A 33-year-old female diagnosed with bipolar I disorder has been functioning well on lithium for 11 months. At her most recent checkup, the psychiatric nurse practitioner states, 'You are ready to enter the maintenance therapy stage, so at this time I am going to adjust your dosage by prescribing:'

Correct Answer: C

Rationale: Bipolar I disorder is a chronic condition requiring long-term management, and lithium remains a first-line mood stabilizer for both acute episodes and maintenance therapy. The key principle in maintenance therapy is to prevent recurrence of manic or depressive episodes while minimizing side effects and maintaining the patient's quality of life. After 11 months of stability, the patient has likely achieved therapeutic lithium levels (typically 0.6–1.2 mEq/L for acute treatment). In the maintenance phase, the goal shifts to sustaining stability at the *lowest effective dose*, often reducing the serum level to 0.6–0.8 mEq/L. This adjustment decreases the risk of long-term adverse effects (e.g., renal toxicity, thyroid dysfunction, or cognitive dulling) while still providing prophylaxis against relapse. Thus, **a lower dosage (C)** is correct because it aligns with evidence-based practice for maintenance therapy—balancing efficacy with safety. **Why other choices are incorrect:** - **A higher dosage (A):** Increasing the dose is unnecessary for a patient already stable on lithium. Higher doses raise serum levels, increasing the risk of toxicity without proven added benefit in maintenance. Elevated levels could lead to adverse effects (e.g., tremors, polyuria, or electrolyte imbalances), undermining adherence and long-term outcomes. - **Once-weekly dosing (B):** Lithium has a narrow therapeutic index and requires consistent dosing to maintain stable serum levels. Its half-life (12–27 hours) necessitates *daily* administration to avoid fluctuations that could trigger breakthrough symptoms or toxicity. Weekly dosing would cause erratic absorption, risking subtherapeutic levels (and relapse) or toxic peaks. - **A different drug (D):** Switching medications is not indicated for a patient responding well to lithium. Lithium has unique neuroprotective and anti-suicidal properties in bipolar disorder, and abrupt changes could destabilize the patient. Alternatives (e.g., valproate or lamotrigine) are reserved for intolerance or inadequate response, neither of which is described here. The rationale hinges on the *maintenance phase objective*: optimizing long-term outcomes by reducing dosage while monitoring for stability. This approach reflects clinical guidelines emphasizing minimal effective dosing to mitigate risks without compromising relapse prevention.

Correct Answer: D

Rationale: During a manic episode, individuals often exhibit symptoms such as hyperactivity, decreased need for sleep, and excessive involvement in activities that can have harmful consequences, such as overconsumption of stimulants like energy drinks. Energy drinks are particularly relevant here because they contain high levels of caffeine and other stimulants, which can exacerbate manic symptoms or even trigger manic episodes in susceptible individuals. The presence of multiple empty energy drink containers would strongly suggest that Luc has been consuming large quantities of these beverages, aligning with the behavioral patterns seen in mania. This makes option D the most plausible answer, as it directly connects the clinical presentation (agitation, hyperactivity) with a common behavioral correlate of mania. Option A (hypodermic needles) is unlikely because while substance abuse can occur during manic episodes, hypodermic needles are more associated with intravenous drug use, which is not specifically tied to the symptoms described. Mania is more commonly linked to stimulant consumption in less invasive forms, such as energy drinks or caffeine pills, rather than injectable drugs. Additionally, the scenario does not mention any signs of intravenous drug use, such as track marks or drug paraphernalia beyond what is on the desk. Option B (fast food wrappers) is incorrect because while poor dietary habits can occur during manic episodes due to impulsivity or neglect of self-care, fast food wrappers are not a direct indicator of manic behavior. They might suggest disordered eating or lack of meal planning, but they do not specifically correlate with the heightened energy and stimulant use characteristic of a manic episode. The question focuses on a behavior (counting items) that is more likely tied to a direct contributor to the agitation, such as stimulant consumption. Option C (empty soda cans) is less likely than energy drink containers because while soda does contain caffeine, the levels are significantly lower than in energy drinks. Soda consumption does not typically lead to the extreme levels of stimulation or agitation seen in full-blown mania. Energy drinks, on the other hand, often contain not only high caffeine levels but also additional stimulants like taurine or guarana, which are more likely to precipitate or worsen manic symptoms. The medic would be more inclined to count energy drink containers as they are a more salient clue to the patient's condition. In summary, the correct answer is D because energy drink containers are the most direct evidence of stimulant overuse, which is a common and clinically relevant behavior during manic episodes. The other options either lack specificity (fast food wrappers, soda cans) or are unrelated to the typical presentation of mania (hypodermic needles). The rationale hinges on the direct link between energy drink consumption and the exacerbation of manic symptoms, making it the most logical choice for what the medic would be counting.

