Bipolar Blog Discussion Paper

Posted: November 12th, 2022

Bipolar Blog Discussion Paper

Case:

S.N. is a 15-year-old Caucasian female who presented to the facility with her uncle and had a history of bipolar disorder type 1. She claimed that she had been in the foster system for the prior years, but that she had just moved in with her uncle two months before. The uncle expressed worry over her niece’s conduct. The patient said that she desired the freedom to spend time at her friend’s place, but that her uncle was opposed to that. She also admitted to using cannabis and having sex with several people, even strangers, as well as other risky habits. She confessed to having the urge to slit her hand on occasion. She is reportedly struggling to sleep and has a low appetite. She denies auditory or visual hallucinations, as well as having thoughts of suicide or homicide. She was also said to have gotten hospitalized at many children’s clinics for suicidal behaviors and depression. She was prescribed medications in the past, but she has not been taking them. Her uncle informed her that he needed her to be evaluated and undergo some therapy sessions. Bipolar Blog Discussion Paper

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Current Medications:

Hydroxyzine 50mg daily

Topamax 25 mg daily

Vital Signs:

BP 122/73, HR 79, RR 16, Temp. 98.6F

Height: 4’9”

Weight: 88 lbs.

BMI: 19.1 – healthy weight

Diagnoses:

Bipolar disorder type 1

Depression

Differential Diagnoses

Schizophrenia

Major depressive disorder

Schizoaffective disorder

Insomnia

Treatment Plan:

There are no indicators of psychosis or instability in this patient, thus ambulatory care is the best option for her at this stage. To evaluate whether an individual is suffering from bipolar disorder, a healthcare professional needs to look at the patient’s medical history (APA, 2013). The primary objective of the treatment plan is to ensure patient safety by increasing medication adherence and treatment commitment. This patient’s secondary aim is to restore some of her impaired functioning so that she can lead her normal life. According to McIntyre et al. (2020), bipolar disorder treatment is lifelong and needs a mix of psychotherapy and psychotherapy usually mood stabilizers and antipsychotics. Bipolar Blog Discussion Paper

Pharmacological Treatment:

An assessment of the possible advantages and drawbacks connected with each drug previously prescribed was undertaken. Pharmacological treatment will have the objective of simplifying her existing regimen, which she is not adhering to well. She claims that she has little understanding of what helps. With this strategy, the goal is to increase drug compliance.

The patient will continue with the current treatment regimen of Hydroxyzine 50mg daily and Topamax 25 mg daily.

Psychotherapy:

The patient should be encouraged to actively engage in psychotherapy sessions. For her safety and well-being, she needs to attend to them every week and acquire coping mechanisms to enhance healthy behavior.

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Lab Tests:

To rule out any acute medical issues that may be present in this patient, the following lab tests will need to be ordered: substance and alcohol screening, liver function test, and ESR rate.

Education:

The patient will be informed about her disease, as well as the need of adhering to the drug regimen provided and engaging in physical activity on a regular basis. She will be taught about the necessity of refraining from marijuana and alcohol, maintaining a healthy diet, and minimizing stresses. She will be urged to participate in support networks as well as to attend all of her psychotherapy sessions as scheduled. Moreover, I will enlighten her uncle about her illness and the ways he may support and help her so that he can better understand her situation. Bipolar Blog Discussion Paper

Referrals/Consults:

The patient should be referred to psychotherapy sessions for individual or group therapy.

Follow-Up:

The patient will be required to return in 4 weeks for an evaluation of her medication compliance as well as her progress in psychotherapy sessions.

References

American Psychiatric Association. (2013). Diagnostic and Statistical Manual (5th Ed). Arlington, VA: APA.

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., … & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841-1856.

