Case History and Protocol Development

1.Assessment ; Describe disease process or patient problem with presenting signs and symptoms, describe demographics and background of individual.

2. Diagnosis ; diagnosis work up and rationale for DSMV diagnoses, Discuss criteria, etiology and epidemiology of conditions identified.

3.Implementation : Describe sessions and /or how you implemented or would implement plans for treatment.

4. Evaluation: as an advanced practice nurse how do you see progress or positive change in your patient? what might you have done differently? how did the treatment plan work for this diagnosis and individual person?


Mood Disorders: Case Study Analysis

Current psychiatric and mental health conditions management require evidence-based strategies for positive patient outcomes. Mood disorders are responsible for significant psychiatric morbidity and related mortalities. Patients presenting with mood disorders can have other coexisting psychiatric conditions and medical comorbidities that implicate their management and outcomes of treatment. The purpose of this paper is three-fold: to describe the assessment and diagnosis of a patient problem, present evidence-based management practices for the patient problem, and evaluate the outcomes of these treatments.

Patient Problem

The patient is a 57-year-old female with a mood problem for a long time now and is under treatment. This patient has been accompanied to the office by her sister-in-law. The reason for this visit is that the patient wanted to establish care. After discharge from her last hospital visit, she had been doing fine. Today she feels depressed and reports markedly low energy. The patient believes that her health problem started about 15 years ago. On presentation to a clinician nine years later, she was diagnosed with bipolar disorder after she presented in the manic phase. The patient also believes that at the beginning, her symptoms accompanied menstruation periods. The patient currently uses unspecified quantities of recreational marijuana daily and has a positive history of rehabilitation years ago. However, she does see her marijuana use as recreational. She has no alcohol use history. Four months ago, she was admitted to a local emergency department because she had gone for 114 hours without sleep. She was discharged on sleeping pills. However, this did not improve her sleeplessness because she later drove for more than 300 miles to a major medical center’s psychiatric unit.

Patient Symptoms

Currently, the patient reports a depressed mood, lack of motivation, low energy, and feeling of guilt. She also reports that occasionally, she experiences anxiety attacks. Her depressed mood is also associated with constant worry. However, she denies extreme anger, suicidal ideations, or homicidal thought. She currently reports no sleeplessness, excess energy, grandiose delusions, mood swings, racing thoughts, or hallucinations.

Medical History

She is a known diabetic patient and is currently on metformin 500mg daily. She also reports chronic nausea and vomiting for which she takes ondansetron 8mg BID. Her other medical problems are hypothyroidism, dyslipidemia, and osteoporosis. During her last visit to the hospital, she also had a depressed mood, for which she was prescribed Zoloft (Sertraline) 75 mg QD. She attended a partial hospitalization program for four weeks during this admission before being discharged home 9 days ago on Zoloft 75mg QID, Depakote (sodium valproate) 750 mg QHS, Seroquel (quetiapine) 200mg QHS, and metformin 500 mg daily.

Background (Family and Social History)

The patient lives with her husband. She is actively involved with family activities. Her sister-in-law report that her current symptoms have significantly interfered with her social and functioning capacity.

Examination (Mental State and Physical)

The patient was awake, alert, and oriented in time, place, and person. She is a petite female who appears her stated age. She is well-dressed and appropriate for the visit. Her general hygiene is neat. She has no symptoms of psychomotor agitation. Her gait and motor functions are normal. She makes adequate eye contact and is not easily distracted. Her speech is coherent, prosody is normal, and speech volume is adequate and not loud. Her subjective mood is depressed and anxious. Objectively, she looks depressed. Her affect is mood congruent and appropriate. Cognitively, her recent, remote, and short-term memories are intact. Her concertation is good. Her thought content is normal. She has no active hallucination or grandiosity. Her blood pressure is 128/86 mmHg, pulse rate 67 BPM, and respiratory rate 18 BPM. She is afebrile.


