A 39-Year-Old Woman Recently Diagnosed with Systemic Lupus Erythematosis Comes

A 39-year-old woman recently diagnosed with systemic lupus erythematosis comes to the office for follow-up accompanied by her husband.  The husband says, "I can understand that she's been depressed about having lupus, but for the past week she seems really upset even though her pain is better.  She keeps picking fights with me, gets angry, and yells at me.  A few minutes later she calms down and starts bawling her eyes out."  The patient states "I'm not myself" and reports that for the past week her mood has been "up and down, but mostly depressed."  She is able to sleep only 5 hours each night.  During the day her energy and motivation are low and she spends most of the time lying on the couch.  Her appetite, which was low before, has declined further.  Medications include hydroxychloroquine, ibuprofen, and multivitamins.  Two weeks ago she began taking prednisone 40 mg daily due to a flare-up with worsening joint pain and fatigue.  The patient does not use alcohol or illicit drugs.  She has no psychiatric history.  There is a family history of bipolar disorder.  Temperature is 36.7 C (98 F) , blood pressure is 126/80 mm Hg, pulse is 82/min, and respirations are 16/min.  Physical examination is unchanged from her last visit.  On mental status examination, the patient's mood is "down" and her affect is mildly reactive.  Her speech is not pressured and she has no flight of ideas, hallucinations, or delusions.  Laboratory results indicate no renal insufficiency or cytopenias, and there is no evidence of nephritis.  Which of the following is the most appropriate next step in management of this patient?

A) Add bupropion
B) Add duloxetine
C) Add lithium
D) Begin cognitive behavioral therapy
E) Reduce prednisone dose

Correct Answer:

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