CASE STUDY 3

ASSESSMENT 3 – PHYSICAL HEALTH CARE IN MENTAL HEALTH – CASE STUDIES

This paper will analyse two case studies by assessing each consumer from a holistic physical wellbeing perspective and provide an intervention package in response to each clinical scenario, addressing the presenting biological, psychological, sexual and social health issues. The case studies involving perinatal care and possible eating disorder have been chosen for this assessment.

Scenario B – Perinatal Care – Breeze

Breeze is a 34 year old woman with type II diabetes and a diagnoses of bipolar affective disorder. Her type II diabetes was previously poorly controlled and now requires insulin to control. As insulin is not the first-line treatment for those with type II diabetes, Breeze’s condition has deteriorated to the point that oral hypoglycaemic medications are no longer effective. Insulin is not generally introduced until at least two oral agents fail to maintain glucose levels. (Abiola et al., 2016). Her body max index (BMI) of 25.8 places her in the overweight range (Yang, et al., 2019). She has been more compliant with monitoring and treatment of her diabetes however complicating this condition is the fact that Breeze smokes 10 cigarettes per day and consumes up to 4-6 alcoholic drinks most days. Cigarette smoking with diabetes puts Breeze at a increased risk for coronary artery disease, stroke and proteinuria (Śliwińska-Mossoń & Milnerowicz, 2017). This alcohol consumption exceeds the recommended intake of one unit per day for females (Evert et al., 2013). In addition to the alcohol consumption being at an unhealthy level, complicating this is the use of carbamazepine medication (600mg BD) for bipolar affective disorder. Carbamazepine is primarily metabolised by the liver and alcohol consumption of 20-40g per day puts women at an increased risk for developing liver disease and therefore this combination can place liver damage at an even higher risk (Entringer, 2020; Subramaniyan et al., 2021). Breeze has only had one manic episode when she was a college student and since this time has been hospitalised for depressive episodes. Breeze is in a supportive relationship and is contemplating having her Implanon removed to start a family. Her age of 34 places her close to what is considered advanced maternal age, which is over the age of 34, and thus also presents further risk to mother and baby (Kahveki et al., 2018).

The physical health care requirements for Breeze need to be addressed as pre-exisiting diabetes can increase the risk factors for both mother and baby and therefore her diabetes control needs to be optimal (Tieu et al., 2017). During pregnancy, insulin is the first-line therapy for pre-existing diabetes and care needs to be taken during the early stages as this is when Breeze is most likely to be insulin sensitive. Therefore careful glucose monitoring is essential to avoid hypoglycaemia (Alexopoulos et al., 2019). To help stabilise blood sugar levels, a healthy BMI needs to be maintained. Breeze’s BMI is at the lower level of overweight so this is something that needs to be considered prior to pregnancy and during pregnancy. Not only is nutrition important for this goal but so too is exercise. Endurance or resistance type exercise has been found to lower the prevalence of elevated blood sugar and therefore would be be helpful with both diabetes and weight control. Additionally, it can also improve glucose levels in type 2 diabetics using insulin (van Dijk, et al., 2012). Although it is important that a healthy weight is maintained prior to and during pregnancy, smoking cessation may negatively effect weight control (Zhu et al.,).

Cessation of smoking can result in weight gain, nevertheless this is negated by the positive outcomes. Breeze smokes up to 10 cigarettes per day which is not only a poor risk with diabetes but smoking during pregnancy is well known to have adverse pregnancy outcomes such as low birth weight or still birth (Yang et al., 2019). Adding to this risk of low birth weight and stillbirth is alcohol consumption during pregnancy. Alcohol is a teratogen that passes the placenta and can cause harm to the foetus and in a severe form is a direct cause of foetal alcohol syndrome (Popova et al., 2017). The alcohol consumption of 4-6 standard drinks most nights is excessive and would be adding to her BMI and increasing blood glucose levels. It may also have an effect on the carbamazepine medication as alcohol can increase the nervous system side effects of this drug such as dizziness, drowsiness and difficulty concentrating. Further to this, it has been suggested that alcohol be avoided, or at the very least limited, while being treated with carbamazepine (Entringer, 2020). If this medication is discontinued, a relapse of bipolar disorder can occur which further leads to pregnancy complications. It is therefore important that Breeze is under the care of a Psychiatrist to ensure her medication regime is safe and at a therapeutic range whilst pregnant (Scrandis, 2017).

