Case #2
A young woman with Depression

A young woman with Depression

 

Decision Point One


 Cyclothymic disorder
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:


Begin Depakote 250 mg orally three times daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Stefanie returns to your office and informs you that she had to stop taking the medication last week. “I have been too tired to do anything,” she explains, “plus, I have gained about 2 pounds since I started this medicine… I can’t keep gaining weight like this.”
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Explain to Stefanie that weight gain and sedation are temporary side effects and encourage her to restart the medication
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.

Whereas the side effects of many medications may be transient, weight gain associated with Depakote can continue for the duration of treatment. Decreasing the dose may serve only to slow the rate of weight gain; but of the available choices, this would be the most correct choice (although not the “correct” answer, it will minimize the side effects of this medication). Doubling the dose will of course increase sedation and most likely weight gain.


Decrease the dose to 125 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.

Whereas the side effects of many medications may be transient, weight gain associated with Depakote can continue for the duration of treatment. Decreasing the dose may serve only to slow the rate of weight gain; but of the available choices, this would be the most correct choice (although not the “correct” answer, it will minimize the side effects of this medication). Doubling the dose will of course increase sedation and most likely weight gain.


Increase the dose to 500 mg orally twice a day, and explain that weight gain and sedation are problematic only at lower doses
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.

Whereas the side effects of many medications may be transient, weight gain associated with Depakote can continue for the duration of treatment. Decreasing the dose may serve only to slow the rate of weight gain; but of the available choices, this would be the most correct choice (although not the “correct” answer, it will minimize the side effects of this medication). Doubling the dose will of course increase sedation and most likely weight gain.


Begin Abilify 10 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Stefanie reports that her mood seems a bit more “stable.” She states that she notices that she has not been as “sad” since she started taking the medication. She does report that for the first 2 weeks, she noticed that whenever she went from a lying or sitting to a standing position, she felt “lightheaded.”
  • She does report that the side effect was quite concerning at times. However, she reports that this is no longer happening.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Maintain current dose of Abilify
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.

Stefanie’s symptoms are most consistent with orthostatic hypotension, which is not uncommon when initiating Abilify. At this point, it sounds as if the side effects have subsided. There is nothing to tell us that we should increase the dose. Similarly, there is nothing in the case to tell us that we should discontinue the Abilify. Instead, routine monitoring should occur.


Increase Abilify to 15 mg orally daily
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.

Stefanie’s symptoms are most consistent with orthostatic hypotension, which is not uncommon when initiating Abilify. At this point, it sounds as if the side effects have subsided. There is nothing to tell us that we should increase the dose. Similarly, there is nothing in the case to tell us that we should discontinue the Abilify. Instead, routine monitoring should occur.


Discontinue Abilify
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.

Stefanie’s symptoms are most consistent with orthostatic hypotension, which is not uncommon when initiating Abilify. At this point, it sounds as if the side effects have subsided. There is nothing to tell us that we should increase the dose. Similarly, there is nothing in the case to tell us that we should discontinue the Abilify. Instead, routine monitoring should occur.


Arrange to see Stefanie every 3 months for routine follow-up

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in twelve weeks
  • Stefanie returns to the clinic in 12 weeks and reports that she feels no different. Her symptoms continue to follow the same pattern as they did when she first came to your office.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Begin cognitive behavioral therapy
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.

The PMHNP’s assessment should include an assessment of the impact of Stefanie’s symptoms on her overall functioning. The PMHNP should discuss treatment options with Stefanie. It could be that the management approach would be simply to monitor Stefanie on an ongoing basis for worsening of symptoms if Stefanie is averse to using medications. Should any future worsening of symptoms be noted, Stefanie may opt to receive pharmacologic treatment at that point. Treatment with psychotherapy to address baseline depression could be beneficial as well. Again, it is important for the PMHNP to determine the severity of existing symptoms; their impact on Stefanie’s life; and, of course, to discuss risks/benefits of treatment so that Stefanie can make an informed choice.


Begin Latuda 40 mg orally daily
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.

The PMHNP’s assessment should include an assessment of the impact of Stefanie’s symptoms on her overall functioning. The PMHNP should discuss treatment options with Stefanie. It could be that the management approach would be simply to monitor Stefanie on an ongoing basis for worsening of symptoms if Stefanie is averse to using medications. Should any future worsening of symptoms be noted, Stefanie may opt to receive pharmacologic treatment at that point. Treatment with psychotherapy to address baseline depression could be beneficial as well. Again, it is important for the PMHNP to determine the severity of existing symptoms; their impact on Stefanie’s life; and, of course, to discuss risks/benefits of treatment so that Stefanie can make an informed choice.


Begin Abilify 10 mg orally daily
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.

The PMHNP’s assessment should include an assessment of the impact of Stefanie’s symptoms on her overall functioning. The PMHNP should discuss treatment options with Stefanie. It could be that the management approach would be simply to monitor Stefanie on an ongoing basis for worsening of symptoms if Stefanie is averse to using medications. Should any future worsening of symptoms be noted, Stefanie may opt to receive pharmacologic treatment at that point. Treatment with psychotherapy to address baseline depression could be beneficial as well. Again, it is important for the PMHNP to determine the severity of existing symptoms; their impact on Stefanie’s life; and, of course, to discuss risks/benefits of treatment so that Stefanie can make an informed choice.