A 38-year-old woman with bipolar disorder has been stable on lithium for the past two years. She comes to her psychiatrist’s office in tears after a two-week history of a depressed mood, poor concentration, loss of appetite, and passive suicidal ideation. Which of the following is the most appropriate next step in the management of this patient?
a. Start the patient on a second mood stabilizer
b. Start the patient on a long-acting benzodiazepine
c. Stop the lithium and start an antidepressant
d. Start an antidepressant and continue the lithium
e. Stop the lithium and start an antipsychotic
the answer is below…
The United States Medical Licensing Examination, or USMLE for short, is a three-part licensing examination that is required in order to receive a license to practice medicine within the United States.
The USMLE assesses a physician’s ability to apply knowledge, concepts, and principles, and to determine fundamental patient-centered skills that are important in health and disease and that constitute the basis of safe and effective patient care. Examination committees composed of medical educators and clinicians from across the United States and its territories prepare the examination materials each year.
This exam is designed by the Federation of State Medical Boards and the National Board of Medical Examiners to determine whether or not an individual understands and can apply the knowledge necessary to practice medicine safely and intelligently.
The USMLE is actually comprised of three different exams that are referred to as steps, which examine the individual’s knowledge of specific topics related to the field of medicine such as basic science, medical knowledge, medical skills, clinical science, and the application of all of these skills and areas of knowledge in the medical field.
All three steps of the USMLE include a series of computerized multiple-choice questions, but the format of the exam and the information covered in each multiple-choice section is different for each step of the USMLE. The USMLE Step II also has a clinical skills portion that examines an individual’s ability to work with real patients and the USMLE Step III has a computerized patient simulation portion in addition to the multiple-choice section of the exam. In order for an individual to receive a license to practice medicine, the individual must pass all three steps of the USMLE.
The correct answer is d; Start an antidepressant and continue the lithium.
Since lithium and other mood stabilizers are more effective in the prevention of manic episodes than in the prevention of depression, antidepressants are used as an adjunctive treatment when depressive episodes develop during maintenance with a mood stabilizer. Since the incidence of antidepressant-induced mania is high (up to 30%), and since antidepressant treatment may cause rapid cycling, the antidepressant should be tapered and discontinued as soon as the depressive symptoms remit. Among the antidepressants in common use, bupropion is considered to carry a slightly lower risk of triggering mania.