You’re in clinic with a 29-year-old twice-divorced man experiencing depressive symptoms. He’s never had a psychiatric diagnosis before, denies substance abuse, and reports no family history of depression or other psychiatric illnesses. This is his first major depressive episode—but before initiating treatment, bipolar disorder screening is an essential step.
What Would You Do Next?
Before starting treatment, what’s the most appropriate next step?
A. Prescribe escitalopram
B. Further screen patient with a tool like the MDQ
C. Refer for Cognitive Behavioral Therapy
D. Watchful waiting
Pause and think through your choice before reading the explanation.
Why Screening Comes First
Before prescribing any antidepressant, it’s critical for PMHNPs to rule out bipolar disorder. Misdiagnosis can lead to serious consequences—SSRIs and other antidepressants have the potential to trigger manic episodes in patients with undiagnosed bipolar disorder, or cause irritability and emotional instability.
This is why option A, prescribing escitalopram, is not the best next step.
CBT (option C) is certainly an evidence-based treatment for depression, but without a definitive diagnosis, it’s premature to develop a full treatment plan. Similarly, watchful waiting (option D) has its place in care, but skipping over proper evaluation steps isn’t appropriate for this case.
When to Suspect Bipolar Disorder
Even when a patient seems straightforward, there are subtle red flags that make bipolar disorder screening necessary, including:
- Multiple failed relationships or chaotic interpersonal history
- Onset of depression before age 25
- First-degree relatives with bipolar disorder
- Previous failed antidepressant trials
In this case, although the patient is over 25 and reports no family history, the repeated divorces raise questions. This clue can nudge us towards screening with tools like the Mood Disorder Questionnaire (MDQ) or Rapid Mood Screener (RMS).
The Correct Next Step
The most appropriate action? Screen with the MDQ. Answer choice B. This step ensures you’re not overlooking an underlying bipolar disorder and helps guide a safer, more effective treatment plan.
As PMHNPs, we’re trained to catch these diagnostic nuances early. By incorporating bipolar disorder screening before initiating antidepressants, we protect patients from potential harm and provide more personalized care.
Want to improve your diagnostic confidence and reduce second-guessing? This blog post on setting strong boundaries with BPD patients also highlights how early, accurate recognition of mental health conditions sets the stage for smoother outcomes—for both you and your patients.
Learn More About Safe, Stress-Free Diagnosing
If this Psych Sage Quiz taught you something new—or reinforced what you already knew—you’re on the right track. Diagnostic skills grow stronger with repeated exposure to clinical questions and structured case reasoning.
Want to speed up your path to accurate, stress-free diagnosing? Watch my free training on mental disorder diagnosis and treatment. And don’t forget to follow @StressFreePsychNP on Instagram for more actionable tips!