St Thomas University Mental Health Patients Essay

Goal:To analyze and apply critical thinking skills in the psychopathology of mental health patients and provide treatment and health promotion while applying evidence-based research.

Chapter 6, Case 1Trisha is a 28-year-old, unemployed white female. She is no stranger to therapy, having seen counselors for most of her teen and adult years. Her friends would describe her as a “wild woman” who takes no crap from anyone. She has held various part-time jobs for the last few years because she usually gets angry at her boss or coworkers and quits. While she has had a string of boyfriends over the years, she has been seeing one man for the last year or so. He too is unemployed and has both an alcohol and methamphetamine problem. She describes the relationship as “addictive and dysfunctional, yet exciting and hot.” Trisha is back in treatment at the urging of her parents, who describe her behavior as erratic and unpredictable. They also claim that she has periods where she “sleeps little and parties lots.” There were also several occasions in the last five years when she was so depressed she didn’t eat or want to leave the house. Her father also admits to periods of depression, and Trisha’s grandfather was diagnosed with manic depression, resulting in numerous hospitalizations in the 1950s and 1960s. Trisha’s only brother died in a car accident several years ago. He was drunk at the time, but she claims he had a long history of depression. Recently Trisha was arrested for disorderly conduct at a friend’s party. She had not slept for nearly 24 hours and was drunk and combative. When she was first approached by police, she solicited them for sex. They report that she was rather hyperverbal and hyperactive. They later had to investigate a complaint from local storeowners for bad checks she wrote in excess of $7,000.Questions:

Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.

YOUR RESPONSE MAY BE DIFFERENT THAN THE DIAGNOSIS AND TREATMENT FOUND IN YOUR TEXTBOOK.

Summarize the clinical case.

What is the DSM5 diagnosis?  Identify the rationale for your diagnosis using the DSM5 diagnostic criteria.

According to the clinical guidelines, which one pharmacological treatment is most appropriate to prescribe? Include the medication name, dose, frequency and rationale for this treatment.

According to the clinical guidelines, which one non-pharmacological treatment would you prescribe? (exclude psychotherapy modalities)  Include the risk and benefits of the chosen rationale for this treatment.

Include an assessment of medication’s appropriateness, cost, effectiveness, safety, and potential for patient adherence.

Use a local pharmacy to research the cost of the medication. Use great detail when answering questions 3-5.

