Psychiatric and Medical Conditions

Kim is a 25-year-old woman who presented to an outpatient clinic for an evaluation. She complained of episodes of sadness, often unexplained, as well as difficulty controlling her temper and handling stressful situations. Her sadness would sometimes last an entire week, was very intense, and occurred all day every day, but she reported that she would eventually return to her normal self. Her sadness was sometimes accompanied by a restless energy and irritability that precipitated arguments with her husband. These arguments would sometimes lead to Kim hitting her husband or throwing things at him. The periods of restless, heightened energy, and irritability would often switch abruptly back to a state of intense, depressed mood. When depressed, Kim would sleep excessively and had a tendency to overeat. She would isolate herself from others, let the housework go, and found it hard to get anything done. During the initial interview, Kim is very animated and dramatic. Her response to the question- “What brings you here to see us today? – lasted 8 minutes without interruption. Kim switched topics a number of times, and her speech was moderately pressured. Her affect would alternate between laughing and crying.
Kim smokes 1-2 packs of cigarettes per day. She drinks 5 caffeinated soft drinks per day. She has been taking birth control pills since she had a baby 8 months ago. She has been somewhat healthy, but since delivering the baby, she continues to gain weight and complains of headaches that are increasing in frequency and duration. These brief, but intense, periods of depressed mood have only started since the delivery of the baby. Prior to the delivery, she was a very outgoing and happy person, and had never been treated for mood or anxiety problems. However, anxiety and depression runs in her family. Her maternal grandfather was diagnosed with “manic depression” and hospitalized in a state mental health facility on 3 occasions. Several other relatives abused alcohol and/or cocaine. Her father was an alcoholic. Kim admits to occasional alcohol use, “only 2-3 times a week.” Her mother had been treated for depression, and also had a history of hypertension and heart disease. Her maternal grandmother had a history of anxiety, diabetes and hypertension.
Kim was diagnosed with Bipolar disorder and placed on divalproex sodium (Depakote) and olanzapine (Zyprexa). The divalproex sodium dosage was titrated to 1500 mg/day in divided doses over 10 days. She was prescribed olanzapine 10mg 1 tablet at bedtime. Her sleep patterns returned to normal and she felt less irritable. This improvement continued over the next 4 weeks, and her brief, depressed moods disappeared. Her serum valproate level was 65µg/mL.
Two months into treatment, Kim calls the office and reports that she’s noticed a 16 lb. weight gain. She states her weight is now at 238 lbs. (height is 5’2). She reports worsening headaches, frequent urination, is always thirsty, and feels hungry all the time. She reports recent, intermittent periods of fatigue. Mood wise, she states she is doing very well.

1. Looking at Kim’s physical symptoms, her history, and her family’s medical/mental history, which psychiatric and medical disorders is she at risk for? Explain why.

2. Based on the information provided above, what labs would you have drawn? Explain why.

3. What education should have been provided to Kim regarding her medications at the initiation of treatment? Would you change her medications at this time? Explain why or why not. If so, what other psychotropic medications could be considered. Explain why.

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4. Based on the information provided above, what lifestyle changes would you recommend to Kim? Explain why.

5. What referrals should be made? Explain why.