Her current diagnosis is bipolar 1 disorder. Bipolar I disorder is a type of bipolar disorder characterized by alternating episodes of mania and major depressive episodes. This patient met the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)’s criteria for bipolar I disorder in the depressive phase (American Psychiatric Association, 2013). Low energy, depressed mood, inappropriate guilt, diminished interest in pleasure activities, and insomnia are some of the symptoms that make her presentation meet criteria A for a depressive episode. Reports by her sister-in-law indicated that her current symptoms had impaired her social functioning. Her depressive symptoms were preceded by a manic episode that was majorly characterized by decreased need for sleep that sleeping pills and increased energy could not improve. Her past psychiatric history is not positive for schizoaffective disorder, schizophrenia, substance use disorder, or medical comorbidity that could be associated with her current presentation.

Etiology of the Diagnosis

Bipolar disorder (BPD) is a chronic recurrent disabling mental health condition. However, the etiology of bipolar disorder remains unclear. Current hypotheses and risk factors put forward to explain the cause of BD suggest that this condition results from multifactorial etiologies. The involvement the human genes has been greatly emphasized. Genetic aberrations, epigenetic factors, and environmental etiologies have been implicated in the causality of BD (Wang et al., 2019). Genetic hypotheses have explained those variations in genetic makeup that lead to abnormalities in the neurotransmitter system, neuroendocrine regulation, immune pathways, neurodevelopment, and biological rhythm (Rowland & Marwaha, 2018). Acquired and inheritable etiologies leading to epigenetic modification of genetic makeup through DNA methylations and affecting DNA myelination and maturation have also been discussed in scientific evidence. Environmental factors that have been proposed to cause BD or increase the likelihood of occurrence of BD are early trauma, substance abuse, and environmental causes of psychological and physical stress. All these factors lead to abnormalities in the neuronal circuitries and communication in the higher centers of the brain that manifest in systemic physiological and behavioral outcomes (Wang et al., 2019). Systemic outcomes such as metabolic syndrome, oxidative stress, and inflammation are some of the consequences of the abnormalities of neuronal circuitries. Behaviorally, mood, energy, activity, and thinking are affected.

Epidemiology of the Diagnosis

According to the centers for disease control and prevention (CDC), bipolar disorder is one of the top three mental health disorders that contribute to the 1 in every 25 prevalence of serious mental health illnesses that affect Americans (CDC, 2021). According to Vieta et al. (2018), BD affects more than 1% of the global population. Rowland & Marwaha (2018) reported that the lifetime risk of BD among adults is about 1% in the global population. In the same review study by Rowland & Marwaha (2018), the overall prevalence of bipolar spectrum disorders was 2.4%. Bipolar I disorder prevalence was 0.6%, while BD II was 0.4%. This review study also found that the prevalence of BD I and BD II was higher in the USA than the other countries (Rowland & Marwaha, 2018). BD I is common in the United States, with about 1 percent of the national adult population affected.

Bipolar disorder is a disease more commonly diagnosed among adults. The mean age at diagnosis is in the third decade of life. Most studies report that BD is bipolar disorder and is more commonly diagnosed in individuals between 20 and 30 years. However, other studies have suggested another peak of the age of onset in the fifth and sixth decades of life, where the patient in this case study falls. Bipolar disorder has been associated with high other epidemiological factors such as low income, unemployment, unmarried individuals, and living in urban environments (Rowland & Marwaha, 2018). No gender disparities have been reported in the epidemiology of BD because equal prevalence rates have been reported in both sexes. However, DSM-5 reported a male preponderance with a ratio of 1.1:1 for males to the female prevalence of BD (American Psychiatric Association, 2013). Conflicting reports have been documented about racial disparities in the epidemiology of BPD. Some studies reported higher rates among Caucasians, while some reported supported higher rates among non-whites. This uncertainty falls back to uniform rates of reporting and scantiness of data in some populations.

Treatment Planning

The choice of a treatment approach is based on risk-benefit analysis and this should be evaluated by caregivers and patients and they should discern these treatment options from alternative treatment approaches. An example would be to consider whether to give a treatment or opt to avoid giving an intervention. It would be essential to evaluate the probable consequences of administering the treatment and the effects of not giving the treatment. In bipolar disorder, it is vital to understand direct harms and the concept of no benefit from a treatment option. Direct harms are effects that result when a given treatment option is offered to a patient when the intention was to provide benefit to a patient. In a case of no benefit, it’s the deterioration of a patient’s condition which results from being exempted from a treatment modality that might otherwise have provided positive effects. It is possible that causing harm to patients may be a negative consequence of administering treatment rather than the act of withholding a treatment option.