Psychopharmacology
MOOD STABILIZING AGENTS, PART 2
Neurobiology of Bipolar Disorder
Alteration of Brain Regions
Brain region:
Hypothalamus (decreased
sleep/arousal)
Brain region: Amygdala
(mood)
Brain region: Basal
forebrain (decreased
sleep/arousal)
Brain region: Prefrontal
cortex (racing thoughts,
grandiosity, distractibility,
talkative, pressured
speech, mood)
Brain region: Nucleus
acumbens (racing
thoughts, goal-directed
grandiosity)
Diagnostic Criteria for Bipolar Disorder I
Must have one or
more episodes of
mania
Must have one or
more depressive
episodes
Depressive
episodes may last
for weeks or
months
May have
hypomania (less
than full blown
mania)
Manic episode
must last for at
least one week
Not a result of intoxication
or medical condition.
(Diagnostic and Statistical Manual of Mental
Disorders [DSM], 2013)
MANIA : DIGFAST
D: Distractibility (low concentration, easily distractible)
I: Insomnia
G: Grandiosity (feelings of greatness, superiority, uniqueness)
F: Flight of ideas (multiple ideas expressed together in speech, making it barely understandable)
A: increase in goal-directed Activities (continuous search for pleasurable activities: spending money, hypersexuality, smoking,
drinking alcohol, taking drugs,…)
S: pressured Speech (rapid speech, talking too much, almost unstoppably)
T: Thoughtlessness (high risk activities: sex, projects, drugs,…)
Major depressive symptoms lasting
for 2 weeks
Diagnostic
Criteria for
Bipolar II
Disorder
At least one hypomanic episode:
less severe than a full blown manic
episode
Not a result of drug intoxication or medical
condition.
(Diagnostic and Statistical Manual of Mental Disorders [DSM], 2013)
Mood swings between major depressive
symptoms and less severe symptoms of BP
Diagnostic
Criteria for
Cyclothymic
Disorder
Hypomanic symptoms episode: less severe
than a full blown manic episode
Cycle of symptoms present more than 2 years
Not a result of intoxication or medical condition.
(Diagnostic and Statistical Manual of Mental Disorders [DSM], 2013)
Mood Stabilizers: Anti-Mania Agents
Valproate and derivatives (divalproex sodium – Depakote)
Carbamazepine (Tegretol)
Gabapentin (Neurontin) (least side effects)
Lamotrigine (Lamictal)
Topiramate (Topamax)
◦ Highly protein bound
◦ Metabolized by the cytochrome P-450 system
◦ Side effects: dizziness, drowsiness, tremor, visual disturbance, nausea, & vomiting
Pharmacological Interventions for
Bipolar Disorder- Anticonvulsants
Different mechanisms of actions
Various anticonvulsants used to manage and treat bipolar
disorder
Effectiveness has been shown to treat mania in bipolar disorders
Several anticonvulsants are used as mood stabilizer drugs to
manage phases of bipolar disorders
Valproic Acid (Depakote)
Off label use: treat
acute manic phase of
bipolar disorder
Valproic Acid’s
characteristics
Dosing: 250-500mg
po tid, Max
60mg/kg/day
Long term use to
minimize future
manic episodes
It may help prevent
future depressive
episodes
Inhibition of voltage
sodium channels
Boosts GABA actions
and regulation of
downstream signal
transduction cascades
Antimanic actions
possibly caused by
excessive
neurotransmission.
It can help treat rapid
cycling and mixed
episodes of mania
➢ Valproic Acid Recommendations
Monitor valproic acid blood levels 50-125 mcg/ml, toxic
level 150 mcg/ml
➢ Valproic Acid’s Common Side Effects
Weight gain
Valproic Acid
(Depakote)
Metabolic complications
Menstrual disturbances
Black box warning: May cause hepatotoxicity, Fetal injury,
and pancreatitis
Used off label: Manic phase of bipolar
disorder
Formulation: ER cap, tab, ER tab, chewable
and suspension.
Carbamazepine
(Tegretol)
Used when patients have not responded to
lithium
Dosing: 400-800 mg maintenance dose
Mechanism of action hypotheses include:
Blockage of voltage-sensitive sodium
channels
Pharmacokinetics
◦ Highly protein bound, metabolized by
P450 system (potential drug-drug
interaction)
Carbamazepine (Tegretol)
Carbamazepine’s characteristic and side effects
Inducer of CYP450 and Self Inducer
Sedation
Bone marrow suppressor
Fetal toxicity
Black box warning: 1) Serious and fatal skin reactions increased with
persons with HLA-B*1502 allele (primarily Asian patients) and, 2)
risk for aplastic anemia or agranulocytosis
Lamotrigine (Lamictal)
FDA Approved: Bipolar I Disorder maintenance
Off label: First-line treatment for bipolar depression, Not approved for acute bipolar mania
Formulation: tabs, dose pack
Gradual dosing: Week 1-2, 25mg daily, Week 3-4, 50mg daily, then adjust as needed by 50mg/daily
➢ Lamotrigine’s characteristics and side effects
Binds to the open channel conformation of voltage-sensitive sodium channels (VSSC)
Lower potency at the sodium channels
Reduces the release of excitatory neurotransmitter glutamate
Increased likelihood to cause serious rashes/Stevens Johnson Syndrome
