CASE STUDY 3

Case Studies of Breeze and Cat

Breeze

Identification of Health Issues

Some health issues to consider for Breeze when planning to have a baby can be the use of the medication carbamazepine when taken during pregnancy and in the first trimester has a high risk of malformation and neural tube defects and increases with higher doses taken such as 400mg a day whereas Breeze takes 600mg twice a day (Grover & Avasthi, 2015). Carbamazepine medication is an anticonvulsant used to treat manic symptoms of bipolar disorder that helps decrease mood changes and help a person feel less agitated (Grover & Avasthi, 2015). Breeze could also be at high risk of post-natal depression as it can be a recurrence of a person that already has a bipolar disorder (Sharma et al., 2017). Breeze also has type 2 diabetes which also puts her and her baby at risk during pregnancy by having high sugar, which causes a larger baby and increases risks of shoulder injuries during delivery, cesarean delivery, congenital malformations, preterm birth, miscarriage or stillbirth, and high blood pressure (Department of Health, 2020).

Breeze's BMI is 25.86, which puts her in an overweight category, and a raised BMI can increase the chances for complications for both her and her baby during pregnancy (Raising Children Network, 2020). Breeze is having the normal standard of drinks per week which is below 10, but it is recommended that women who are planning for pregnancy to stop drinking as a safe option as this can reduce the risks of miscarriage, stillbirth, and premature labour during pregnancy (The National Health and Medical Research Council, 2020). Breeze also smokes ten cigarettes a day which is also a risk factor for complications in pregnancy such as low birth weight, congenital disabilities, preterm birth, and perinatal death (The Royal Australian College of General Practitioners, 2019).

Holistic Intervention Plan

Breeze is wanting to have a baby and start a family with her partner. To help Breeze achieve this goal, we will make a care plan that holistically addresses her health issues stated above that essentially integrates into her perinatal care. We would need to educate Breeze on the risks of her medication carbamazepine during pregnancy as she is on a higher dose which has a higher risk of malformation of the fetus and neural tube defects when used in the first trimester (Grover & Avasthi, 2015). The pharmacological strategy in Breeze's case can be medication-free pregnancy if asymptomatic, as the Australian clinical guideline recommends that carbamazepine not be used in pregnancy because of its increased risks of major malformation (Austin & Highet, 2017). Breeze would need to be discontinued slowly over two to six weeks from carbamazepine before conception and monitored closely for relapse of symptoms (Grover & Avasthi, 2015). This option is only for a woman who has had few episodes of the disorder and long periods of mood stability; in Breeze's case, she only had a manic episode in college. However, Breeze can recommence back on carbamazepine at the lowest effective dose after delivery to manage her symptoms as breastfeeding is supported with the use of carbamazepine because of its lower concentration in breast milk (Boyce & Buist, 2016). Managing depressive symptoms, cognitive behaviour therapy (CBT) can help reduce depressive symptoms and implement behavioural strategies when dealing with the demand of caring for an infant and with post-natal care (Boyce & Buist, 2016). .

Preconception Type 2 diabetes has poor pregnancy outcomes and increased risks of complications, such as the effect on their glycaemia levels (Rudland et al., 2020). According to the Australasian Diabetes in Pregnancy Society (ADIPS) 2020 guideline, woman with diabetes should attend preconception counselling and aim to optimise their glycaemic levels from an obstetrician before trying to conceive for a baby as this can enable a more positive pregnancy outcome and reduce the rate of miscarriage and perinatal mortality (Rudland et al., 2020). Review Breeze's insulin regime and monitoring of her blood glucose levels during pregnancy. Insulin such as lispro and aspart is considered first in line for managing hyperglycaemia in pregnant women, and the use of metformin, a non-insulin glucose-lowering agent, could be required throughout pregnancy to control hyperglycaemia levels and shown to have low levels in breastmilk (Rudland et al., 2020). Educating Breeze on blood glucose self-monitoring before and after meals is different from preconceptions and during pregnancy (Rudland et al., 2020). For example, preconception pre-meal <6.0 one-hour post-meal <8.5 and two-hour post-meal <7.5 and in pregnancy pre-meal <4.0-5.3, one-hour post-meal <5.5-7.8, and two-hour post-meal <5.0-6.7 (Rudland et al., 2020). Diet alone can achieve adequate glycaemia for the woman, so insulin or oral glucose-lowering agents may not be required (Rudland et al., 2020). Breeze can benefit from having a diabetes educator or dietitian to help in giving her nutritional advice on following a healthy eating plan that can assist her in managing blood glucose levels, providing adequate nutrition for her and her baby, and achieving appropriate weight changes during her pregnancy (Rudland et al., 2020). Preconception advice, education, and appropriate referral will be given regarding smoking cessation and zero alcohol intake to Breeze to minimise the risks and complications that can arise during pregnancy (Rudland et al., 2020).

