropriate as a stand-alone or add-on therapy?
A. Venlafaxine
B. Cyproheptadine
C. Aripiprazole
D. Bupropion (Correct Answer)
E. Paroxetine
Explanation: ***Bupropion***
- **Bupropion** is an antidepressant that works via **norepinephrine-dopamine reuptake inhibition**, and unlike most common antidepressants, it is **not associated with sexual dysfunction**.
- It can be used as a **stand-alone treatment** or as an **add-on therapy** to counteract sexual side effects from other antidepressants like SSRIs.
- This makes it the ideal choice for this patient.
*Venlafaxine*
- **Venlafaxine** is a **serotonin-norepinephrine reuptake inhibitor (SNRI)**, and like SSRIs, it can cause or worsen **sexual dysfunction**.
- It is unlikely to resolve the patient's complaint of sexual side effects.
*Cyproheptadine*
- **Cyproheptadine** is an **antihistamine** with **serotonin antagonist** properties that is sometimes used **off-label to treat SSRI-induced sexual dysfunction**.
- However, it is **not an antidepressant** itself and therefore would not be appropriate as a **stand-alone therapy** for major depressive disorder.
- The question specifically asks for "medication used to treat major depressive disorder," which excludes cyproheptadine despite its utility for sexual side effects.
*Aripiprazole*
- **Aripiprazole** is an **atypical antipsychotic** that is approved as an **adjunctive treatment** for major depressive disorder.
- While it can be an add-on, it is **not typically used to mitigate sexual side effects** and can sometimes have its own sexual side effects.
*Paroxetine*
- **Paroxetine** is an **SSRI** that is notoriously associated with a **high incidence of sexual side effects**, including decreased libido, delayed orgasm, and anorgasmia.
- Using paroxetine would likely **exacerbate** rather than alleviate the patient's complaint.
Question 5: A 27-year old gentleman presents to the primary care physician with the chief complaint of "feeling down" for the last 6 weeks. He describes trouble falling asleep at night, decreased appetite, and recent feelings of intense guilt regarding the state of his personal relationships. He says that everything "feels slower" than it used to. He endorses having a similar four-week period of feeling this way last year. He denies thoughts of self-harm or harm of others. He also denies racing thoughts or delusions of grandeur. Which of the following would be an INAPPROPRIATE first line treatment for him?
A. Paroxetine
B. Electroconvulsive therapy (Correct Answer)
C. Citalopram
D. Psychotherapy
E. Sertraline
Explanation: ***Electroconvulsive therapy***
- This is generally reserved for **severe depression** that is unresponsive to other treatments or for depression with **psychotic features**, severe suicidality, or catatonia.
- Given the patient's presentation, **ECT** would be an overly aggressive **first-line** treatment choice.
*Paroxetine*
- **Paroxetine** is a **SSRI** and is considered a **first-line antidepressant** for major depressive disorder.
- It works by increasing serotonin levels in the brain to improve mood.
*Citalopram*
- **Citalopram** is an **SSRI** and is also a **first-line treatment option** for major depressive disorder, often well-tolerated.
- It helps regulate mood and alleviate symptoms like those described by the patient.
*Psychotherapy*
- **Psychotherapy**, particularly **cognitive-behavioral therapy (CBT)** or **interpersonal therapy (IPT)**, is often a **first-line treatment**, either alone or in combination with medication, for depression.
- It can help the patient address negative thought patterns and coping mechanisms.
*Sertraline*
- **Sertraline** is another **SSRI** commonly used as a **first-line agent** for major depressive disorder due to its efficacy and relatively favorable side-effect profile.
- It helps to improve symptoms such as low mood, sleep disturbances, and decreased appetite.
Question 6: A 22-year-old man comes to the physician because of generalized fatigue for the past 3 months. During this time, his grades have declined in his college courses because he has had difficulty focusing on assignments and sometimes sleeps in class. He no longer plays the drums for his band and has stopped attending family events. His temperature is 37°C (98.6°F), pulse is 60/min, and blood pressure is 130/80 mm Hg. Physical examination shows no abnormalities. On mental status examination, he describes his mood as “ok.” He has a flat affect. There is no evidence of suicidal ideation. His speech is slow in rate and monotone in rhythm, and his thought process is organized. He has no delusions or hallucinations. Which of the following is the most appropriate next step in treatment?
