Question

A patient with depression was given Imipramine for 2 weeks. Relatives noticed increased excitement, colourful clothes, increased talking. What is the next step in management ?

• A. Antipsychotic with Imipramine continued
• B. Discontinue Imipramine and start Valproate
• C. Continue Imipramine alone
• D. Manage with Valproate alone

Answer 1

The Correct Option is A

Concept first: an antidepressant given to a vulnerable patient can trigger a switch into mania, exposing a bipolar disorder. The patient here, now excited, talkative and dressing flamboyantly after two weeks of imipramine, has done exactly that.

The marked answer adds an antipsychotic while keeping imipramine going, on the logic that the illness now has two poles: the depression that imipramine was treating and the fresh mania that the antipsychotic will calm. Continuing imipramine alone would leave the mania unchecked, while using valproate alone or simply swapping to valproate would, in this framing, undertreat the depressive side.

Worth noting for exams: standard psychiatry teaching often favours stopping the precipitating antidepressant and starting a mood stabilizer plus antipsychotic when a clear manic switch occurs, since a continued antidepressant can sustain the mania. Here, however, the recall key is to add an antipsychotic and continue imipramine.
Ref: Arvind Arora Review of Psychiatry.