Case Presentation
Lyn is a 50-year-old Caucasian female-presenting difficulty sleeping, difficulty socializing with people, and being easily irritable when talking to people. She spends time doing nothing, does not go anywhere, and does not share with anyone. Having been fired and unable to pay her rent, she moved in with her mother and felt worthless. Besides, she has a decreased appetite, very little motivation to seek employment, and difficulty concentrating. Lyn's only son was convicted to ten years' imprisonment nine months ago, and his girlfriend and three-year-old son will be moving in with her in her mother's house. This means more stress for Lyn since she has never liked her.
HPI and Clinical Impression
Lyn has a history of abusing marijuana half a gram 2-3 times in a week to help her sleep. However, she denies a history of psychiatric inpatient admissions, suicidal thoughts, and a history of psychotic symptoms. Assessment reveals a history of hypomanic episodes in her early 20's. She also has a history of the intermittent treatment of depressive symptoms using monotherapy antidepressants or a combination of benzodiazepine and antidepressant and sometimes supplemented with Lorazepam and diazepam. She also reports receiving treatments for her moods symptom three years back. However, she has never complied with therapy for more than 5-6 months. She has a family history positive of bipolar disorder. Psychiatric diagnoses include moderate cannabis use and bipolar disorder type II.
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Psychopharmacologic Treatments and Related Endpoints
Psychotherapy includes psychoeducation, cognitive behavioral therapy, and family-focused therapy. These therapy types are essential in the treatment of BPD in that they result in more prolonged remissions, lead to shorter duration of episodes, and even during an acute episode, they lead to better moods (Stahl, 2017). Moreover, these therapies lead to higher recovery rates, reduction in cognitive impairments, and increased overall functioning. The main aim of this is to improve psychopharmacologic adherence to the medication by teaching the patient about bipolar disorder and its treatment (Bowden et al., 2012). By doing this, the learns the triggers of the symptoms, the warning signs for episodes, and the patient also understands the disorder's biological roots.
Psychoeducation includes developing plans to prevent relapse, recognizing prodromal symptoms of an episode, educational sessions, and implementing strategies to manage the episodes. This includes regulation of activity and regulation of sleep. On the other hand, family-focused therapy involves enhancing communication with caregivers and family members to learn to ask for help or to work through or prevent conflict. It also uses strategies for promoting emotional reactivity by using a behavioral approach (Bowden et al., 2012). Cognitive-behavioral therapy is concerned with increasing patient's adherence to treatment and cognitive restructuring.
Medical Management Needs
The standard pharmacotherapy treatment for BPD consists of occasional psychotherapy and medication management. However, medications have general ceiling effects in that they require switching depending on the individual's symptoms and episodes and require evaluation over time (Stahl, 2017). According to research, more proactive medication management combined with intensive psychosocial therapy is more effective than standard care. The first-line treatment for Lyn Should be using Divalproex, an atypical antipsychotic, or Lithium. Besides, treatment should include mood stabilizers such as carbamazepine, valproate, and Lamotrigine. A combination of fluoxetine and olanzapine can also be effective in her treatment (McCormick et al., 2015). These medications decrease the risk of suicide in patients with BPD. Lithium should only be used in the absence of potential complications. Besides, it has a narrow therapeutic range and takes two to three weeks to abate BPD symptoms and hence require regular studies of the patient's serum.
For acute episodes, sodium valproate is effective. Also, pharmacologic therapy must be in accordance with an individual's risk factors and physical health status. As a result, the patient's thyroid and baseline health status must be assessed before using Lithium for treatment. This is because the drug can cause thyroid toxicity, and since the kidneys metabolize it, it can cause progressive renal insufficiency (Conolly & Thase, 2011). Even though valproate also poses a risk of hepatotoxicity, it is usually considered the option for people with renal problems since the liver metabolizes it.
Community Support Resources
Community resources include the depressive and bipolar support alliance (DBSA). This alliance is for persons who have mood disorders in the US. They provide peer support, a wealth of encouraging tales, tools, and education to assist people pursue their way to well-being. Moreover, the National Alliance of Mental Illness (NAMI) works to educate and support patients' mental illnesses. It, therefore, help enhance the quality of illness for individuals living with mental illnesses. The website provides useful information, such as the latest research advances, statistics, and facts on various mental health disorders. American Psychological Association (APA) is another community resource available for people with BPD (APA, 2014). The association provides relevant information about psychopharmacology and psychopharmacologist.
Follow-Up Plan
Follow-up involves using structured instruments to evaluate the patient every six months for five years systematically. This includes the recording of new episodes, remissions, and subsequent hospitalizations. It also involves assessing the severity of symptoms, attempted suicide rate, quality of life, treatment compliance, psychiatric comorbidities, and other factors (Shabani et al., 2010). The instruments to be used include; Young-Mania rating scale (Y-MRS) and Clinical Global Impression, among others.
References
American Psychiatric Association. (2014). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
Bowden, C. L., Perlis, R. H., Thase, M. E., Ketter, T. A., Ostacher, M. M., Calabrese, J. R., . . . Sachs, G. S. (2012). Aims and results of the NIMH systematic treatment enhancement program for bipolar disorder (STEP-BD). CNS Neuroscience & Therapeutics, 18 (3), 243-249. doi: 10.1111/j.1755-5949.2011.00257.x.
Connolly, K. R., & Thase, M. E. (2011). The clinical management of bipolar disorder: A review of evidence-based guidelines. Primary Care Companion for CNS Disorders , 13 (4). http://dx.doi.org/10.4088/PCC.10r
McCormick, U., Murray, B., & McNew, B. (2015, September). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners , 27 (9), 530-542. http://dx.doi.org/10.1002/2327-6924.12275 .
Shabani, A., Taheri, A., Azadforouz, S., Abbasi, C. N., Mousavi, Z., Zangeneh, K., ... & Kokar, S. (2010). Bipolar Disorder Patients Follow-up (BDPF): methods and materials. Journal of research in medical sciences: the official journal of Isfahan University of Medical Sciences , 15 (4), 229.
Stahl, S. M. (2017). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (6th ed.). New York, NY: Cambridge University Press.