The management of bipolar illness is a sensitive area with numerous research ongoing. The emergent management approaches have included pharmacotherapy coupled with psychotherapeutic approaches which include family-focused therapy and cognitive behaviour therapy. The choice of a treatment approach is dependent on the caregiver and the patient. The forms of choices to be made can be viewed from the following perspectives: 1) which medications or physical treatment options would suit a patient?; 2) what interventions can be applied to curb the adverse effects that result from pharmacotherapy that may have led to patient risks?; 3) is it plausible to administer other treatment options apart from pharmacotherapy implied for the patient?; and 4) is it possible to include other nonpharmacologic treatment approaches for a given patient to disregard psychotherapeutic treatment they are receiving at that time?

Bipolar disorder is characterized by recurrent episodes of elation and depression which affect the functionality of an individual in various setups. This illness may have significant morbidity and mortality and these can be curtailed by various medications and evidence-based psychotherapeutic (EBPs) options. Clinicians should evaluate and understand the best treatment approaches that are supported by evidence and to effect this, the author analysed various randomized control trials (RCTs) that focused on psychotherapeutic treatments in the management of the bipolar disorder in adult patients. It was identified that treatment approaches with evidence supporting their use included social rhythm therapy, cognitive behaviour therapy and interpersonal therapy. Additionally, psycho-education, peer support programs and family-focused therapy are also supported by evidence. Other treatment approaches that may prove beneficial include technology-assisted strategies, functional remediation and recovery. Moreover, illness management and mindfulness-based cognitive therapy may also prove beneficial. The findings from RCTs indicate that coupling medication and these psychotherapeutic options may have a treatment advantage over the choice to use medication therapy only. There are numerous benefits of adjunctive EBPs and these include improving the functionality of individuals, reducing the chances of relapse and shortening the duration needed for remission to occur. Bipolar disorder also leads to cognitive, psychosocial and relational effects and EBPs may be vital in helping patients overcome them. It is proposed that the benefits of EBPs in bipolar disorder should be explored. (Novick, 2019)

Implementation of Interventions and Management of the Health Problem

The patient was mainly managed on pharmacotherapy alone. She was on quetiapine, sertraline, valproic acid, and metformin. However, her symptoms are not well maintained. Therefore, her treatment goals at this moment are to elevate the depressed mood, increase the feeling of energy, reduce the sense of guilt, and increase her levels of motivation. Her occasional worries and feeling of anxiety are not her concerns today and not priority goals for her treatment today as well. Despite management on sertraline, an antidepressant in the class of selective serotonin reuptake inhibitors (SSRIs), her depression is not well managed. Antidepressants are not considered a first-choice treatment for bipolar disorder and bipolar depression, to be specific. Her local practitioner prescribed this medication to manage acute depressive symptoms.

The first decision today was not to increase the sertraline dose but discontinue it and start lamotrigine. Lamotrigine belongs to the class of newer antipsychotics that have been successfully used in the treatment of mental health illnesses such as convulsions and bipolar disorders. Her manic symptoms seemed to be well controlled on valproic acid and Seroquel. The stabilization to maintain her mood would be achieved by medication with a low risk of reverting symptoms to mania. Therefore, lamotrigine was preferred to an actual antidepressant to achieve the goals of treatment today. Lamotrigine lifts depression in BD instead of treating mania. This makes it more appropriate for this patient at this moment in treatment. A review study by Besag et al. (2021) found that lamotrigine is appropriate for bipolar depression in the absence of acute mania. Thus, it should be considered the first choice in these cases because of its efficacy and tolerability.

