Within patient reporting recent suicidal thoughts and past suicidal attempts, do you feel starting her on Lithium is appropriate at this PHP level of care and setting?
The case of this patient is complex and requires certain evaluations. On the one hand, Lithium seems to be an appropriate decision for treating this 31-year-old woman who is diagnosed with alcohol use disorder, bipolar II disorder, and generalized anxiety disorder (GAD). Lithium was proven one of the best suicide preventing options for long-term treatment (Lewitzka et al., 20115). Compared to placebo, lithium can be a part of monotherapy or pharmacotherapy along with antidepressants (Kessing et al., 2018). There is no definite answer to the question of how lithium helps patients. Still, the possibility to reduce the risks of suicides among people is the achieved outcome that makes physicians and psychiatrists choose this medication.
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On the other hand, it is necessary to admit that in addition to the already mentioned mental health complications, the patient suffers from multiple suicidal thoughts and attempts during the last ten years with only two psychiatric hospitalizations. The level of her participation in patient hospitalization programs remains zero. Lithium, as well as other medications, is characterized by toxicity and overdose in case it is not observed by a professional practitioner.
The use of this medication can be lethal for some patients. Therefore, it is recommended to change traditional treatment (if this one is chosen) to treatment under thorough observations in a clinical setting. The patient is the mother of three children. She may not memorize things and forget to take medications or hide them to protect her children. Her treatment should be safe for her and her family. Therefore, Lithium can be appropriate at this PHP level of care only in case the level and the setting are changed for the next two weeks.
With history of bipolar and presenting depressed mood, would you consider starting this patient on Lamictal at this point in place of Lexapro?
Modern patients are free to choose treatment methods that can be offered in hospital settings. Lithium and Lexapro are the drugs that are frequently recommended for patients with bipolar disorders, suicidal thoughts, and depressed mood. In this case, the patient possesses the characteristics of all these mental health problems and has to deal with them in order to be a good mother and a socially responsible person. However, there is also the way of treatment that includes Lamictal, also known as Lamotrigine. The investigation by Terao, Ishida, Kimura, Yarita, and Hara (2017) shows that Lamotrigine is effective for patients with bipolar II disorder.
This drug helps to reduce the frequency and severity of mood changes in bipolar disorder patients. However, Lexapro is defined as an antidepressant with few adverse effects compared to other selective serotonin reuptake inhibitors (SSRIs).
The comparison of Lamictal and Lexapro shows that both drugs are approved by the FDA. Both of them aim at treating the cases of depression and anxiety. However, Lamictal is defined as the drug to treat bipolar disorders. Therefore, regarding the fact that the patient does not have allergies and does have a family history of schizophrenia, it seems to be rational to use Lamictal in place of Lexapro. The main positive effect of Lexapro is the possibility to reduce bipolar recurrence. In this case, the patient reports several suicidal thoughts and past diagnoses of GAP and alcohol use disorder. She asks to help her because she cannot stop drinking on her own. It is not enough to stop acute bipolar disorder at this moment. The goal is to make sure that the same cases do not occur in the future.
Kessing, L. V., Bauer, M., Nolen, W. A., Severus, E., Goodwin, G. M., & Geddes, J. (2018). Effectiveness of maintenance therapy of lithium vs other mood stabilizers in monotherapy and in combinations: A systematic review of evidence from observational studies. Bipolar Disorders, 20(5), 419-431. Web.
Lewitzka, U., Jabs, B., Fülle, M., Holthoff, V., Juckel, G., Uhl, I.,… Bauer, M. (2015). Does lithium reduce acute suicidal ideation and behavior? A protocol for a randomized, placebo-controlled multicenter trial of lithium plus treatment as usual (TAU) in patients with suicidal major depressive episode. BMC Psychiatry, 15(1), 117-130. Web.
Terao, T., Ishida, A., Kimura, T., Yarita, M., & Hara, T. (2017). Preventive effects of Lamotrigine in bipolar II versus bipolar I disorder. The Journal of Clinical Psychiatry, 78(8), 1000-1005. Web.