W7 Bipolar Case Study

Bipolar Case Study by Barbra Scheirer

1. What information, if any, would you like to know that was not included in the case?

There is a lot of information not given in the scenario and what was given by the patient may or may not be reliable. I would like to know if he has any mediation allergies, any medical history, any psychiatric history, if he smokes, drinks, or does drugs. It would also be helpful to know if the patient is agreeable to be on medications. I would like to confirm any family history of any psychiatric illnesses. I would like to know if the patient had any prior episodes of mania or depression, and if the voices he hears are telling him to harm himself or others. I would like to know if he has had any recent stressors or if the patient knows what caused his symptoms to begin. I would also like to know how long his symptoms have been continuing.

2. Which psychiatric symptoms are a treatment priority for this case? His mania and associated symptoms including hallucinations, lack of sleep, psychosis, flight of thoughts, rapid speech, ideas of grandeur, and delusions (McIntyre et al., 2020).

3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)? The only non-pharmacologic issue in this case that I can identify is his relationship with his co-worker who makes fun of him.

4. List one medication that would be appropriate for this case. Include the name and starting dose. I would prescribe Lithium 300mg po BID and adjust per plasma levels of 0.8 mEq/L (Puzantian & Carlat, 2016).

5. Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.

I choose lithium because it is the gold standard for bipolar disorder and is more useful for euphoric mania than for mixed and rapid-cycling types of bipolar disorder (Puzantian & Carlat, 2016). It is also known for its anti-suicide effects in bipolar and unipolar mood disorders (Puzantian & Carlat, 2016). Lithium has been found to reduce manic symptoms substantially (Stahl, 2013). Mechanism of action is unknown and complex. Lithium alters the sodium transport across the cell membranes in nerve and muscle cells (Stahl, 2017). It inhibits inositol monophosphatase, may alter intracellular signaling through actions on secondary messaging systems, it reduces protein kinase C activity, and increases cytoprotective proteins (Stahl, 2017).

6. What laboratory testing/monitoring is needed for safely prescribing this medication? Baseline electrolytes including kidney function, urine specific gravity, lithium level every 1-2 weeks until desired serum level is achieved, then every 2-3 months for the first 6 months, then every 6-12 months, once stable (Stahl, 2017). I would also check TSH level on initiation (Puzantian & Carlat, 2016). Weight should also be monitored (Stahl, 2017).

7. Are there any contraindications or safety issues associated with this medication? Lithium is contraindicated in patients with renal failure, cardiovascular insufficiency, Addison’s disease, and untreated hypothyroidism (Chokawala et al., 2021). I would not use lithium if a patient has Brugada syndrome, severe dehydration, sodium depletion, or an allergy to lithium (Stahl, 2017).

8. What non-pharmacologic interventions do you recommend? Do you recommend, including, but not limited to psychotherapy, complimentary and holistic therapies? I would recommend CBT therapy, family-focused therapy, psychoeducation, exercise, and balanced diet. Psycho-education (PE) is educating a patient regarding the illness and treatment when applied to mental disorders (Naik, 2015). Family-focused therapy (FFT) focuses on reducing high levels of stress and conflict in families of bipolar patients, thereby improving the patient’s illness course (Naik, 2015). I would also try to get John on a sleep schedule. I would suggest John try to avoid over-stimulating activities. I would suggest stress-reduction techniques.

9. What are the safety concerns, if any, associated with this case? How will you address safety? I would address safety concerns such as suicide risk with a screening tool and have the patient contract for safety. I am also concerned with the patient not getting any sleep and him inadvertently get hurt at work or hurting himself or others by operating a car while not being able to focus on his activity. I would admit John to the hospital stabilize his mood, titrate his medication, and start psychotherapy.

10. When would you follow up with this patient? Once discharged, I would follow up with this patient 2 weeks after discharge to evaluate his symptoms and need for medication adjustments.

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References

Chokawala, K., Lee, S., & Saadabadi, A. (2021). Lithium. StatPearls. Retrieved October 12, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK499992/

McIntyre, R., Goldstein, B., Lopez-Jaramillo, C., Malhi, G., Neirenberg, A., & Majeed, A. (2020). Bipolar disorders. The Lancet, 396(10265), 1841–1856. https://doi.org/10.1016/50140-6736(20)31544-0

Naik, S. (2015). Management of bipolar disorders in women by nonpharmacological methods. Indian Journal of Psychiatry, 57(6), 264. https://doi.org/10.4103/0019-5545.161490

Puzantian, T., & Carlat, D. (2016). Medication fact book for psychiatric practice (3rd ed.). Carlat Publishing.

Stahl, S. (2013). Stahl's essential psychopharmacology (4th ed.). Cambridge University Press.

Stahl, S. (2017). Stahl's essential psychopharmacology prescribers guide (6th ed.). Cambridge University Press.