Plan Referrals

Breeze would see a general practitioner (GP) who would be her first contact as they would liaise and refer to an obstetric, dietitian, and psychiatrist and monitor and manage her risks and symptoms during the perinatal period and management plan of her long-term care (Boyce & Buist, 2016). A referral to a psychiatrist would benefit Breeze as they can overlook her ceasing of the medication and manage her symptoms by regular monitoring and assessment of medication dose and also helping with psychosocial strategies such as CBT in helping to manage her symptoms and applying problem-solving and coping strategies postpartum (Boyce & Buist, 2016). A referral to a dietitian who offers evidenced-based dietary advice to patients with diabetes and makes a plan for a healthy diet, better manage their diabetes, and improve blood sugar levels and help manage body weight (Diabetes Australia, 2021).

Community Resources

Breeze would benefit from a Quitline service for the cessation of smoking. Quitline can help provide more information about quitting, and if she cannot quit, nicotine replacement therapy (NRT) can be used as this shows it a safer option in pregnancy and does not have harmful products than smoking (The Royal Australian College of General Practitioners, 2019). Breeze can benefit from a community program called Beat It which specialises in physical activity and lifestyle program that is delivered by exercise physiologists who have trained in diabetes (Diabetes NSW & ACT, 2021). This eight-week program focuses on individuals exercises in two group sessions a week tailored to people with diabetes wanting education on healthier living (Diabetes NSW & ACT, 2021). Pregnant woman with diabetes is encouraged to remain active (Rudland et al., 2020) while physical exercise has shown to decrease depressive symptoms in bipolar disorder by releasing endorphins, which are chemicals that improve mood and feelings of wellbeing (Boyce & Buist, 2016).

Narrative Description of Outcomes

As Grover & Avasthi (2015) demonstrated, when Breeze sees a psychiatrist for ceasing her medication carbamazepine during preconception, it will help reduce risks such as malformation of the fetus neural tube defects early pregnancy. It is estimated that this can occur between two to six weeks (Grover & Avasthi, 2015). Breeze's glycaemia levels in preconception can be controlled and her diabetes to a safe level to reduce the rate of miscarriage and perinatal mortality in early pregnancy, which can be achieved in three months (Rudland et al., 2020). Recommendation of Quitline can help Breeze in cessation of smoking or by applying nicotine patches as it is safer during pregnancy as she can find it hard to quit as she smokes ten cigarettes per day and likely to have withdrawal symptoms of nicotine easily (The Royal Australian College of General Practitioners, 2019).

Cat

Identification of Health Issues

Some health issues to consider for Cat would be her low BMI of 17.0, which puts her at category mild for anorexia nervosa (Rowe, 2017). Cat also has a disordered eating habit where she binges and induces vomiting and causing her dizziness, pounding heart, and fainted on occasion. Cat is at high risk of complications due to purging, as this can lead to choking and sudden death, electrolyte imbalances which can cause irregular heartbeat in conjunction with excessive weight loss, which can be an early sign of cardiovascular problems (Rowe, 2017). Cat can also be at risk of neurological problem such as not enough blood passing to the brain, causing dizziness and fainting when standing up, and gastrointestinal problems such as bloating, constipation and rupture of oesophagus and stomach, and also menstrual irregularities which she states that she has not had her period over a year (Rowe, 2017). Cat may be experiencing symptoms of bulimia nervosa because of the binge eating and which follows with a compensating behaviour such as self-induced vomiting at least once a week with a low weight (Rowe, 2017).

Cat is diagnosed with borderline personality disorder (BPD), a mental illness in which the person suffers from distorted self-image, unstable relationships, impulsiveness, and extreme intense emotions (May et al., 2016). Cat had experienced childhood trauma and was self-harming and suicidal attempts from her mid-teens. Eating disorders are common in people with BPD and puts one at greater risk of being associated with a history of sexual abuse, and self-harming can also cause a person to engage in problematic eating behaviour (Sansone & Sansone, 2011). Cat also is impulsive and engages in high-risk behaviours such as substance use of methamphetamine and engages in casual unprotected sex. Methamphetamine can cause nerve and chemical damages in the brain, worsen BPD by impacting emotions and decision-making, and increase the risk of BPD symptoms such as self-harming and suicidal behaviours (Christiansen, 2020). Cat having BPD also puts her at higher risk of contracting sexually transmitted infections (STIs) and at risk of being coerced to have sex, experiencing date rape, or being raped by a stranger (Sansone & Sansone, 2011). Cat is also estranged from her family and has flatmates worried for her where she resides in the shared house.

