Bipolar I Disorder: The Daily PANCE Blueprint

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Bipolar I Disorder: The Daily PANCE Blueprint

A 26-year-old woman presents with two weeks of low mood, poor sleep, and loss of interest, and asks to restart an antidepressant. While taking her history she mentions that last year — off all medication — she went through a week of barely sleeping, racing thoughts, spending sprees, and feeling "unstoppable," during which she started three businesses. She has no current suicidal thoughts. Which of the following is the most appropriate pharmacologic management?

A. Start a selective serotonin reuptake inhibitor (SSRI) alone
B. Start a tricyclic antidepressant
C. Start a stimulant
D. Start a benzodiazepine
E. Start a mood stabilizer (e.g., lithium) or an atypical antipsychotic

Answer and topic summary

The answer is E. Start a mood stabilizer (e.g., lithium) or an atypical antipsychotic

That prior week of decreased need for sleep, racing thoughts, grandiosity, overspending, and increased goal-directed activity is a manic episode — which makes the diagnosis bipolar I disorder, and today a bipolar depressive episode, not unipolar major depression. The key teaching point and the trap: starting an antidepressant alone (an SSRI or a TCA) in bipolar disorder can precipitate a manic switch or rapid cycling. The appropriate foundation is a mood stabilizer (lithium, valproate) or an atypical antipsychotic such as quetiapine or lurasidone; an antidepressant, if ever used, is added only under mood-stabilizer cover. Stimulants and benzodiazepines do not treat the underlying illness.

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Covered under ⇒ PANCE Blueprint Psychiatry ⇒ Bipolar and Related Disorders

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