THIS IS AN EXAMPLE OF A BIPOLAR BLOG: Blog #4 New outpatient visit – simplifying an overcomplicated and ineffective medication regimen This case study is from clinical experience. Name: CM Race/Sex: Caucasian female Age: 23 Case: CM is a 23 year old married Caucasian female who presents via telemedicine through a local Medicaid clinic for psychiatric evaluation and medication management. The patient reports that she just moved back to Louisiana from Missouri to be closer to her family. She states that she was diagnosed with bipolar disorder when she was 18 and that she has been treated on an outpatient basis since then. She states that she has also been diagnosed with generalized anxiety disorder and post-traumatic stress disorder. She reports that she has been out of her medications the 2 weeks half because she had to get set up with Louisiana Medicaid after the move. She states that she believes has had hypomanic/manic episodes in the past with her most recent one being 1.5 years ago, but she is not entirely sure of what that is. She reports that her physician diagnosed her with bipolar disorder after telling him that her mother is diagnosed with it. She states that these “episodes” resulted in her staying up for about 4 nights in a row without feeling like she needed to sleep. She states that she did not feel euphoric, but rather irritable and agitated. She reports that she spends much more time in the depressed phase. CM states that she is currently depressed and reports lack of energy/motivation, insomnia, anxiety, weight gain of 15 pounds in the last 3 months, feelings of hopelessness, anhedonia, and irritability. The patient states that she has had passive suicidal ideations in the past, but has never had a plan and has never attempted to kill herself. She has never been hospitalized despite the previous episodes and SI. Currently she denies SI, HI, or auditory/visual hallucinations. She states that she has feelings of constant worry for herself and loved ones. She states that her anxiety completely takes over her at times and that she has had trouble socializing. CM states that she has not had a job since she was 20 years old because it is too hard for her to function around people on a daily basis. In addition to her psychiatric problems, CM is also diagnosed with polycystic ovarian syndrome and carpal tunnel syndrome which cause her pain throughout the day. Bipolar Blog Discussion Paper

The patient reports that she was molested by her stepfather from the ages of 8-12. She reports flashbacks, nightmares, and trouble trusting people as a result of the abuse. She reports difficulty in her marriage due to her anxiety, depression, and irritability. She graduated from high school, but never attended college. She states that she sleeps in until around noon every day and stays up until around 1 AM every night. She states that no longer how much she sleeps she still feels tired. CM also reports that she smokes about half of a pack of cigarettes daily and also smokes marijuana daily. She denies abuse of alcohol or other substances. She states that although she stable on her current medication regimen, she still has felt very depressed. She states that at times she is only partially compliant with her treatment as she feels that the medications take away from her personality. Her main complaint is daytime over-sedation from the medications. Current Medications: · Bupropion XL 150 mg daily · Viibryd 20 mg daily · Ziprasidone 40 mg QAM + 60 mg HS · Lorazepam 1 mg PRN · Metformin 1000 mg BID · Omeprazole 20 mg daily · Naproxen 500 mg BID Vital Signs: BP 125/75, HR 88, RR 20, Temp. 98.3F Height: 63” Weight: 293 lbs. BMI: 51.9 – Obese Class III (152 lbs. overweight) Diagnoses: Bipolar disorder, unspecified (primary diagnosis) – must clarify current phase; most likely depressed, but should rule out possibility of mixed episode Generalized anxiety disorder Post-traumatic stress disorder, chronic Nicotine dependence Cannabis dependence, uncomplicated Polycystic ovarian syndrome Carpal tunnel syndrome Gastroesophageal reflux disease Metabolic Syndrome Obesity Differential Diagnoses: MDD Panic disorder Personality disorder, unspecified Conversion disorder Insomnia Treatment Plan: Outpatient treatment is appropriate for this patient as she is stable and denies SI, HI, and signs of psychosis at this time. Over time, her diagnosis should be clarified to rule out the chance that she was misdiagnosed with bipolar disorder. When a patient presents in an episode major depression, the provider must rely on a reliable history to determine whether the diagnosis is bipolar disorder (APA, 2013). However, the working diagnosis should be bipolar disorder and the current/most recent phase should be described. The main goal of the treatment plan will be to promote safety via promoting medication compliance and engagement in treatment. Another goal for this patient will be regaining some of the lost functionality so that she can achieve her personal goals. Pharmacological Treatment: Medication reconciliation was performed along with reviewing potential benefits and negatives associated with each one. The goal of pharmacological management will be to simplify her current regimen that she is not compliant with. She states that she barely knows what works and what does not. The idea here is addition by subtraction and to promote medication compliance. Discontinue Viibryd – lack of efficacy and noncompliance Discontinue AM dosage of Ziprasidone – patient reports daytime over-sedation Discontinue Lorazepam – during interview it was revealed that the patient was taking more frequently than allotted to her; she also revealed that she was taking her husband’s prescribed clonazepam at times; this along with marijuana dependence requires attention to potential benzodiazepine misuse – will DC until these issues are addressed Continue Bupropion XL to stabilize mood – the patient reports that this medication has been helpful and she has been compliant with it Continue Ziprasidone 60 mg HS to stabilize mood – will assess for efficacy without AM dosage Start Hydroxyzine HCl 25 mg AM + 50 mg HS to Tx anxiety and improve sleep Consider prazosin HS to Tx PTSD-related nightmares and improve sleep Consider re-continuation of a long-acting benzodiazepine like clonazepam later in treatment if necessary and appropriate. Clonazepam has advantages over several other benzodiazepines including: easy tapering, longer-acting, less potential for abuse, and improved tolerability (Stahl, 2020). Bipolar Blog Discussion Paper

