Case #2
A young woman with Depression

A young woman with Depression

 

Decision Point One


 Bipolar I, current phase, depressed
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:


Begin Latuda 40 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Stefanie states that she thinks that her depression “may be a bit better.” She also reports that she has only had one of her “make everything right” days.
  • She does report that she has been having a new problem: the inability to “sit still.” She states that she notices that she has to move every few minutes, otherwise, she feels uncomfortable.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Increase Latuda to 80 mg orally daily
Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have 5 or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

In this case, the Latuda was clearly causing problems with akathisia. Defined as an inability to sit still, or an inner feeling of restlessness, akathisia can be quite concerning to those with the condition.

In this case, increasing the Latuda is the worst thing you can do, as that will most likely intensify the akathisia. Reminding the client to take the medication with food is important because Latuda should be taken with a 350-calorie meal in order to ensure absorption of the drug. However, in this case, the side effect Stefanie is complaining about is not food-related.

Cogentin would not be appropriate since beta-blockers (propranolol 20–40 mg orally BID) are considered first-line treatment for drug-induced akathisia. Cogentin could be used, but it is not a first-line treatment.

Of the available options, decreasing the dose of Latuda is the most correct answer; however, the proper course of action would be to discontinue the drug. Alternatively, decreasing the offending drug could alleviate the symptoms.


Remind Stefanie to take her Latuda with a meal
Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have 5 or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

In this case, the Latuda was clearly causing problems with akathisia. Defined as an inability to sit still, or an inner feeling of restlessness, akathisia can be quite concerning to those with the condition.

In this case, increasing the Latuda is the worst thing you can do, as that will most likely intensify the akathisia. Reminding the client to take the medication with food is important because Latuda should be taken with a 350-calorie meal in order to ensure absorption of the drug. However, in this case, the side effect Stefanie is complaining about is not food-related.

Cogentin would not be appropriate since beta-blockers (propranolol 20–40 mg orally BID) are considered first-line treatment for drug-induced akathisia. Cogentin could be used, but it is not a first-line treatment.

Of the available options, decreasing the dose of Latuda is the most correct answer; however, the proper course of action would be to discontinue the drug. Alternatively, decreasing the offending drug could alleviate the symptoms.


Decrease Latuda to 20 mg orally daily
Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have 5 or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

In this case, the Latuda was clearly causing problems with akathisia. Defined as an inability to sit still, or an inner feeling of restlessness, akathisia can be quite concerning to those with the condition.

In this case, increasing the Latuda is the worst thing you can do, as that will most likely intensify the akathisia. Reminding the client to take the medication with food is important because Latuda should be taken with a 350-calorie meal in order to ensure absorption of the drug. However, in this case, the side effect Stefanie is complaining about is not food-related.

Cogentin would not be appropriate since beta-blockers (propranolol 20–40 mg orally BID) are considered first-line treatment for drug-induced akathisia. Cogentin could be used, but it is not a first-line treatment.

Of the available options, decreasing the dose of Latuda is the most correct answer; however, the proper course of action would be to discontinue the drug. Alternatively, decreasing the offending drug could alleviate the symptoms.


Lamictal 100 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Stefanie presents today with concerns about a rash that began about 1 week after starting the Lamictal dose. The rash appears as erythematous macules and papules that initially began on her stomach, but spread to the periphery over the past 2 weeks. The lesions multiplied until they became confluent, and now involve the oral mucosa as well as her hands and feet. Stefanie denies fever, chills, lymphadenopathy, sore throat, malaise, or arthralgia.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Transfer to the hospital immediately
Guidance to Student

Exanthematous reactions are the most common adverse drug reaction, and the above description of Stefanie’s rash is consistent with an exanthematous reaction. These rashes generally resolve within 2 weeks after you discontinue the offending medication; however, some sources argue that exanthems may resolve without stopping the medication, especially if there are no other alternatives to the offending agent.

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

Since there are other therapeutic options to treat Stefanie, the most appropriate course of action would be to discontinue the Lamictal. It should also be noted that the drug should have been started at 25 mg orally for at least 2 weeks, and then titrated upward to minimize the risk of rashes.

The description of this rash plus the absence of constitutional symptoms such as fever, chills, lymphadenopathy, sore throat, malaise, or arthralgia are inconsistent with Stevens-Johnson syndrome/toxic epidermal necrolysis; therefore, emergent transport to the ER would be unnecessary.


Discontinue Lamictal
Guidance to Student

Exanthematous reactions are the most common adverse drug reaction, and the above description of Stefanie’s rash is consistent with an exanthematous reaction. These rashes generally resolve within 2 weeks after you discontinue the offending medication; however, some sources argue that exanthems may resolve without stopping the medication, especially if there are no other alternatives to the offending agent.

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

Since there are other therapeutic options to treat Stefanie, the most appropriate course of action would be to discontinue the Lamictal. It should also be noted that the drug should have been started at 25 mg orally for at least 2 weeks, and then titrated upward to minimize the risk of rashes.

The description of this rash plus the absence of constitutional symptoms such as fever, chills, lymphadenopathy, sore throat, malaise, or arthralgia are inconsistent with Stevens-Johnson syndrome/toxic epidermal necrolysis; therefore, emergent transport to the ER would be unnecessary.