A. Diazepam therapy
B. Escitalopram therapy (Correct Answer)
C. Phenelzine therapy
D. Reassurance
E. Amitriptyline therapy
Explanation: ***Escitalopram therapy***
- The patient presents with symptoms consistent with **major depressive disorder**: generalized fatigue, anhedonia (stopped playing drums, attending family events), poor concentration, and hypersomnia (sleeping in class) for 3 months.
- An **SSRI like escitalopram** is a first-line pharmacotherapy for MDD, particularly given its good tolerability profile and effectiveness in addressing core depressive symptoms.
*Diazepam therapy*
- **Diazepam is a benzodiazepine**, primarily used for acute anxiety or insomnia, and can be habit-forming.
- It is not indicated as a first-line treatment for major depressive disorder due to its addictive potential and lack of efficacy for core depressive symptoms.
*Phenelzine therapy*
- **Phenelzine is a MAOI (monoamine oxidase inhibitor)**, which are older antidepressants typically reserved for atypical depression or treatment-resistant depression due to their significant side effects and dietary restrictions.
- It is not appropriate as a first-line agent, especially given safer and equally effective options like SSRIs.
*Reassurance*
- The patient's symptoms are significant, persistent for 3 months, and causing functional impairment (decline in grades, social withdrawal); therefore, **simple reassurance is insufficient** and would delay appropriate treatment.
- These symptoms warrant a more proactive and evidence-based therapeutic approach.
*Amitriptyline therapy*
- **Amitriptyline is a TCA (tricyclic antidepressant)**, which are generally associated with a higher incidence of side effects, such as anticholinergic effects, sedation, and cardiac conduction abnormalities, compared to SSRIs.
- While effective for depression, it is typically not a first-line treatment due to its less favorable side effect profile compared to SSRIs like escitalopram.
Question 7: A 29-year-old man is being monitored at the hospital after cutting open his left wrist. He has a long-standing history of unipolar depressive disorder and multiple trials of antidepressants. The patient expresses thoughts of self-harm and does not deny suicidal intent. A course of electroconvulsive therapy is suggested. His medical history is not significant for other organic illness. Which of the following complications of this therapy is this patient at greatest risk for?
A. Acute kidney injury
B. Acute coronary syndrome
C. Anterograde amnesia
D. Intracranial hemorrhage
E. Retrograde amnesia (Correct Answer)
Explanation: ***Retrograde amnesia***
- **Retrograde amnesia**, specifically memory loss for events occurring prior to the treatment, is a common and often transient side effect of **electroconvulsive therapy (ECT)**.
- While generally temporary, it can be distressing for patients and is a significant consideration when recommending ECT, especially in patients with otherwise healthy brains.
*Acute kidney injury*
- **Acute kidney injury (AKI)** is not a typical direct complication of **ECT**.
- While fluid and electrolyte imbalances or certain medications used during ECT (e.g., muscle relaxants) could theoretically impact renal function in predisposed individuals, it is not a primary concern in a patient with no significant history of organic illness.
*Acute coronary syndrome*
- **Acute coronary syndrome (ACS)** is a potential risk associated with the physiological stress of **ECT**, which can include transient **hypertension** and **tachycardia**.
- However, in a 29-year-old with no significant medical history, the risk is considerably lower compared to older patients or those with pre-existing cardiovascular disease.
*Anterograde amnesia*
- **Anterograde amnesia**, the inability to form new memories after the treatment, is typically less common and usually milder than retrograde amnesia following **ECT**.
- While some patients may experience transient difficulty recalling new information immediately post-ECT, it is usually less pronounced than the impact on remote memories.
*Intracranial hemorrhage*
- **Intracranial hemorrhage** is an extremely rare and severe complication of **ECT**, typically associated with pre-existing cerebral vascular abnormalities or uncontrolled hypertension during the procedure.
- In a young patient with no organic illness, the risk of this complication is exceedingly low.
Question 8: A 26-year-old man is brought to the emergency room by his roommate after he was found attempting to commit suicide. His roommate says that he stopped him before he was about to jump off the balcony. He has been receiving treatment for depression for about a year. 6 months ago, he had come to the hospital reporting decreased interest in his daily activities and inability to concentrate on his work. He had stopped going out or accepting invitations for any social events. He spent several nights tossing and turning in bed. He also expressed guilt for being unable to live up to his parents’ expectations. His psychiatrist started him on fluoxetine. He says that none of the medications have helped even though the dose of his medication was increased on several occasions, and he was also switched to other medications over the course of the past year. He has mentioned having suicidal thoughts due to his inability to cope with daily activities, but this is the first time he has ever attempted it. Which of the following would this patient be a suitable candidate for?
