A 20-Year-Old Woman With Past History Of MDD Is Brought To
A 20 Year Old Woman With A Past History Of Mdd Is Brought To the Local
A 20-year-old woman with a history of major depressive disorder (MDD) is presented to the emergency department exhibiting significant behavioral and mood disturbances. She appears restless and agitated, pacing in the waiting room. Her family reports recent job loss from her role as a tattoo artist, indicating occupational impairment. Recent history also reveals sleep deprivation over four nights, rapid and tangential speech, and engaging in high-cost purchases including a $20,000 car and a $40,000 van, which she intends to use for her mobile tattoo business in Naples, Florida. She displays a lack of insight into the seriousness of her condition and considers her presence at the ED a waste of time. She demonstrates grandiosity, believing she is too important to be constrained by others, suggestive of manic or hypomanic features.
Paper For Above instruction
This case involves a young woman with a known history of major depressive disorder who is currently exhibiting signs consistent with a manic or hypomanic episode. Her clinical presentation includes heightened energy, decreased need for sleep, increased goal-directed activity, impulsivity evidenced by reckless financial decisions, distractibility, rapid speech, and grandiosity—all characteristic symptoms of a manic episode according to DSM-5-TR criteria. The recent decline in occupational functioning and her elevated mood, visibly restless behavior, and impulsive spending further support this diagnosis.
Diagnosis Based on DSM-5-TR Criteria
Based on the information provided, the patient's presentation aligns with a diagnosis of Bipolar I Disorder, currently in a manic episode. The DSM-5-TR specifies a manic episode as a distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week and present most of the day, nearly every day. During this period, three or more symptoms such as increased energy, decreased need for sleep, grandiosity, talkativeness, racing thoughts, distractibility, and reckless behavior are evident (American Psychiatric Association, 2022). Her history of depressive episodes, combined with current manic features, supports a diagnosis of Bipolar I Disorder. It is essential to evaluate her pharmacological and non-pharmacological treatment options, considering the severity and impact of her symptoms.
Pharmacological Treatment and Rationale
The primary pharmacological intervention for an acute manic episode is the use of mood stabilizers, with lithium being the gold standard due to its proven efficacy in controlling manic episodes and reducing recurrence risk (Yatham et al., 2018). Lithium not only stabilizes mood but also reduces suicidal behaviors associated with bipolar disorder. Given her severe presentation, initiation of lithium therapy would be appropriate. Alternatively, valproic acid is a commonly used initial agent, especially in patients with mixed features or rapid cycling (Calabrese et al., 2017).
Current clinical guidelines recommend starting lithium at a dose that aims to achieve therapeutic serum levels between 0.6 and 1.2 mEq/L (Malhi et al., 2018). Close monitoring of serum lithium levels, renal function, and thyroid function is essential to prevent toxicity. Lithium's anti-manic effects typically become evident within 1-2 weeks, necessitating patience and adherence to monitoring protocols.
The rationale for choosing lithium includes its efficacy in rapidly controlling manic symptoms, its longstanding track record, and potential anti-suicidal effects. Since lithium is cost-effective, especially when available in generic formulations, it offers a practical option for treatment adherence, provided the patient agrees to regular blood tests and follow-up.
Non-pharmacological Treatment and Rationale
Non-pharmacological management of bipolar disorder, especially during acute episodes, includes psychoeducation and structured support to ensure medication adherence and symptom monitoring (Miklowitz & Goldstein, 2019). Psychoeducation empowers the patient with knowledge about her condition, helps recognize early warning signs of mood episodes, and fosters insight into the importance of ongoing treatment.
In addition, establishing a routine sleep and activity schedule is crucial, given her sleep deprivation and behavioral hyperactivity. Psychoeducation is particularly advantageous because it reduces relapse risk, improves medication adherence, and enhances self-management skills (Colom et al., 2019). Moreover, involving family members in psychoeducational interventions may offer additional support, increase compliance, and provide an external monitoring system, which is vital given her impulsivity and recent behavioral escalation.
The cost-effectiveness, safety, and adherence of non-pharmacological strategies are high when combined with medication. These approaches are low risk and can significantly prevent relapse and hospitalization if early signs of mood episodes are observed.
Cost, Effectiveness, Safety, and Adherence Considerations
Psychotropic medications vary in cost depending on formulation, dosage, and geographic location. Lithium, especially in generic form, is one of the most cost-effective mood stabilizers, with a current approximate monthly cost of $10-$20 in the United States when obtained from local pharmacies (GoodRx, 2023). Its efficacy in acute mania and prevention of future episodes supports its selection despite the need for blood monitoring due to potential toxicity.
In terms of safety, lithium carries risks of nephrotoxicity and hypothyroidism, requiring regular lab monitoring. Patient adherence hinges on the ability to attend routine follow-up appointments, comprehend the medication's importance, and tolerate minor side effects such as tremor or gastrointestinal discomfort. Psychoeducation mitigates non-adherence risks by emphasizing treatment benefits.
Alternative medications like valproic acid or atypical antipsychotics can be considered if lithium intolerance or contraindications develop, but they tend to be more expensive or have different side effect profiles. The chosen medication must balance efficacy, safety, patient preferences, and financial feasibility, with lithium remaining a cost-effective first-line agent for bipolar manic episodes in most cases (Yatham et al., 2018).