A young woman 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.
Bipolar I, current phase, depressed
Bipolar II, current phase, hypomanic
Cyclothymic disorder
Decision Point One
Bipolar I, current phase, depressed
Decision Point Two
Begin Latuda 40 mg orally daily
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Stefanie states that she thinks that her depression “may be a bit better.” She also reports that she has only had one of her “make everything right” days.
She does report that she has been having a new problem: the inability to “sit still.” She states that she notices that she must move every few minutes, otherwise, she feels uncomfortable.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Increase Latuda to 80 mg orally daily
Remind Stefanie to take her Latuda with a meal
Decrease Latuda to 20 mg orally daily
Decision Point Three
Increase Latuda to 80 mg orally daily
Guidance to Student
In order to meet the criteria for a major depressive episode, the client needs to have 5 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 three 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, the Latuda was clearly causing problems with akathisia. Defined as an inability to sit still, or an inner feeling of restlessness, akathisia can be quite concerning to those with the condition.
In this case, increasing the Latuda is the worst thing you can do, as that will most likely intensify the akathisia. Reminding the client to take the medication with food is important because Latuda should be taken with a 350-calorie meal in order to ensure absorption of the drug. However, in this case, the side effect Stefanie is complaining about is not food related.
Cogentin would not be appropriate since beta-blockers (propranolol 20–40 mg orally BID) are considered first-line treatment for drug-induced akathisia. Cogentin could be used, but it is not a first-line treatment.
Of the available options, decreasing the dose of Latuda is the most correct answer; however, the proper course of action would be to discontinue the drug. Alternatively, decreasing the offending drug could alleviate the symptoms.
Required Readings
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author.
Standard 13 “Collaboration” (pages 78-79)
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
“Bipolar and Related Disorders”
Gabbard, G. O. (2014). Gabbard’s treatment of psychiatric disorders (5th ed.). Washington, DC: American Psychiatric Publications.
Chapter 13, “Acute and Maintenance Treatment of Bipolar and Related Disorders”
Marsee, K., & Gross, A. F. (2013). Bipolar disorder or something else? Current Psychiatry, 12(2), 43–49. Retrieved from http://www.mdedge.com/currentpsychiatry/article/66320/bipolar-disorder/bipolar-disorder-or-something-else
Miller, L. J., Ghadiali, N. Y., Larusso, E. M., Wahlen, K. J., Avni-Barron, O., Mittal, L., & Greene, J. A. (2015). Bipolar disorder in women. Health Care for Women International, 36(4), 475–498. doi:10.1080/07399332.2014.962138
Schouws, S. M., Comijs, H. C., Dols, A., Beekman, A. F., & Stek, M. L. (2016). Five-year follow-up of cognitive impairment in older adults with bipolar disorder. Bipolar Disorders, 18(2), 148–154. doi:10.1111/bdi.12374
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Chapter 8, “Mood Disorders” (pp. 347–386)
Note: This is review from the Learning Resource in Week 2.
Stahl, S. M. (2014). Prescriber’s Guide: Stahl’s Essential Psychopharmacology (5th ed.). New York, NY: Cambridge University Press.
Note: All Stahl resources can be accessed through the Walden Library using the link below. This link will take you to a login page for the Walden Library. Once you log in to the library, the Stahl website will appear. http://ezp.waldenulibrary.org/login?url=http://stahlonline.cambridge.org/
To access information on specific medications, click on The Prescriber’s Guide, 5th Ed. tab on the Stahl Online website and select the appropriate medication.
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Assignment 2
Write three possible nursing interventions for a child who is hospitalized for failure to thrive. The work must be done in APA style . 300- 400 words. References should be within last 5 years.
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Based on the information provided in the scenario, the psychiatric/mental health nurse practitioner (PMHNP) would diagnose Stefanie with Bipolar II, current phase, depressed. This diagnosis is supported by her symptoms of decreased need for sleep, increased goal-directed activity, periods of energy followed by periods of sadness and emptiness, fatigue, and decreased ability to concentrate. These symptoms meet the criteria for a hypomanic episode and a major depressive episode, but not for a manic episode, which is required for a diagnosis of Bipolar I.
Decision Point Two involves starting Stefanie on Latuda 40 mg orally daily. At Decision Point Three, Stefanie reports improvement in her depressive symptoms but new symptoms of restlessness and inability to sit still. The PMHNP decides to increase the dose of Latuda to 80 mg orally daily. This is an appropriate decision as increased restlessness and inability to sit still can be symptoms of akathisia, a common side effect of antipsychotic medication. Increasing the dose may help alleviate these symptoms while also improving her depressive symptoms.
