A young adult male is brought to the psychiatric emergency department with hyperactivity, excessive speech, and grandiose delusions. Which of the following drugs would you expect to be prescribed for him?

Appeared in: RUHS, Jaipur, PB B.Sc Nursing Entrance-2019

Explanation

The patient's symptoms of hyperactivity, excessive speech, and grandiose delusions are classic indicators of an acute manic episode.
Lithium carbonate is a first-line mood stabilizer and the gold-standard treatment for acute mania, as confirmed by major treatment guidelines.
It works to reduce the severity of manic symptoms and helps in long-term prevention of mood episodes in bipolar disorder.
The therapeutic serum level for acute mania is generally between 0.8 and 1.2 mEq/L, requiring careful monitoring.

Why Other Options Were Wrong

Option A: Fluphenazine Decanoate is a long-acting depot antipsychotic. Its slow onset of action makes it unsuitable for managing an acute manic episode; it is designed for long-term maintenance therapy in schizophrenia.
Option B: Fluoxetine is an SSRI antidepressant. Using an antidepressant as monotherapy in a patient with bipolar mania can worsen the manic symptoms or precipitate a switch from depression to mania.
Option D: Zolpidem is a sedative-hypnotic agent used exclusively for the short-term management of insomnia. It has no mood-stabilizing properties and does not treat the underlying cause of mania.

Related Visual

Clinical Relevance

Nursing practice connection: This is primarily an exam-oriented knowledge point with limited direct bedside application, so retain Pharmacological management of acute mania as background academic context rather than a clinical decision trigger.
A critical nursing responsibility is educating patients on lithium about the importance of maintaining consistent salt and fluid intake, as dehydration or low sodium intake can dramatically increase lithium levels and cause toxicity.
Nurses must be able to recognize and differentiate between common side effects (like fine tremor) and signs of toxicity (like coarse tremor, confusion, and ataxia), and know when to hold the dose and notify the provider.
What if? If this patient presented with the same symptoms but had a history of severe kidney disease, lithium would likely be contraindicated. The provider would probably choose an alternative first-line agent like valproic acid or an atypical antipsychotic (e.g., olanzapine, risperidone).

How to Approach the Question

First, analyze the patient's presenting symptoms: hyperactivity, excessive speech, and grandiose delusions. Recognize this cluster as the classic presentation of an acute manic episode.
Next, consider the therapeutic goal: to stabilize the patient's mood and reduce manic symptoms.
Evaluate the medication options based on their primary pharmacological class and indication.
Identify Lithium carbonate as the primary mood stabilizer specifically indicated for acute mania.
Systematically rule out the distractors: Fluphenazine Decanoate (long-acting antipsychotic for schizophrenia), Fluoxetine (SSRI antidepressant that can worsen mania), and Zolpidem (hypnotic for sleep).
Conclude that Lithium carbonate is the most appropriate and expected prescription for this clinical scenario.

Concept Tested & Keywords

Concept Tested: Pharmacological management of acute mania
Stem keywords: hyperactivity, excessive speech, grandiose delusions, psychiatric emergency
Lead-in keywords: which of the following drugs
Clinical cues: The triad of hyperactivity, excessive speech, and grandiose delusions is a classic presentation of an acute manic episode.
Negative lead-in flag: false

Question ID

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Reference Book

E6 Kaplan Sadock's Synopsis of Psychiatry-2022 (pp 1-3768 of 3768) p. 1197-1199

E6 Robert Boland, Marcia L. Verduin - Kaplan and Sadock's Comprehensive Text of Psychiatry-Wolters Kluwer Health (2024) (pp 1-16525 of 16525) p. 5563-5565

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