Interactive Case Challenge - Bipolar in Perinatal Setting

CE / CME

eCase: Treatment Considerations for Bipolar in a Perinatal Setting

Physician Assistants/Physician Associates: 1.00 AAPA Category 1 CME credit

Social Workers: 1.00 ASWB ACE CE Credit

Pharmacists: 1.00 contact hour (0.1 CEUs)

Psychologists: 1.00 APA CE Credit

Nurses: 1.00 Nursing contact hour

Physicians: Maximum of 1.00 AMA PRA Category 1 Credit™

Released: December 22, 2022

Expiration: December 21, 2023

Joseph F. Goldberg, MD

CME/CE Information

Activity

Progress

Course Completed

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Pre-Activity Introduction Case Presentation References

Margaret is a 30-year-old woman who was hospitalized for a manic episode during her freshman year in college and stabilized on a combination of lithium, divalproex, and aripiprazole. She had a remote history of alcohol use disorder and cannabis use disorder in high school, which predated her manic episode; these substance use disorders have since been in remission. She remained well on her pharmacology regimen for several years until experiencing a depressive episode at age 25, which responded to replacement of aripiprazole with quetiapine 300 mg/day. During the next 2 years, her mood remained euthymic but she gained 25 lbs and was diagnosed with prediabetes (hemoglobin A1C 6.3%). Now married and planning to become pregnant, her psychiatrist advised stopping both lithium and divalproex before conception due to concerns about possible teratogenic effects or obstetrical complications. Approximately 4 months after discontinuing those medicines and remaining solely on quetiapine, she has not conceived and has become increasingly depressed and passively suicidal. Her psychiatrist added sertraline up to 150 mg/day but produced no benefit and has advised switching the sertraline to venlafaxine for “broader antidepressant coverage.” Margaret now presents for a second opinion consultation. Her mental status exam at that time is notable for the following:

Depressed mood with sad affect
Slowed speech
Passive suicidal ideation without intent or plan
Initial and middle insomnia with next-day fatigue
Poor concentration
No signs of psychosis or mania

Laboratory values are pertinent for normal thyroid function, complete blood count, and comprehensive metabolic profile.

What would you advise Margaret as a next step in her care?

A .
Advise that she resume lithium, divalproex, and aripiprazole because she remained well on that regimen for several years

19.7%
B .
Stop the sertraline for lack of efficacy and recommend discontinuing quetiapine in favor of a diet and exercise program as the mainstay of her treatment, without any further pharmacotherapy changes

9.8%
C .
Stop the sertraline for lack of efficacy and replace quetiapine with lurasidone, cariprazine, or lumateperone as the core treatment

56.3%
D .
Continue the sertraline and quetiapine but add back lithium cotherapy

14.2%

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