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Manic episode — USMLE Step 3 MCQ

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HardPsychiatryManic episodeUSMLE Step 3

A patient hospitalized for acute mania has had an unsatisfactory response to an adequate trial of quetiapine monotherapy. eGFR is 18 mL/min/1.73 m², liver tests and platelets are normal, pregnancy is excluded, and there is no pancreatitis history. Which pharmacologic escalation is most appropriate?

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Correct answer: A — Add valproate to quetiapine with baseline and ongoing safety monitoring

The best answer is “Add valproate to quetiapine with baseline and ongoing safety monitoring”. The VA/DoD guideline suggests adding lithium or valproate to a selected antipsychotic after an unsatisfactory monotherapy response. Advanced CKD makes lithium poorly suited, while normal hepatic and platelet studies and absence of pregnancy support carefully monitored valproate. Lamotrigine is not an acute antimanic treatment, antidepressants can worsen mania, and a benzodiazepine is at most a short-term adjunct.

Reference: 2023 VA/DoD Clinical Practice Guideline for Management of Bipolar Disorder: https://www.healthquality.va.gov/guidelines/MH/bd/index.asp