Due december 24 at 1 pm est

Week 4: Grand Rounds

Gina Ashman

College of Nursing-PMHNP, Walden University

NRNP 6675: PMHNP Care Across The Lifespan II

December 21, 2022

According to Yatham et al, Bipolar II is most misdiagnosed as MDD because most patients come for treatment during the depressed phase. However, there are some features of bipolar depression that can help a clinician differentiate between unipolar and bipolar depression. Failure of treatment with several antidepressants given an ample duration of trial is one factor that may indicate it is bipolar depression. Other atypical depression features such as irritability, leaden paralysis, psychomotor retardation, hypersomnia or hyposomnia as well as racing thoughts at night are symptoms of bipolar depression. (Yatham et al, 2018).

Subjective:

CC (chief complaint): “I have mood swings, irritability, depressed mood lasting for days, short fuse, and only a few good days a month. Sometimes sleeping too much sometimes sleeping too little.”

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HPI: JK. is a 30 yo White female that came for evaluation today for mood swings, irritability, depressed mood lasting for days, short fuse, a few “good days” a

month. She reports sometimes sleeping too much and sometimes sleeping too little. She has tried 3 different SSRIs. Sertraline, Lexapro, fluoxetine. No side effects to any of them. Lexapro worked well at first but seemed to get less effective over time. Sertraline never felt helpful.

Fluoxetine helped a little bit. Eventually maxing out on them all. She is not taking anything now.

Past Psychiatric History: The patient has had no inpatient psychiatric treatment.

Substance Current Use and History: She has no history of substance use.

Family Psychiatric/Substance Use History: Mother with hx of depression and anxiety. The father has a hx of depression. Maternal grandmother has a hx of anxiety and depression. Maternal

Grandfather has no psychiatric or substance use history..

Psychosocial History: She is single and lives alone. She was raised by her biological parents. She indicates her physical needs were met growing up but states, “Mom has a lot of her own problems to worry about rather than talk to me.”

Medical History: She has no significant medical history.” She is up to date with all immunizations.

Current Medications: none

Allergies: He has no known drug allergies. She reports an allergy to seafood and pollen.

Reproductive Hx: G0P0

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Objective: T- 98.7, P- 78, R 16, BP= 130/80 Ht 5’ 7, Wt 160 lbs

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ROS:

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General: Normotensive, in no acute distress.

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Head: Normocephalic, no lesions.

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Eyes: PERRLA, EOM’s full, conjunctivae clear, fundi grossly normal.

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Ears: EAC’s clear, TMs normal.

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Nose: Mucosa normal, no obstruction.

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Throat: Clear, no exudates, no lesions.

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Neck: Supple, no masses, no thyromegaly, no bruits.

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Chest: Lungs clear, no rales, no rhonchi, no wheezes.

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Heart: RR, no murmurs, no rubs, no gallops.

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Abdomen: Soft, no tenderness, no masses, BS normal.

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Back: Normal curvature, no tenderness.

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Extremities: FROM, no deformities, no edema, no erythema.

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Neuro: Physiological, no localizing findings.

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Skin: Normal, no rashes, no lesions noted.

Objective:

D
iagnostic results: All labs without acute findings.

Assessment:

Mental Status Examination: Jk is a 30 yo White female. During the interview, she

presents with slightly anxious mood. She was was cooperative, pleasant, and dressed approximately. Her speech was appropriate rate and coherent. Her orientation to self, others, time, and place was appropriate. She denied suicidal, homicidal ideation.

According to the DSM-5, A diagnosis of anxiety requires the prescence of The anxiety, worry, or physical symptoms that cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

(NIH.org., 2016).

Differential Diagnoses:

1. Bipolar II

2. MDD

3. GAD

Diagnostic Impressions: Bipolar II

Reflections: Prior to making a diagnosis, it is noted that her depression has been treatment resistant; however, treatment resistant depression alone does not account for the mood swings and a few “good days”. MDD Anxious Distress Specifier would also not be the diagnosis that is accurately described by mood swings, irritability, depressed mood, and hypersomnia/hyposomnia. Therefore, based on the patient’s symptoms and clinical history, Bipolar II would be the working diagnosis for this patient.

Case Formulation and Treatment Plan: Jk is exhibiting symptoms of all three differential diagnoses, Bipolar II, MDD, Anxiety. She was willing to receive treatment to improve his mood and sleep. Sufficient time was given to explore and clarify her concerns. As her clinician, I would review records for Thyroid values and hormone values. According to Thase, two pivotal trials known by the acronyms of BOLDER (BipOLar DEpRession) I and II demonstrated that two doses of quetiapine (300 mg and 600 mg given once daily at bedtime) were significantly more effective than placebo, with no increased risk of patients switching into mania. Pooling the two studies, quetiapine was effective for both bipolar I and bipolar II depressions and for patients with (and without) a history of rapid cycling.  Considerations prior to initiating treatment with quetiapine would be assessment of all known drug allergies, BMI, and endocrine disorders. I would start quetiapine at 75 mg at bedtime and titrate with 75 mg on day 2, 3, 4 until the dose is 300 mg XR qhs by day 4. This medication would be a monotherapy mood stabilizer that would also help insomnia. The patient would be given instructions to avoid mixing medication with alcohol, avoiding operating a car or any machinery after taking this medication. If the patient is morbidly obese or has diabetes, I would try Lexapro 20 mg qd since she had some positive effect on Lexapro initially without any side effects, but I would combine Abilify 5 mg qd with Lexapro. Another alternative could be Risperdal 1 mg qd to avoid prescribing 2 medications. Additionally, I would suggest CBT for the patient.

References

Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.15, DSM-IV to DSM-5 Generalized Anxiety Disorder

https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t15/

Thase, M. E. (2007). BOLDER II study of quetiapine therapy for bipolar depression. 
Future Neurology, 
2(4), 373–377.

https://doi.org/10.2217/14796708.2.4.373

Substance Abuse and Mental Health Services Administration. Impact of the DSM-IV to DSM-5 Changes on the National Survey on Drug Use and Health [Internet]. Rockville (MD): Substance Abuse and Mental Health Services Administration (US); 2016 Jun. Table 3.15, DSM-IV to DSM-5 Generalized Anxiety Disorder

https://www.ncbi.nlm.nih.gov/books/NBK519704/table/ch3.t15/

Yatham LN, Kennedy SH, Parikh SV, Schaffer A, Bond DJ, Frey BN, Sharma V, Goldstein BI, Rej S, Beaulieu S, Alda M, MacQueen G, Milev RV, Ravindran A, O’Donovan C, McIntosh D, Lam RW, Vazquez G, Kapczinski F, McIntyre RS, Kozicky J, Kanba S, Lafer B, Suppes T, Calabrese JR, Vieta E, Malhi G, Post RM, Berk M. Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disord. 2018 Mar;20(2):97-170.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5947163/