Lamictal and valproate have drug-drug interactions that can jeopardize the patient’s safety. Therefore, patient education on possible symptoms resulting from this interaction is provided. Based on these decisions, the patient was discharged on additional lamotrigine 25mg PO QID. Four weeks later, the patient presented with good symptoms control on additional lamotrigine. The depressed mood improved, manic symptoms were absent, there were no extreme moods, and appetite and sleep also improved. Things were definitely better for the next three months. However, she reported increased weight gain that was related to valproate and quetiapine. Therefore, these two medications were substituted with cariprazine. Cariprazine is an FDA-approved medication for bipolar I depression. Stahl et al. (2020) reported good efficacy and safety profiles of cariprazine among bipolar patients with depression. For the next six months, good symptomatic control was enhanced by lamotrigine and cariprazine (1.5mg PO QID). However, the depressive symptoms reoccurred. Therefore, sertraline was reintroduced to her regimen, which controlled her symptom well. However, her insurance stopped paying for cariprazine. Therefore, aripiprazole was used to substitute cariprazine. The patient was discharged on aripiprazole 30mg PO daily, lamotrigine 25mg PO QID, and sertraline 100mg QID.

Evaluation of the Patient Progress and Progress

The journey with this patient has been marked with medication substituting and adverse effects. However, it is undeniable that most of the treatment goals were met with each decision made. The first decision to stop sertraline was based on evidence-based practice and ethical decision-making. The goal was to minimize side effects and maximize efficacy. Sertraline is an antidepressant associated with suicidality and an adverse effect. Therefore, its use was not warranted at this moment as the risk outweighed the benefits. Lamotrigine, on the other hand, has reported suicidality but is considered safer due to its tolerability. At this point, what I might have done differently was discontinue Depakote and increase the Seroquel dose to maintain manic symptoms. Depakote increased lamotrigine concentrations in the system, thus risking adverse events with Lamictal. The rash is the most commonly reported adverse event of Lamictal that I would be attempting to avoid in this patient. This rash is usually life-threatening and occurs between the second and eighth week of treatment. Cost implications are serious factors that I would consider before starting cariprazine.

To evaluate patient outcomes, suicidality scores during every visit, patient health questionnaire (PHQ-9) score for depression during every visit, weight measurements, blood pressure assessments, and quality of life scores will be used to evaluate the effectiveness of the management. These evaluation strategies will be appropriate because, alongside evaluating patient safety, the quality of treatment will also be monitored and evaluated. The decision to change patient regimens based on her personal factors will ensure patient-centered care. Considering cost and adherence will be ensured in future appointments. My treatment plan worked because it achieved the patient care goals set at the beginning. Despite the challenges and safety issues, I intended to reduce polypharmacy at the end of the care. Collaborating with her physician to coordinate the management of his medical conditions is another different thing that I would do in this patient’s case.


The patient in this discussion met DSM-5 criteria for bipolar I disorder. She also had other medical conditions, such as dyslipidemia, diabetes mellitus, and hypothyroidism. Bipolar is commonly diagnosed in adults in the third and sixth decades of life. No significant gender predilection has been reported. Proposed etiologies suggest that the role of genes and environment is significant. My management of this patient, who had already been on Seroquel, Depakote, and Zoloft, involved substituting Zoloft for Lamictal. Later in treatment, weight gain necessitated the substitution of Depakote and sequel for cariprazine, but cost implication led to the use of aripiprazole. I consider the management of this patient successful because I met my care objectives.


American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5 (R)) (5th ed.). American Psychiatric Association Publishing.

Besag, F. M. C., Vasey, M. J., Sharma, A. N., & Lam, I. C. H. (2021). Efficacy and safety of lamotrigine in the treatment of bipolar disorder across the lifespan: a systematic review. Therapeutic Advances in Psychopharmacology11, 20451253211045870.

CDC. (2021, November 23). About Mental Health.

Rowland, T. A., & Marwaha, S. (2018). Epidemiology and risk factors for bipolar disorder. Therapeutic Advances in Psychopharmacology8(9), 251–269.

Stahl, S. M., Laredo, S., & Morrissette, D. A. (2020). Cariprazine as a treatment across the bipolar I spectrum from depression to mania: mechanism of action and review of clinical data. Therapeutic Advances in Psychopharmacology10, 2045125320905752.

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., Gao, K., Miskowiak, K. W., & Grande, I. (2018). Bipolar disorders. Nature Reviews. Disease Primers4(1), 18008.

Wang, Z., Jun, C., Gao, K., Yang, H., & Fang, Y. (2019). Perspective on etiology and treatment of bipolar disorders in China: Clinical implications and future directions. Neuroscience Bulletin35(4), 608–612.

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