Psychiatrist referral and review would be recommended to ensure a therapeutic relationship prior to, during and after pregnancy. The aim is to monitor Breeze’s mental health and to provide prescriptions for medications that are safe for Breeze during pregnancy and to intervene early if there is any deterioration in her mental health. For her physical health, a referral to an Endocrinologist would be essential to ensure a prenatal work up and education is provided with how to best manage her diabetes during pregnancy. This is particularly important noting the current alcohol and tobacco consumption. A referral to a dietician prior to pregnancy, or at the very least in early pregnancy, is also recommended to help Breeze maintain a healthy weight and optimal glucose levels and to ensure food consumed is of a high nutritional value. (Alexopoulos, 2019). As per recommendations for all women planning a family, pre-natal screening, such as sexually transmitted infections (STI’s) would be arranged, and the commencement of pre-natal vitamins would be suggested to prepare Breeze for pregnancy and to reduce the risk of in utero complications to the baby (Gomes et al., 2016)

In the immediate future, the goal for Breeze would be to cease smoking and cut back on alcohol with the aim to eliminate this altogether. Group behavioural therapies would be recommended as these have shown to be more effective than self-help options (Zhu et al., 2017). ‘Short course’ quit smoking can assist participants to prepare to quit smoking and also review their progress and establish future plans (Greenhalgh et al., 2020). Any pharmacological intervention that aides in the cessation of smoking would need to be safe for diabetics. Planning pregnancy is a great motivation tool for modification to both smoking and drinking. If Breeze’s partner is also participating in these habits it would be helpful to extend this support to him. It would be encouraged to replace the habit of alcohol consumption with exercise as this will not only improve Breeze’s physical health with weight control but also assist with diabetes management (van Dijk, et al., 2012). Alcohol consumption would be continually monitored to determine if any further intervention is required.

Assuming Breeze and her partner are committed to these healthy lifestyle changes and goals are achieved regarding smoking and drinking cessation, it would be expected that she aim for pregnancy within the next 12 months. This would be on the provision it has been established by her Endocrinologist that she is a safe risk for pregnancy and any fertility treatment. Postnatally, Breeze will require close monitoring as she will be at a higher risk of relapse of bipolar (Scrandis, 2017).

Scenario C – Possible Eating Disorder – Cat

Cat is a 21 year old woman with a BMI of 17. Her weight has reduced from 60 kilograms (kgs) to 43 kgs in the last 12 months and she has stated that she ‘use to be fat’. She has experienced feelings of dizziness when she stands, heart pounding and of further concern, she has also fainted on a couple of occasions. There has been a cessation of her period for over a year. The physical symptoms of postural hypotension, heart palpitations and amenorrhea can all be signs of an eating disorder (Jahraus, 2018). In addition to this, her BMI of 17 is well below the normal BMI range of 18.5-25 (Yang et al., 2019). Over the last 6 months Cat has been smoking methamphetamine during the weekends and stays up all night and frequently engages in casual unprotected sex. During this period she is not thinking about food and will become ravenous midweek and binges on McDonalds, after which guilt then drives her to vomit. This eating behaviour can be seen in people with anorexia nervous, bulimia nervosa and binge eating disorder (Jahraus, 2018). Cat has a diagnosis of borderline personality disorder and is known to mental health and emergency services for self-harm and suicide attempts. It is not uncommon for people with borderline personality disorder to also meet the diagnostic and statistical manual (DSM) for other mental illnesses such as eating disorders and substance abuse (Lieb et al., 2004). Self-injury started in her mid-teens in response to interpersonal stress and experienced childhood sexual abuse. Cat is estranged from her family and has been living in a share house with other young people.

