NR566 Week 7 Bipolar Disorder

10 August 2024

NR 566 Management of Psychiatric Conditions in Primary Care Presentation: Bipolar Disorder

Presenter: Fatme Bazzi

Patient Scenario

Patient Profile:

  • Age/Gender: 22-year-old Female
  • Presenting Complaints:
    • Feeling sad and experiencing a sense of worthlessness.
    • Reports being easily tearful and emotional.
    • Stress eating leading to weight gain.
    • Trouble sleeping.
    • Episodes of increased confidence, talkativeness, and social behavior, which are uncharacteristic of her usual demeanor.
    • Mood is positively reactive during assessment, with outbursts of laughter that do not align with her baseline mood.
    • Increased libido with reports of engaging in casual sexual encounters with random men met at bars.

Medical History:

  • Current Illness: Hypothyroidism, managed with Levothyroxine 125 mcg once daily.
  • Past Psychiatric History:
    • Diagnosed with ADHD as a child, previously treated with Adderall, which was discontinued due to exacerbation of symptoms.
    • Diagnosed with depression two years ago and treated with antidepressants.
    • History of a suicide attempt at age 19 after taking a large amount of antidepressants.
  • Family Medical History: Mother has a history of major depression and is currently on medication.

Social History:

  • Lives with her mother and younger brother, but has a distant relationship with them.
  • Struggles with maintaining friendships and has no close friends.
  • Works part-time at a Coney Island restaurant.
  • Does not attend college.
  • Occasional alcohol consumption.

Current Medications:

  • Fluoxetine 20 mg twice daily.
  • Birth control pills.

Discussion and Analysis

Clinical Presentation and Diagnosis:

  • The patient’s symptoms of fluctuating mood, including periods of intense sadness and worthlessness, interspersed with episodes of elevated mood, increased sociability, and impulsive behavior, suggest a potential diagnosis of Bipolar Disorder. Bipolar Disorder is characterized by episodes of depression and mania or hypomania, and the patient’s presentation aligns with these criteria.
  • The patient’s history of depression, prior ADHD treatment, and a suicide attempt further supports the possibility of a mood disorder beyond unipolar depression. The impulsivity observed in her behavior, such as engaging in risky sexual activities and the positively reactive mood during the assessment, are indicative of hypomanic or manic episodes.

Treatment Considerations:

  • Mood Stabilization: The management of Bipolar Disorder in primary care requires careful consideration of both depressive and manic symptoms. The current use of fluoxetine, an SSRI, could potentially exacerbate manic symptoms if used without a mood stabilizer. Therefore, the addition of a mood stabilizer is warranted.
  • Medication Recommendation:
    • Divalproex Sodium: A mood stabilizer such as divalproex sodium (250 mg three times daily) is recommended to help stabilize her mood and prevent the cycling between depressive and hypomanic episodes. Divalproex sodium is effective in managing both manic and depressive symptoms in Bipolar Disorder.
    • Continued Use of Fluoxetine: The patient may continue on fluoxetine 20 mg twice daily to address her depressive symptoms. However, close monitoring is essential to ensure that the SSRI does not trigger manic episodes.

Monitoring and Follow-Up:

  • Regular follow-up appointments are necessary to monitor the patient’s response to the new medication regimen. It is crucial to assess for any signs of manic or hypomanic episodes, as well as any adverse effects from the mood stabilizer.
  • The patient should be educated on the importance of medication adherence, potential side effects, and the need for consistent follow-up care.
  • Psychoeducation about Bipolar Disorder, its symptoms, and the importance of maintaining a stable routine, including regular sleep and avoidance of alcohol, should be provided.

Psychosocial Interventions:

  • Therapy and Support: Referral to a mental health professional for psychotherapy, such as Cognitive Behavioral Therapy (CBT), can be beneficial in helping the patient develop coping strategies and address maladaptive behaviors associated with her mood disorder.
  • Social Support: Encouraging the patient to build a support network and engage in activities that promote well-being and reduce social isolation is essential.

Conclusion

The management of Bipolar Disorder in primary care involves a multifaceted approach that includes pharmacological treatment, psychoeducation, and psychosocial support. By addressing both the depressive and manic symptoms, healthcare providers can help stabilize the patient’s mood and improve her overall quality of life. Continuous monitoring and patient engagement are key to the successful management of this complex psychiatric condition.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Association. https://doi.org/10.1176/appi.books.9780890425596

Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, 381(9878), 1672-1682. https://doi.org/10.1016/S0140-6736(13)60857-0

Hirschfeld, R. M. A. (2014). Guideline watch: Practice guideline for the treatment of patients with bipolar disorder (2nd edition). American Psychiatric Association. https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar-watch.pdf

Nivoli, A. M. A., Colom, F., & Murru, A. (2011). New treatment guidelines for acute bipolar depression: A systematic review. Journal of Affective Disorders, 129(1-3), 14-26. https://doi.org/10.1016/j.jad.2010.08.019

Vázquez, G. H., Baldessarini, R. J., & Tondo, L. (2014). Co-occurrence of anxiety and bipolar disorders: Clinical and therapeutic overview. Depression and Anxiety, 31(3), 196-206. https://doi.org/10.1002/da.22140

Weisler, R. H., Nolen, W. A., & Neijber, A. (2011). Efficacy and safety of quetiapine in combination with lithium or divalproex for maintenance of patients with bipolar I disorder (International trial 126). Journal of Affective Disorders, 128(1-2), 192-203. https://doi.org/10.1016/j.jad.2010.06.020