Assignment: Practicum: Decision Tree (Due in Week 7)

Case #2 A young woman with Depression with Depression

 

SUBJECTIVE

Stefanie is a 32-year-old female from Puerto Rico who presents to your office today with complaints of difficulty sleeping. You learn that Stefanie can go for a few days with minimal sleep (about 3 hours/night), but does not seem to be fatigued the next day. Stefanie explains that after 3 days with minimal sleep, she “crashes” and has a good night’s sleep. She states that sleep will be “alright” for a few days, even a few weeks, and then she will have a similar issue with sleep.

You learn throughout the assessment process that Stefanie has had this problem for years. She noticed that it began in college and thought it was just because of the workload and academic demands. However, she found that it persisted after college. She also notices that she has periods where she will engage in increased amounts of goal-directed activity. She states that things will just “pile up” at work and she gets this burst of energy to “make everything right.” She states that these bursts will last most of the day. She states that these periods show up probably every 2 to 3 weeks.

Stefanie also confesses to problems with being “down in the dumps.” She states that when she has her episodes in which she endeavors to “make everything right,” she feels fantastic and on top of the world. However, when these periods of energy end, she reports that she feels “depressed”—but then states: “well, maybe not depressed, but I definitely feel sad and empty.” She also endorses feelings of fatigue and a decreased ability to concentrate when she is feeling sad. She finally tells you: “I have lived with this for so long, I have to admit that it is finally a relief to tell someone how I feel!”

OBJECTIVE

Stefanie is dressed appropriately to the weather. She has no gait abnormalities. Physical assessment is unremarkable. Gross neurological assessment is within normal limits.

MENTAL STATUS EXAM

Stefanie is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Self-reported mood is “sad.” Affect does appear consistent with dysphoria. Eye contact is normal. Speech is clear, coherent, and goal directed. She denies visual or auditory hallucinations. No overt evidence of paranoid or delusional thought processes noted. She denies suicidal or homicidal ideation and is future oriented.

At this point, please discuss any additional diagnostic tests you would perform on Stefanie.

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING DIAGNOSES WOULD THE PSYCHIATRIC/MENTAL HEALTH NURSE PRACTITIONER (PMHNP) GIVE TO STEFANIE?

In your write-up of this case, be certain to link specific symptoms presented in the case to DSM–5 criteria to support your diagnosis.

 Cyclothymic disorder

Decision Point One

 Bipolar I, current phase, depressed

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

Begin Latuda 40 mg orally daily

Lamictal 100 mg orally daily

Begin psychotherapy using a psychodynamic approach

 Bipolar II, current phase, hypomanic

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

Begin Lithium 300 mg orally twice a day

Begin Olanzapine 10 mg orally at bedtime

Begin Abilify 10 mg orally daily

Decision Point Two

Begin Depakote 250 mg orally three times daily

RESULTS OF DECISION POINT TWO

 Client returns to clinic in four weeks

 Stefanie returns to your office and informs you that she had to stop taking the medication last week. “I have been too tired to do anything,” she explains, “plus, I have gained about 2 pounds since I started this medicine… I can’t keep gaining weight like this.”

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Explain to Stefanie that weight gain and sedation are temporary side effects and encourage her to restart the medication

Decrease the dose to 125 mg orally twice a day

Increase the dose to 500 mg orally twice a day, and explain that weight gain and sedation are problematic only at lower doses

 Cyclothymic disorder

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:

Begin Depakote 250 mg orally three times daily

Begin Abilify 10 mg orally daily

Arrange to see Stefanie every 3 months for routine follow-up

Decision Point One

 Bipolar I, current phase, depressed

Decision Point Two

Lamictal 100 mg orally daily

RESULTS OF DECISION POINT TWO

 Client returns to clinic in four weeks

 Stefanie presents today with concerns about a rash that began about 1 week after starting the Lamictal dose. The rash appears as erythematous macules and papules that initially began on her stomach, but spread to the periphery over the past 2 weeks. The lesions multiplied until they became confluent, and now involve the oral mucosa as well as her hands and feet. Stefanie denies fever, chills, lymphadenopathy, sore throat, malaise, or arthralgia.

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.

Restart lithium at 150 mg orally twice a day

Discontinue lithium and start Latuda 40 mg orally daily

Change lithium to extended-release preparation and start Eskalith CR 450 mg orally three times/day

Decision Point Three

Restart lithium at 150 mg orally twice a day

Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have 3 or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

In this case, Stefanie had side effects related to Lithium. Lithium could be restarted at half the dose (150 mg orally twice a day) for several days, then slowly titrated upward. Eskalith CR is the extended-release version of Lithium, but 450 mg orally three times/day is too much.

In consideration of the actual diagnosis and the potential side effects related to Lithium, the PMHNP may consider Latuda as an alternative treatment.