It is noted that Cat has an extensive mental health history however the area of most concern at this point would be her significant weight loss of 17 kilograms over the last 12 months and the associated behaviours contributing to this weight loss. Her previous BMI of 23.7 was in the normal weight range (Yang et al., 2018). In terms of an eating disorder, such as anorexia nervosa, Cat’s current BMI of 17 would be classified as mild. That said, BMI alone is not sufficient to measure the risk to an individual and clinical symptoms must also be considered to determine intervention regimes (Reas & Ro, 2017). Symptoms such as orthostatic hypotension, cardiac arrhythmia and syncope are indicative of electrolyte imbalances and potential cardiac failure. In addition to these symptoms, the absence of menses for the past 12 months indicates the chronic nature of this disordered eating (Jahraus, 2018). Further information would be necessary to determine Cat’s diagnosis however her view that she was fat with a previous healthy BMI of 23.75, her current BMI of 17 and her lack of nutritional intake for days on end and purging could indicate anorexia nervosa and bulimia. Also affecting her physical ill health is the food she is consuming is low in nutritional value and once eaten is later purged. Perpetuating the low BMI is the regular methamphetamine use.

Cat has been smoking methamphetamine most weekends over the last 6 months and during this time she doesn’t think about food. Methamphetamine is a drug that is extremely addictive and one of the known side effect of it is decreased appetite. Furthermore, in the 1950’s and 1960’s it was prescribed as an aid for weight loss before its harmful side effects and addictive nature had become apparent (Salani et al., 2020). In chronic use, extreme weight loss can occur which would further complicate Cat’s current BMI and her dangerous physical symptoms of postural hypotension, palpitations and syncope. In addition to the impact that methamphetamine has on appetite, it also increases libido and if used during sexual encounters, there is a higher chance of risky behaviours such as unprotected sex and multiple sexual partners (Salani et al., 2020). Cat frequently engages in unprotected sex and subsequently is at an extremely high risk for STI’s.

Initial intervention would include blood tests to check electrolytes levels as the purging behaviour is associated with a number of electrolyte changes which can be life threatening if left untreated, particularly if potassium levels are depleted (Mahler & Walsh, 2016). Once this is addressed and stabilised a referral to a dietician is essential to intervene with Cat’s current unhealthy relationship with food. It is likely there would be nutritional deficits noting that when Cat is eating she is consuming fast food. Not only is the volume of food consumed insufficient to accommodate her nutritional needs but the fast food she is consuming is not balanced and likely high in sodium which can further reduce potassium levels (Mahler & Walsh, 2016). Cat would be referred to her GP for STI screening in the short term and for a longer term to review and monitor her physical symptoms to ensure her cardiovascular symptoms have resolved and her BMI is increasing.

Information would be provided to Cat for Alcohol and Drug Information Service (ADIS 24/7). This can be a point of reference for her to help contact the best service for her needs and also provide much needed education on the dangers of methamphetamine (Queensland Health, 2020). A referral to community services to re-engage with her family would be offered in collaboration with Cat. Her unhealthy lifestyle may be perpetuated by her current living situation so family support would also help with her leading a more healthy lifestyle.

Cat’s vital signs improved after a hospital admission to rehydrate and increase nutritional intake. Cat is now living in a healthier environment surrounded by family. She has ceased drug use, gained weight and with the help of a dietician has established a much healthier relationship with food and nutrition. As supported by Jahraus (2018) as a result of her weight gain and her BMI now within a healthy range, Cat’s overall health has improved and her period has returned to a normal cycle. Cat has also re-engaged with therapy to help with her emotional regulation to reduce the risk of relapse and remains motivated to seek employment.

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