Continue Lamictal
Guidance to Student

Exanthematous reactions are the most common adverse drug reaction, and the above description of Stefanie’s rash is consistent with an exanthematous reaction. These rashes generally resolve within 2 weeks after you discontinue the offending medication; however, some sources argue that exanthems may resolve without stopping the medication, especially if there are no other alternatives to the offending agent.

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers.

Since there are other therapeutic options to treat Stefanie, the most appropriate course of action would be to discontinue the Lamictal. It should also be noted that the drug should have been started at 25 mg orally for at least 2 weeks, and then titrated upward to minimize the risk of rashes.

The description of this rash plus the absence of constitutional symptoms such as fever, chills, lymphadenopathy, sore throat, malaise, or arthralgia are inconsistent with Stevens-Johnson syndrome/toxic epidermal necrolysis; therefore, emergent transport to the ER would be unnecessary.


Begin psychotherapy using a psychodynamic approach

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Stefanie reports that she is doing “alright.” She states that she does not like her therapist and feels as though therapy is not helping. She states that her symptoms are stable and does not know if counseling is for her.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Encourage Stefanie to find a new counselor
Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers. Lithium in this case may be a bit ambitious. Similarly, the starting dose of Lamictal is also a bit ambitious in consideration of Stefanie’s overall symptom profile. Also, the Lamictal dose listed is too high and risk of adverse drug rashes increases if Lamictal is initiated at too high a dose. Lamictal should be initiated at 25 mg orally daily, and slowly titrated up to achieve symptomatic control.

In this case, Stefanie did not like the counselor she began working with. The PMHNP knows that in the case of cyclothymic disorder, counseling could help with depressive symptoms. If a client does not like or get along with their counselor, the PMHNP should encourage the client to find another counselor and try working with that person. The therapeutic alliance is an essential component of counseling and if the client perceives absence of alliance, the likelihood of an effective working relationship decreases.


Discontinue counseling and begin Lamictal 100 mg orally daily, instead
Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers. Lithium in this case may be a bit ambitious. Similarly, the starting dose of Lamictal is also a bit ambitious in consideration of Stefanie’s overall symptom profile. Also, the Lamictal dose listed is too high and risk of adverse drug rashes increases if Lamictal is initiated at too high a dose. Lamictal should be initiated at 25 mg orally daily, and slowly titrated up to achieve symptomatic control.

In this case, Stefanie did not like the counselor she began working with. The PMHNP knows that in the case of cyclothymic disorder, counseling could help with depressive symptoms. If a client does not like or get along with their counselor, the PMHNP should encourage the client to find another counselor and try working with that person. The therapeutic alliance is an essential component of counseling and if the client perceives absence of alliance, the likelihood of an effective working relationship decreases.


Begin Lithium 300 mg orally twice a day
Guidance to Student

In order to meet the criteria for a major depressive episode, the client needs to have five or more symptoms (refer to DSM–5 major depressive episode criteria). She only demonstrates criteria # 1: depressed mood most of the day, nearly every day, as indicated by either subjective reports (e.g., feels sad, empty, or hopeless) or observation made by others (e.g., appears tearful); criteria # 6: “fatigue or loss of energy nearly every day”; and criteria # 8: “diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others).” Thus, Stefanie does not meet the criteria for a major depressive episode as she only has three out of the needed five criteria for the diagnosis of a major depressive episode.

In order to meet criteria for a hypomanic episode, the client needs to have a period of abnormally and persistently elevated, expansive, or irritable mood, and abnormally and persistently increased activity or energy, lasting at least 4 consecutive days and present most of the day, nearly every day. Stefanie’s symptoms last 3 days. Additionally, during the period of mood disturbance, the person must have three or more of the qualifying symptoms. Stefanie only has an increase in goal-directed activity and distractibility. Thus, Stefanie does not meet criteria for a hypomanic episode as she only has a decreased need for sleep and an increase in goal-directed activity.

Since Stefanie has symptoms of both hypomania and depression (but does not meet the criteria for a major depressive or hypomanic episode), and since these behaviors do not occur in the context of a drug/substance or medical condition, Stefanie meets the diagnostic criteria for cyclothymic disorder.

Some providers will treat cyclothymic disorder with pharmacologic agents used to treat bipolar disorder because individuals with cyclothymic disorder have a higher risk of progression to bipolar disorder. However, there is no consensus in the literature as to the optimal treatment, or if prophylactic psychopharmacologic treatment is beneficial in consideration of the side effects associated with antipsychotics and mood stabilizers. Lithium in this case may be a bit ambitious. Similarly, the starting dose of Lamictal is also a bit ambitious in consideration of Stefanie’s overall symptom profile. Also, the Lamictal dose listed is too high and risk of adverse drug rashes increases if Lamictal is initiated at too high a dose. Lamictal should be initiated at 25 mg orally daily, and slowly titrated up to achieve symptomatic control.

In this case, Stefanie did not like the counselor she began working with. The PMHNP knows that in the case of cyclothymic disorder, counseling could help with depressive symptoms. If a client does not like or get along with their counselor, the PMHNP should encourage the client to find another counselor and try working with that person. The therapeutic alliance is an essential component of counseling and if the client perceives absence of alliance, the likelihood of an effective working relationship decreases.