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Continue other medications for medical problems per PCP/other providers Psychotherapy: The Medicaid clinic offers weekly counseling/cognitive behavioral therapy and the patient should be encouraged to actively engage in these meetings. Over time, the patient may attend less frequently, but as she is a new patient she should be seen at least weekly to assess for safety, while also learning new coping skills to improve her quality of life. Lab Tests: Standard new patient labs to be drawn to rule out acute medical problems: Lipid panel, TSH, Hgb A1c, CBC, CMP, UDS, UA, UPT Education: Medication compliance should be emphasized with this patient. She reports that she has been partially compliant with medications since she started receiving psychiatric treatment. The patient should be educated that these medications only work over time and their therapeutic actions are dependent on consistency of dosing. The patient should be encouraged to develop a sleep routine so that she can have some nighttime consistency. She reports a lack of quality sleep and that she does not go to sleep or wake up at the same time every day. Napping should be discouraged to prevent inability to sleep at night. Educate the patient to stop smoking marijuana as this can undermine treatment and adds another mood-altering variable to the equation. Offer smoking cessation education as the patient reports smoking half of a pack of cigarettes daily. Tell her that this can affect mood and sleep. Discuss possibility for prescribing aids for this such as bupropion or nicotine replacement products. Referrals/Consults: Medical follow-up – The patient is currently 152 pounds overweight and is diagnosed with metabolic syndrome at age 23. She has a very high chance of developing various medical issues such as diabetes and heart disease. Although she is presenting for psychiatric treatment, providers should still take a holistic approach and encourage the patient to seek medical care. OB/GYN – The patient states that she is diagnosed with PCOS, but that she has not been to see her women’s health physician in several years. Bipolar Blog Discussion Paper

The clinic should assist the patient with finding a new OB/GYN in the area as she just relocated from Missouri. Dietician – The patient could receive help with her diet so that she can manage her weight more effectively. She states that she mainly eats fast food and is not knowledgeable about healthy eating or exercise. She is stagnant and stays at home most of the day. Occupational therapy – An OT can assist the patient with interventions to more effectively manage her carpal tunnel syndrome. EMDR – The clinic offers cognitive based therapy as required by Medicaid for funding. However, this patient could also benefit from EMDR, so a referral should be made if the patient desires to complete a program to process her past trauma. Follow-Up: The patient’s medication regimen is being altered a fair amount, so she should return to the clinic for assessment in one month. Once her condition is stabilized, then less frequent visits could be appropriate. Before the next appointment, the patient should have labs drawn so that they can be reviewed. She should also attempt to get an appointment with her PCP before then so that they can be notified of medication changes and she can sign release forms so that her providers can communicate about treatment planning. References: American Psychiatric Association. (2013). Diagnostic and Statistical Manual (5th Ed). Arlington, VA: APA. Stahl, S. M. (Ed.). (2020). Stahl’s essential pharmacology: Prescriber’s guide (2nd ed.). Cambridge University Press. Bipolar Blog Discussion Paper