Admission Date: 8/10/2018
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Allergies: Seasonal (pollinosis)
VS: BP 132/85, HR 72, Respirations 16, Pulse Ox 96%
Chief Complaint: “I feel the flight of ideas and hypermaniacal episodes”
HPI: A 34-year-old patient complains about concentration and depression. He has recently impulsively quit his job and has not been sleeping for the last several days. JS denies alcohol and illicit drug abuse, yet confirms smoking a pack of cigarettes per day. The patient admits that he becomes angry and aggressive, which he regrets afterward. He suggests that he has depression and claims to feel worthlessness and critically increased fatigue, which occurred 2 months ago.
Past Psychiatric History: The patient was diagnosed with major depression in 2017 after his wife’s death in the car accident and anxiety disorder in 2013 after losing his job. JS takes Celexa 30 mg per day. No suicidal attempts are reported.
Hx of Violence to others: No incidents.
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Previous psychiatric hospitalizations: 0
Trauma History: Psychological trauma caused by the death of the wife and dismissal.
Family Psychiatric History: the older brother has anxiety disorder diagnosed at the age of 18.
Background and Social History:
Place of Birth: South Carolina
Father: Deceased, SC
Mother: Deceased, MO
Social: Communicates with friends once a week and visits the brother’s family once a month.
Alcohol: 2 bottles of beer on weekends
Legal HX: None
Med/Surgical HX: N/A
Medications: Celexa 30 mg PO daily
Labs: the functional MRI (fMRI) shows increased neuronal activity, WNL including Na+ and thyroid levels is normal.
Mental Status Exam: Normal speech, cooperative, anxious, disoriented to some extent, depressed, tends to avoid eye contact, proves psychosis, responds to questions adequately, mood swings, increases in energy, and depressing thoughts.
Primary Psychiatric Diagnoses:
- Bipolar II disorder; DSM: 296.89
- Generalized anxiety disorder; DSM: 300.02
- Major depression; DSM 296.32
- Bipolar disorder and depression – Lithium 300mg PO BID and Celexa 30 mg PO daily;
- Anxiety disorder – Xanax 0,5 mg PO per day and Lamotrigine 25 mg PO daily;
As a 34-year-old patient-facing severe depression, JS has been showing a fast decline in the number of social interactions and developing symptoms such as pessimism, and hopelessness. Therefore, the patient requires stabilizers of mood (Timoleptics). Lithium has to be administered to the patient starting at 600 mg/L. The specified dosage should be reduced to 300 mg/L as the patient begins to recover.
Thus, possible side effects can be avoided (Malhi, Tanious, Das, Coulston, & Berk, 2013). Besides, the administration of SSRIs such as Celexa will be required to strengthen the inhibitory effect of endogenous GABA (Farinde, 2013). SSRIs and monitoring checks are required to ensure that the patient’s condition does not aggravate. The patient has had mood swings, which is typical for a bipolar disorder (Malhi et al., 2013). Therefore, Lithium should be seen as the key measure for addressing the specified symptoms (Tränkner, Sander, & Schönknecht, 2013). Xanax and Lamotrigine, in turn, should be used as the means of addressing the development of the anxiety disorder in the patient.
The case under analysis shows that sociocultural and socioeconomic factors play a crucial role in diagnosing disease and locating the available treatment options, as well as developing and implementing a particular intervention plan. Particularly, it is crucial to create a socially welcoming environment in which the patient will feel inclined to communicate and participate in interactions with community members. With the help of the specified measure, the process of recovery will occur at a faster pace. Particularly, family involvement should become a crucial part of the therapy, with family members and friends assisting the patient in addressing the disorder.
The following questions may be formulated to contribute to the discussion of the case:
- How will improving health outcomes of the patient affect the dosage of the prescribed medication, considering side effects and combinations?
- What are the issues that should be taken into account while changing medical treatment for this patient?
Answers to the Questions
Question 1: Answer
When considering the administration of the prescribed drugs to the patient, one should keep in mind that there is a strong probability of the patient developing side effects in case the dosage of Lithium remains the same throughout the recovery process. Therefore, it is strongly recommended to reduce the dose of the medication administered to the patient as the latter shows the signs of health improvement.
Otherwise, the side effects may include nausea, vomiting, loss of appetite, and drowsiness. While seemingly mild, the specified outcomes may aggravate to the point where a patient’s death will ensue (Malhi et al., 2013). Therefore, a drop in the dosage of Lithium during the recovery phase is recommended. Particularly, in the acute control phase, 600 mg/day is required, whereas the transfer to the long-term control will imply a shift to 300 mg/day.
Question 2: Answer
During the treatment process, the transfer from using Lamotrigine to applying Celexa in combination with Xanax may become necessary. In the specified scenario, one must keep in mind that, when used together with Celexa, Xanax has a strong sedative effect, which means that the patient may develop drowsiness. Therefore, the identified outcomes must be taken into consideration when shifting from the use of Lamotrigine to Celexa.
The stimulation of benzodiazepine receptors that can be found in the allosteric center of the postsynaptic GABA receptors will have a positive effect on the patient’s current state of health. Besides, the shift toward social interactions should occur at the later stage of the recovery. Therefore, potential communication issues need to be identified and prevented respectively. Thus, a smooth transition to the realm of social interactions and communication within the community will be facilitated.
Farinde, A. (2013). Bipolar disorder: A brief examination of lithium therapy. Journal of Basic and Clinical Pharmacy, 4(4), 93-94.
Malhi, G. S., Tanious, M., Das, P., Coulston, C. M., & Berk, M. (2013). Potential mechanisms of action of lithium in bipolar disorder. CNS Drugs, 27(2), 135-153.
Tränkner, A., Sander, C., & Schönknecht, P. (2013). A critical review of the recent literature and selected therapy guidelines since 2006 on the use of lamotrigine in bipolar disorder. Neuropsychiatric Disease and Treatment, 9, 101-111.