Correct Answer: D

Rationale: Major depressive disorder (MDD) is characterized by persistent sadness, anhedonia, and neurovegetative symptoms like sleep disturbances, appetite changes, and psychomotor agitation or retardation. The correct response is D because early morning awakening with inability to return to sleep (terminal insomnia) is a hallmark symptom of MDD, reflecting disruptions in circadian rhythms and hypothalamic-pituitary-adrenal axis dysfunction commonly seen in depression. This symptom is more severe than general insomnia and specifically linked to the melancholic features of depression. Option A describes psychomotor agitation, which can occur in MDD but is less specific and more characteristic of mixed features or comorbid conditions like anxiety disorders. Restlessness alone lacks the diagnostic specificity of sleep disturbances for MDD. Option B reflects excessive focus on goals, which may suggest anxiety or perfectionism but does not align with core depressive symptoms like anhedonia or hopelessness. While stress can contribute to depression, this behavior alone is not pathognomonic. Option C mentions unintended weight loss, which is a recognized symptom of MDD, but the timeframe (5 lbs over 5 months) is less clinically significant unless paired with other criteria. The DSM-5 requires "significant" weight change (e.g., >5% body weight in a month), making this example subtler and less definitive than the sleep disturbance in D. In contrast, option D’s description of early morning insomnia is a classic neurovegetative sign of MDD, often accompanied by diurnal mood variation (worse mood in mornings). Its inclusion in diagnostic criteria and strong association with biological markers (e.g., cortisol dysregulation) make it a more robust indicator of MDD than the other options. The other choices either lack specificity (A, B) or clinical severity (C) to stand alone as definitive symptoms.

Correct Answer: A

Rationale: Questions about anxiety management, disordered eating, and alcohol use are relevant to identifying comorbid conditions with major depressive disorder, but the question 'Do rules apply to you?' does not directly address common comorbid mental health conditions associated with major depressive disorder.

Correct Answer: A

Rationale: **Rationale:** **Correct Answer (A): Conducting routine suicide screenings at a senior center.** Suicide risk is a critical concern in older adults with major depressive disorder (MDD), as this population has one of the highest suicide rates, particularly among older white males. Depression in older adults is often underdiagnosed due to overlapping symptoms with medical conditions or the misconception that sadness is normal in aging. Routine suicide screenings proactively identify at-risk individuals, allowing for timely interventions such as therapy, medication, or social support. This approach addresses a life-threatening complication of MDD and aligns with evidence-based practices for geriatric mental health. By contrast, the other options either perpetuate myths or overlook actionable strategies. **Incorrect Answers:** **B: Identifying depression as a natural, but treatable outcome of aging.** This choice is problematic because it reinforces the harmful stereotype that depression is an inevitable part of aging. While older adults face unique stressors (e.g., chronic illness, bereavement), depression is never "natural" and always warrants clinical attention. Framing it as such may discourage individuals from seeking help, exacerbating isolation and untreated symptoms. Effective interventions must challenge this myth and emphasize depression as a medical condition requiring targeted treatment, not a normative experience. **C: Identifying males as at a greater risk for developing depression.** This is factually incorrect. While older males have higher suicide *completion* rates, women are statistically more likely to *develop* depression due to biological, hormonal, and social factors. Misidentifying risk groups could lead to inadequate screening for women or misplaced focus in prevention efforts. Accurate risk assessment must distinguish between prevalence (higher in women) and lethality (higher in men) to tailor interventions appropriately. **D: Stressing that most individuals experience only a single episode of major depression in a lifetime.** This statement is misleading and contradicts clinical evidence. MDD is often recurrent, with ~50% of patients experiencing a second episode after their first. Older adults are especially vulnerable to recurrence due to cumulative stressors and comorbidities. Promoting this misconception could result in poor long-term monitoring, reduced adherence to maintenance therapy, and unrealistic expectations about prognosis. Effective management requires preparing patients for potential relapse and emphasizing sustained care. **Key Takeaways:** Answer A stands out as the only intervention directly addressing a high-priority, actionable aspect of geriatric depression (suicide prevention). The incorrect options either misrepresent risk factors (C), minimize the severity of depression (B), or provide inaccurate prognostic information (D). Effective care for older adults with MDD requires precise risk assessment, myth dispelling, and proactive measures to mitigate the most severe outcomes.