Master the board step 3

Psychiatry
a. What is the most common cause of progression to rapid cycling bipolar?
b. How should you manage rapid cycling bipolar?
c. What other medical conditions predispose a patient to rapid cycling bipolar?
d. What drug has been shown to prevent suicidal ideation in bipolar disorder?
e. A 32-year-old known bipolar patient who is undergoing maintenance therapy
with lithium presents with a positive pregnancy test. How will you manage this
patient’s bipolar disorder?
Answers:
a. Use of antidepressants: Do not give antidepressants prophylactically unless the
question describes previous severe depressive episodes. In that case, antidepressants
are only given for a few weeks.
b. Gradually stop all antidepressants, stimulants, caffeine, benzodiazepines, and alcohol.
c. Hypothyroidism: Check TSH in any patient with rapid cycling bipolar and replace
thyroid hormones if needed.
d. Lithium
e. Discontinue lithium (to avoid heart abnormalities): Choose ECT therapy for firsttrimester
patients with manic episodes. Use lamotrigine in 2nd or 3rd trimester.
Treatment
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First-line treatment: monotherapy with lithium, lamotrigine, or risperidone
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Second-line treatment: aripiprazole, divalproex, quetiapine, and olanzapine
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Patients with multiple recurrences require combination therapy.
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Always plan for psychotherapy and cognitive behavioral therapy.
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Avoid teratogenic drugs such as lithium, valproate, and carbamazepine in
female patients.
Lithium can lead to
Ebstein’s anomaly and
diabetes insipidus.
Cyclothymia
When the patient presents with a history of recurrent episodes of depressed
mood and hypomanic mood for at least 2 years, the diagnosis is cyclothymia.
It resembles a milder form of bipolar affective disorder.
Treatment
Psychotherapy is the first step in management. Many people function without
medications and learn to manage their hypomanic dispositions (especially
artists). Start divalproex when functioning is impaired. Divalproex is more
effective in cyclothymia than lithium.
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