Holistic Intervention Plan

Education will be provided to Cat regarding her disordered eating and purging behaviour and the risks mentioned above that can come with continuing this behaviour. A multidisciplinary team approach would be effective in Cat's care, such as GP, dietitian, and psychiatrist. The focus will be on nutrition intervention and weight restoration, where she can return to a normal range of BMI of 18.5-24.9 (Harrington et al., 2015). Initial first assessment and blood counts and urinalysis can be done through her GP to determine hydration status, pH level, specific gravity, and ketone levels, which can help identify underlying issues and help with ongoing monitoring and treatment of Cat (Harrington et al., 2015). Nutritional assessment and establishing of meal plans and education to Cat can be done by a dietitian. A healthy eating plan consists of three regular meals and three snacks and usually consist of protein, vegetables, and healthy snacks for people with an eating disorder as this will ensure the right amount of vitamins and minerals are received and energy to resume daily activities (NSW Ministry of Health, 2018). A meal plan is based on calorie-rich food intake that helps with weight restoration, and the target expected is to be 90% from the person's weight according to age, height, and sex (Harrington et al., 2015). Weight restoration also normalises menses, usually within a couple of months (Harrington et al., 2015). Psychotherapy successfully treats an eating disorder that helps reduce distorted body image and dysfunctional eating habits with the emphasis placed on the person's thoughts, emotions, behaviours, and patterns of thinking (Butterfly Foundation, 2021).

Dialectical behaviour therapy (DBT) is an evidence-based psychotherapy that is considered a gold standard in BPD treatment (May et al., 2016). DBT is a 24-week program focusing on four skills: mindfulness, distress tolerance, emotional regulation, and interpersonal effectiveness (SANE Australia, 2017). DBT has been shown to effectively treat comorbid conditions such as self-harming and suicidal behaviours, substance use, and binge eating and purging behaviours (May et al., 2016). DBT helps in learning ways to accept and tolerate distress and helps the person cope with emotions and respond more adaptively; for example, Cat, when facing with emotions, might take methamphetamine and engages in risky behaviour of unprotected sex in order to escape the intolerable feeling (Salters-Pedneault, 2020). There is also evidence to suggest high rates of substance misuse in eating disorders such as methamphetamine to control appetite and weight (NSW Ministry of Health, 2018). A study by Stiglmary et al. (2014) (cited in Salters-Pedneault, 2020) concluded after 12 months that DBT reduced the symptoms of BPD and suicidal and self-harming behaviours and found that 77% of people no longer met the criteria for BPD. Cat also needs an STI screening test which can include blood tests, swabs, or urine tests to eliminate any diseases related to an STI, or if positive, then appropriate steps for treatment options will be discussed (Royal Australian College of General Practitioners, 2016).

Plan Referrals

Cat would need to see a GP who would be the first contact and help with initial assessments and refer to the appropriate multidisciplinary healthcare team and ongoing long-term management (Harrington et al., 2015). A referral to a psychiatrist would benefit Cat as they can help treat BPD and manage the symptoms and comorbid symptoms through DBT (SANE Australia, 2017). A referral to a dietitian can help Cat in educating and meal planning with rich calorie foods to help in weight restoration and help restore energy with vitamins and minerals (NSW Ministry of Health, 2018).

Community Resources

Cat can benefit from alcohol and drug information service (ADIS) NSW in the community where they provide support and education, information and crisis counselling via group sessions, telephone 24/7, and individual and referral to services which can help gain education about the drug and its risks and eventually cessation of methamphetamine use (NSW Government, n.d.). Cat can benefit from reaching out to Head to Health where they can help her with valuable resources and services of finding another housing as the shared house she currently lives, and the situation can be contributing to her mental health condition and making it harder manage can have a negative effect on her physical and mental wellbeing (Department of Health, 2019).

Narrative Description of Outcomes

As demonstrated by the NSW Ministry of Health (2018), weight restoration can happen when Cat is seen by a dietitian and psychiatrist, which can give her skills to regulate emotions and mindfulness techniques to help her with her comorbid symptoms of bulimia nervosa while also helping her to have more nutrients in her body to function properly. Recovery can be a slow process, and some people have relapses during treatment, but menses can appear within six months despite still being underweight (Harrington et al., 2015). Cat having DBT with a psychiatrist can see a reduction in her BPD symptoms and comorbid symptoms, which can occur in 24 weeks (SANE Australia, 2017). One of the barriers for Cat might be not wanting to talk about her trauma in DBT as it is a sensitive subject therefore may prolong her DBT treatment and affect some goals.

