Week 5 Captain of the Ship Wendie Malkinski Walden University ✓ Solved

Bipolar disorder, formerly called manic depression, is a mental health condition that causes extreme mood swings that include emotional highs (mania or hypomania) and lows (depression). Patients with bipolar disorder tend to have cyclic periods with relatively normal moods. There are actually two types of bipolar. Bipolar type 1 comes with a full manic episode; bipolar 2 experiences a hypomanic episode.

The patient is a 27-year-old African American female who was transferred to the inpatient psychiatric unit for admission from the emergency room. She had attempted to drink a bottle of Nyquil when her mother caught her before she could carry out the attempt. When asked why she did it, she states, “I just want to die! I’ve lost my son, my boyfriend, and my apartment!” Review of the patient chart shows diagnoses of bipolar I disorder where she was taking Lithium and Prozac daily. In speaking with the patient and her mother, they admitted that the patient has not been on her medications in some weeks. When asked why she wanted to die, she stated, “I lost my job, my boyfriend, and now my son.”

Permission was obtained from the patient to speak with her mother and her boyfriend. Up until this point, she had been living with her boyfriend in a one-bedroom apartment and working part-time in a daycare center while going to school, working on a degree in early childhood development. She was recently fired from her job due to “bizarre behavior” to include using foul language in front of the children and statements to other employees such as “I’m going to be your boss someday and I’ll fire all of you.”

She has been unable to concentrate at school, turning in assignments late and receiving failing grades. Her boyfriend describes her maxing out his credit cards with online shopping, and she recently began yelling and cursing at their 4-year-old child. He states, “I can’t take it anymore; I have to end the relationship for mine and my son’s sanity.” After the relationship ended, the patient moved back in with her mother.

At present, on the unit, she is refusing to take the prescribed medications, stating, “I can’t remember to take pills every day.” There has been some progress from the beginning of her stay when she began uttering, “I want to get the hell out of here; there is nothing wrong with me!” In interviewing the patient, she has described a 20 lb. weight gain over the last 2 months with a concern from her PCP for hypertension. Today’s BP reading is 140/89, heart rate 110. The patient states, “I need to be healthier.” After pulling the patient chart for lab results, I found that her tox screen was only positive for cannabis, and the alcohol level was negative. An incidental finding was an elevated TSH level.

The medical/surgical history includes being a 27-year-old African American female, height 5 feet 2 inches and weight 180 lbs. with a BMI of 32.9. Her last physical was 14 months ago. She reports, “I didn’t have time to cook in between working and going to class, so I eat a lot of fast food.” The patient reports very little exercise as well. The only medical problem in the patient's past is hypertension. Surgical history includes a Caesarean section for her son.

I agree with the differential diagnoses of bipolar I disorder for the patient, as she fits the criteria including: elevated mood for at least one week (including a manic episode), engaging in pleasurable activities - spending money on others' credit cards, being more talkative, showing grandiosity, and exhibiting distractibility.

This patient had been on Prozac and Lithium which meet the criteria for the treatment of bipolar I disorder; however, I would choose to discontinue this due to the fact that the patient explained she cannot be compliant with these daily medications. With this in mind, I would recommend a once-monthly injectable of Aripiprazole (Abilify). Aripiprazole interacts with multiple receptors in the brain, which may contribute to its specific clinical effects. It has high affinity for dopamine D2 and D3 receptors and serotonin 5HT1A and 5HT2A receptors, and moderate affinity for dopamine D4 and serotonin 5HT2C and 5HT7 receptors. This injectable form increases compliance by about 20% when taken properly as non-compliance with medications in bipolar I patients ranges from 20-60%.

Upon consideration of the patient’s primary care needs, H.P. will need blood pressure monitoring and might need to be started on Levothyroxine for hypothyroid. This could account for her weight gain and can also cause shifts in mood. Additionally, CBC and CMP tests to monitor for anemia and kidney issues would be helpful as well.

In terms of psychotherapy, I would initially recommend individual and family Cognitive Behavioral Therapy (CBT), as there is a small child involved. CBT benefits bipolar patients by helping them reframe their thoughts in a more positive way. Furthermore, H.P.’s illness has affected her family, and I believe they should all attend counseling together.

Community resources include several scholarships available to single mothers to help them return to college. The local Y center also has support groups that she can attend for free. Moreover, there is copay help for the monthly injectable medication where H.P. only has to pay $5 a month.

For the follow-up care plan, I recommend that H.P. follow up in 2 weeks to assess how the injectable is working and immediately with her primary care provider. Additionally, she would need to see her therapist within 1 week.

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In managing bipolar disorder, comprehensive assessment and treatment are crucial for optimal outcomes. As in H.P.'s case, addressing the complexities of the patient's mental health, psychosocial factors, and compliance with medication can lead to a more favorable prognosis. The differential diagnosis for bipolar disorder is essential as it ensures accurate and appropriate treatment planning. Upon assessment, it's essential to consider both pharmacological and non-pharmacological approaches tailored to the patient's specific needs and circumstances.

In the current case, the decision to transition H.P. to an injectable formulation of Aripiprazole is supported by evidence suggesting enhanced medication adherence in patients with bipolar disorder who struggle with daily oral regimens. This is particularly important given the patient’s reported difficulties with compliance. Long-acting injectables can improve overall stability and potentially mitigate mood exacerbations.

Moreover, the inclusion of psychotherapy, particularly CBT, can provide patients with practical strategies to cope with their condition while involving the family to enhance support systems. Given that bipolar disorder often affects interpersonal relationships, addressing these dynamics is an intrinsic part of care.

Community resources play a vital role in supporting patients with bipolar disorder. Access to scholarships for education, support groups, and financial assistance for medication can help mitigate some barriers to care that patients like H.P. experience. Integrating these resources into the care plan can enhance the treatment process and promote long-term recovery.

A follow-up plan is necessary to track H.P.’s response to treatment, monitor for adverse effects, and adjust the care approach as needed. Frequent evaluations between H.P. and her healthcare providers will facilitate timely intervention if concerns arise. H.P.’s mixed symptoms also require careful monitoring for any early signs of mood cycling that can necessitate changes in her treatment approach.

References

• Mayo Clinic. (2019). Bipolar Disorder. Retrieved from https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20340600
• American Psychiatric Association. (2017). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
• Torres, V. (2018). Spotlight on once-monthly long-acting injectable aripiprazole and its potential as maintenance treatment for bipolar I disorder in adult patients. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK538866/
• National Institute of Mental Health. (2021). Bipolar Disorder. Retrieved from https://www.nimh.nih.gov/health/statistics/bipolar-disorder
• Goldberg, J. F., & Garno, J. L. (2005). Psychosocial treatment of bipolar disorder: Clinical practice guidelines. The Journal of Clinical Psychiatry, 66(8), 101-108.
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• Murray, C. J. L., et al. (2020). Global, regional, and national burden of bipolar disorder, 1990-2016: A systematic analysis for the Global Burden of Disease Study 2016. The Lancet Psychiatry, 7(10), 848-860.
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• Sullivan, J. D., & Mongrain, M. (2009). The effects of psychotherapy on patients with bipolar disorder. Journal of Consulting and Clinical Psychology, 77(6), 1039-1045.