Question

A 28-year-old woman presents to her primary care physician because of depressed mood. She states that she has been depressed for as long as she can remember and feels bad about herself almost all of the time. She states that her only happy moments were during her hon- eymoon two years ago, and during a ski trip in college when she felt “on top of the world.” She confides that for a couple weeks last month she felt life was no longer worth living. At that time, she was having extreme difficulty 

sleeping, a complete loss of energy, and a lack of appetite. A review of the patient’s history shows that during the past two years she has seen a physician for complaints of stomach up- set, fatigue, headaches, and an unintentional 3.6-kg (8-lb) weight gain. Physical examina- tion and results of laboratory tests are within normal limits. Which of the following is an ad- verse effect the patient may experience during the course of the treatment of this illness?

(A) Agranulocytosis 

(B) Anorgasmia 

(C) Arrhythmia

 (D) Polyuria

(E) Stevens-Johnson syndrome 

Answer 1

The correct answer is D. This patient has a history of at least one major depressive episode and at least one hypomanic episode without the presence of mixed or manic episodes, a his- tory consistent with bipolar II disorder. Treat- ment for this disorder is a mood stabilizer, most commonly lithium. A common adverse effect of this therapy is nephrogenic diabetes insipidus, in which the principal cells of the renal collecting duct are unable to respond to ADH secreted by the posterior pituitary. As a result, the patient will be unable to concen- trate urine and will thus experience frequent urination.

Answer A is incorrect. Agranulocytosis is a tox- icity associated with clozapine, an atypical an- tipsychotic. This medication is generally used in treatment of schizophrenia, but may be used in cases of mania that are unresponsive to first-line drugs such as lithium. Although the patient did have a history of a hypomanic epi- sode, there is no indication for clozapine as a first-line treatment for bipolar II disorder.

Answer B is incorrect. Anorgasmia is a com- mon adverse effect of selective serotonin reuptake inhibitors. This class of medication, which includes fluoxetine, paroxetine, sertra- line, and citalopram, is commonly used in the treatment of major depression. Although this patient has a history of feeling depressed, she also has a history notable for a hypomanic epi- sode. A major depressive episode is diagnosed if the patient has 5/9 symptoms for at least two weeks, including Sleep changes, loss of Interest (anhedonia), Guilt, Energy loss, Concen- tration changes, Appetite changes, Psychomo- tor abnormalities, and Suicidal thoughts (SIG E CAPS). One of the symptoms has to be de- pressed mood or anhedonia. Major depressive disorder is diagnosed after a major depressive episode without a history of mania, hypoma- nia, or mixed episodes (when criteria for both manic and major depressive episode are simul- taneously present for at least one week), and is further specified by modifiers such as recur- rent, chronic, or postpartum onset.

Answer C is incorrect. Arrhythmias are a well-known adverse effect of the tricyclic anti- depressants. This class of medications, which includes imipramine, clomipramine, and amitriptyline, work to block the reuptake of norepinephrine and serotonin. They are com- monly used medications in the treatment of major depression, obsessive compulsive disor- der, and fibromyalgia. However, the patient in this case has a clinical history most consistent with bipolar II disorder, and thus a mood sta- bilizer such as lithium should be used rather than an antidepressant, which could lead to further manic episodes in this patient.

Answer E is incorrect. Stevens-Johnson syn- drome is a well-known adverse effect of carba- mazepine, an anti-epileptic drug that is some- times used to treat bipolar disorder. Although this patient has a medical history consistent with bipolar II disorder, first-line treatment is generally with a different mood stabilizer such as lithium, as this medication has been proven effective, is cheaper, and has a relatively less severe adverse-effect profile.