Lamotrigine levels are not required
Black box warning: Stephen-Johnson’s syndrome is a medical emergency (life threatening)
Off label use: bipolar disorder
Formulation: tablets and suspension
Dosing: 600mg-1,200mg po bid
Oxcarbazepine’s characteristics and side effects
MOA: Similar mechanism of action of carbamazepine
Oxcarbazepine
(Trileptal)
Binds open change conformation of the VSSC
Less sedative than carbamazepine
Less bone marrow toxicity
Fewer CYP 3A4 interactions
May cause Stevens-Johnson syndrome
Gabapentin (Neurontin)
Pregabalin (Lyrica)
USED AS AN ADJUNCTIVE
AGENT FOR BIPOLAR
DISORDER
VERY LIMITED ACTION AS
MOOD STABILIZERS
OFF LABEL USE:
NEUROPATHIC PAIN,
FIBROMYALGIA, ALCOHOL
DEPENDENCE AND
ANXIETY DISORDERS
BLOCKS VSCCS, WHICH
CAN HELP IMPROVE
SEIZURES, PAIN, AND
ANXIETY
FORMULATION: CAPS
AND SOLUTION
GABAPENTIN DOSING:
300MG-600MG PO TID
PREGABALIN IS
CONSIDERED A SCHEDULE
V DRUG
GABAPENTIN MAY BE
CONSIDERED A
SCHEDULED DRUG IN
SOME STATES
FDA Approved: Anticonvulsant, Migraine headache prophylaxis, and in
combination with Phentermine for weight loss for obese patients
Off label use: alcohol dependence, bulimia
Topiramate
(Topamax)
Formulation: tablets and capsules
Dosing: 100-150mg po bid
Topiramate’s characteristics and side effects
• Potentiates the inhibition of GABA
• Effects as a mood stabilizer have been limited
• Used as an adjunctive agent for bipolar disorder to manage weight gain,
insomnia, anxiety
D2 antagonistic actions
Other
Pharmacological
Interventions for
Bipolar DisorderAtypical
Antipsychotics
Mechanism of action to manage mania is unknown
Used as an adjunctive agent in bipolar disorder
Believed to reduce glutamate hyperactivity via antagonistic actions
of 5HT2A leading to reduction of manic and depressive symptoms
Used to manage psychotic symptoms associated with mania
Used to prevent recurrence of mania
Not formally approved as mood stabilizers
Used as a calming agent
Used as need for agitation, insomnia, and to attempt to halt manic symptoms
Used intermittently with mood stabilizers to prevent more severe symptoms
They need to be used with caution
Other Pharmacological Interventions for
Bipolar Disorder-Benzodiazepines
Other Pharmacological Interventions for
Bipolar Disorder
➢Wakefulness Drugs
Modafinil and Armodafinil
Off label use: bipolar depression
Used as adjunctive agent to atypical antipsychotics
➢ Hormones and Natural products
Omega 3 fatty acid
Believed to have mood stabilizing properties
Inositol used as an augmenting agent
Vitamin folate is used with a mood stabilizing anticonvulsants
Used in case by case basis
Other
Pharmacological
Interventions for
Bipolar DisorderAntidepressants
Monotherapy is not recommended
May be used in combination with mood stabilizers
Wellbutrin the most recommended
antidepressant and TCAs the least recommended
Choosing the right treatment for the patient
Prudent assessment of patient’s symptoms:
Avoid antidepressant monotherapy
A combination of mood stabilizers is a recommended approach to manage
symptoms
Best evidence-based combinations include:
Lithium and an antipsychotic agent
Valproic Acid and an antipsychotic agent
Gender considerations
Women with bipolar disorder are more prone to experience
depression compared to men
Choosing the
right treatment
for the patient
Women are more likely than men to report atypical or vegetative
symptoms (e.g. increased appetitive and weight gain)
Anxiety and eating disorders are more frequent in women with
bipolar disorder
A postpartum period is a critical period for women to experience
depressive, manic, mixed, or psychotic symptoms associated with
bipolar disorder
Chlorpromazine-Thorazine
Clozapine—Clozaril
Lurasidone-Latuda
Antipsychotics
Olanzapine—Zyprexa
Quetiapine—Seroquel
Risperidone—Risperdal
Ziprasidone—Geodon
Aripiprazole—Abilify
Typical, 1st generation antipsychotic
FDA Approved for bipolar mania in adults, severe
behavioral problems in children
Chlorpromazine
(Thorazine)
Side Effects
Available in tabs and IM injection
Weight gain
Erectile dysfunction, retrograde ejaculation, loss of libido
and anorgasmia in men and women
Seizures – generalized grand mal
Black box warning and Beers Criteria list: Avoid in patients
with dementia
Neuroleptic malignant syndrome: combination of motor
rigidity, hyperthermia, and autonomic dysregulation of blood
pressure and heart rate (both go up)
Can be fatal if untreated
Chlorpromazine
(Thorazine)
Adverse Effects
Drug collects in skin and sunlight causes pigmentation
changes – grayish-purple splotching like bruising)
Can also occur in eye and cause brown in cornea
Agranulocytosis
Black box warning and Beers Criteria list: Avoid in patients with
dementia
Atypical Antipsychotic
Used when other antipsychotics have failed
Reduces the risk of suicide in patients with schizophrenia
Clozapine
(Clozaril)
Neutropenia (WBC