A. Electroconvulsive therapy (Correct Answer)
B. Exposure therapy
C. Cognitive behavioral therapy
D. Olanzapine
E. Amitriptyline
Explanation: ***Electroconvulsive therapy***
- The patient exhibits **severe, treatment-resistant depression with active suicidal ideation and a recent attempt**, making ECT an appropriate and often life-saving intervention.
- ECT is highly effective for severe depression, especially when other treatments have failed and there is an **imminent risk of suicide**.
*Exposure therapy*
- This therapy is primarily used for **anxiety disorders, phobias, and PTSD**, where it helps individuals confront fears.
- It is not indicated for treating severe, persistent depressive episodes or acute suicidal ideation.
*Cognitive behavioral therapy*
- While CBT is effective for depression, this patient's **severe and refractory nature of his depression**, coupled with an active suicide attempt, indicates a need for a more rapid and intensive intervention than CBT alone can provide.
- CBT by itself would generally not be sufficient for a patient with **acute suicidal risk** who has failed multiple pharmacological treatments.
*Olanzapine*
- Olanzapine is an **antipsychotic medication** that can be used as an adjunct in treatment-resistant depression, but it is not typically the first-line augmentation strategy after multiple antidepressant failures and is not as rapidly effective for acute suicidality as ECT.
- Using an atypical antipsychotic like olanzapine alone would not address the immediate, life-threatening risk as effectively as ECT in this severe situation.
*Amitriptyline*
- Amitriptyline is a **tricyclic antidepressant (TCA)**, which is an older class of antidepressants.
- Given the patient has failed multiple prior antidepressant trials and presents with severe, suicidal depression, starting another antidepressant, especially a TCA with its **higher side effect profile and slower onset of action**, would not be appropriate for immediate risk management.
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
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.
Question 10: A 17-year-old white female with a history of depression is brought to your office by her parents because they are concerned that she is acting differently. She is quiet and denies any changes in her personality or drug use. After the parents step out so that you can speak alone, she begins crying. She states that school has been very difficult and has been very depressed for the past 2 months. She feels a lot of pressure from her parents and coaches and says she cannot handle it anymore. She says that she has been cutting her wrists for the past week and is planning to commit suicide. She instantly regrets telling you and begs you not to tell her parents. What is the most appropriate course of action?
A. Prescribe an anti-depressant medication and allow her to return home
B. Refer her to a psychiatrist
C. Explain to her that she will have to be hospitalized as she is an acute threat to herself (Correct Answer)
D. Tell her parents about the situation and allow them to handle it as a family
E. Prescribe an anti-psychotic medication
Explanation: ***Explain to her that she will have to be hospitalized as she is an acute threat to herself***
- This patient is actively suicidal and engaging in **self-harm (cutting)**, which represents an immediate and serious risk to her life, necessitating **involuntary hospitalization** for her safety.
- In cases of acute suicidality, the ethical principle of **beneficence** (acting in the patient's best interest) and **non-maleficence** (avoiding harm) overrides confidentiality to ensure the patient's immediate safety.
*Prescribe an anti-depressant medication and allow her to return home*
- While an antidepressant may be part of long-term management, simply prescribing medication and sending her home is **inappropriate and dangerous** given her active suicidal ideation and self-harm.
- Antidepressants can have a delayed onset of action (2-4 weeks) and, in some adolescents, may initially increase the risk of **suicidal thoughts**, making close monitoring essential.
*Refer her to a psychiatrist*
- A referral to a psychiatrist is crucial for comprehensive evaluation and long-term treatment, but it does **not address the immediate danger** presented by her active suicidal plans and self-harm.
- An urgent psychiatric consultation or hospitalization is needed first, with a referral following stabilization.
*Tell her parents about the situation and allow them to handle it as a family*
- While parents must be informed, simply delegating the responsibility to them is **insufficient and potentially negligent** given the patient's acute suicidal risk.
- **Medical professionals** have a duty to ensure the safety of a suicidal minor, which often requires a higher level of intervention than parental supervision alone.
*Prescribe an anti-psychotic medication*
- There is **no indication of psychosis** in this patient's presentation; her symptoms are consistent with severe depression and acute suicidality.
- Prescribing an antipsychotic would be **inappropriate** and could cause unnecessary side effects without addressing the underlying depressive disorder or acute suicidal crisis.
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