References

Austin, M, & Highet, N. (2017). Mental health care in the perinatal period: Australian clinical practice guideline. Centre of Perinatal Excellence, 1-120. https://www.cope.o rg.au/health-professionals/health-professionals-3/review-of-new-perinatal-mental-health-guidelines/

Australian Government Department of Health. (2019). Home and housing. https://hea dtohealth.gov.au/meaningful-life/feeling-safe-stable-and-secure/home-and-housing

Australian Government Department of Health. (2020). Pregnancy care guidelines: 32 hyperglycaemia. https://www.health.gov.au/resources/pregnancy-careguidelines/pa rt-f-outine-maternal-health-tests/hyperglycaemia

Boyce, P., & Buist, A. (2016). Management of bipolar disorder over the perinatal period. Australian Family Physician, 45(12), 890-893. http://www.racgp.org.au/afp/2016/ december/management-of-bipolar-disorder-over-the-perinatal-period/

Butterfly Foundation. (2021). Eating disorders treatment. https://butterfly.org.au/eating-disorders/eating-disorders-treatment/

Christiansen, T. (2020). Prevalence of borderline personality disorder and methamphetamine use. https://www.therecoveryvillage.com/meth-addiction/related-topics/borderline-personality-disorder/

Diabetes Australia. (2021). Managing type 2 diabetes. https://www.diabetesaustralia.co m.au/living-with-diabetes/managing-your-diabetes/managing-type-2/

Grover, S., & Avasthi, A. (2015). Mood stabilisers in pregnancy and lactation. Indian Journal of Psychiatry, 57(2), 308-323. https://doi.org/10.4103/0019-5545.161498

Harrington, C. B., Jimerson, M., Haxton, C., & Jimerson, C. D. (2015). Initial evaluation, diagnosis, and treatment of anorexia nervosa and bulimia nervosa. American Family Physician, 91(1), 46-52. https://web-a-ebscohost-com.ezproxy.scu.edu.au/eho st/pdfviewer/pdfviewer?vid=2&sid=3b554bb8-66b2-47f4-ab8d de1474981546%40s essionmgr4008

May, M. J., Richardi, M. T., & Barth, S. K. (2016). Dialectical behaviour therapy as treatment for borderline personality disorder. Mental Health Clinician, 6(2), 62-67. https://doi.org/10.9740/mhc.2016.03.62

NSW Government. (n.d). Alcohol and drug information service (ADIS) NSW. Retrieved June 8 2021 from https://yourroom.health.nsw.gov.au/getting-help/Pages/adis.aspx

NSW Ministry of Health. (2018). NSW eating disorder toolkit: A practice-based guide to inpatient management of children and adolescents with eating disorders. https://www.health.nsw.gov.au/mentalhealth/resources/Publications/nsw-eating-disorders-toolkit

Raising Children Network. (2020). Health pregnancy for women who are overweight. https://raisingchildren.net.au/pregnancy/health-wellbeing/healthy-lifestyle/healthy-pregnancy-overweight

Rowe, E. (2017). Early detection of eating disorders in general practice. Australian Family Physician, 46(11), 833-838. https://www.racgp.org.au/afp/2017/november/early-detection-of-eating-disorders/

Royal Australian College of General Practitioners. (2016). Guidelines for preventive activities in general practice. https://www.racgp.org.au/download/Docu ments/Guidelines/Redbook9/17048-Red-Book-9th-Edition

Rudland, L. V., Price, L. A. S., Hughes, R., Barrett, L. H., Lagstrom, J., Porter, C., Britten, L. F., Glastras, S., Fulcher, I., Wein, P., Simmons, D., McIntyre, D., & Callaway, L. (2020). ADIPS 2020 guideline for pre-existing diabetes and pregnancy. The Royal Australian and New Zealand College of Obstetricians and Gynaecologists, 60(6), 18-52. https://doi.org/10.1111/ajo.13265

Salters-Pedneault, K. (2020). Dialectical behaviour therapy for BPD. https://www.verywellmind.com/dialectical-behavior-therapy-dbt-for-bpd-425454

SANE Australia. (2017). Dialectical behaviour therapy. https://www.sane.org/information-stories/facts-and-guides/dialectical-behaviour-therapy-dbt

Sansone, A. R., & Sansone, A. L. (2011). Sexual behaviour in borderline personality: A review. Innovations in Clinical Neuroscience, 8(2), 14-18. https://search-ebscohost-com.ezproxy.scu.edu.au/login.aspx?direct=true&db=rzh&AN=65397944&site=ehost-live

Sharma, V., Doobay, M., & Baczynski, C. (2017). Bipolar postpartum depression: An update and recommendations. Journal of affective Disorders, 219, 105-111. https://doi.org/10.1016/j.jad.2017.05.014

The National Health and Medical Research Council. (2020). Australian guidelines to reduce health risks from drinking alcohol. https://www.nhmrc.gov.au/about-us/publications/australian-guidelines-reduce-health-risks-drinking-alcohol

The Royal Australian College of General Partitioners. (2019). Supporting smoking cessation: A guide for health professionals. https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/supporting-smoking-cessation

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