A History of the Patient’s Present Illness

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The adult patient has stated that they are experiencing bouts of invincibility and optimism in which they feel that they can accomplish anything and go on very long bouts of artistic creation and discussion. Along with these bouts of artistic creation and discussion, the patient also says that they are routinely discouraged by their family members when they talk about their artistic goals and feels extremely frustrated when their family does not support them in their dreams and endeavors. While having artistic goals and muses is normal, the patient also reports that they have extremely long (three months or longer) bouts of depression where they never want to make art again and contemplate committing suicide since they think that no one will ever enjoy their art.

The patient’s diagnosis for bipolar II disorder stems from their lengthy record of staying in depressive states rather than showing and experiencing hypomanic tendencies and episodes. Altshuler, Sugar, McElroy, Calimlim, Gitlin, Keck, et al. (2017) write that patients with bipolar II disorder may experience depression up to three times as much as they would experience any stints of hypomania (p. 266). So, when creating a clinical management plan for this patient, it will be important to create a plan that includes counseling-based interventions and gives them the economic security to practice their art as often as possible. The need for them to have time to practice their art may be a strong cause of their depression, as they usually begin to get depressed after their family members discourage them and ask about their future.

Recommended psychopharmacologic treatments
Because bipolar disorder (both I and II) is characterized by its polarity in a patient’s moods, mood stabilizers and antidepressants have frequently been used to treat patients and their symptoms (Altshuler et al., 2017). Knowing this, one of the mood stabilizers that have been studied the most in terms of how it can treat patients with bipolar disorder is aripiprazole. According to Muneer (2016) aripiprazole is a drug that was originally tested and approved to be used for the treatment of schizophrenia but has now been seen to work for bipolar disorder as well. In this, the medication’s ability to treat bipolar disorder lies in its “pharmacodynamic properties of partial agonism, functional selectivity, and serotonin-dopamine activity modulation ,” which Muneer deems as “the new exemplars in the treatment of major psychiatric disorders” (Abstract section, para. 1).

The clinical endpoint for the use of this medication is an improvement in the depressive episodes that this patient is experiencing. LaRossa’s (2017) scale that measures the severity of illness that a patient with bipolar disorder is suffering from makes note to measure the manic and depressive episodes of a patient while also comparing them to past cases. Knowing this, Muneer (2016) writes that “improvement in essential depressive symptoms occurred with flexibly dosed aripiprazole monotherapy in subjects with more severe major depressive episodes than those with less severe manifestations in bipolar I disorder” (Third Generation Antipsychotics section, para. 4). While Muneer’s study focused on the depressive effects of bipolar I disorder, their findings could still be relevant for this client’s bipolar II disorder, as their study found that the pre-study diagnoses of mania may have affected the drug’s effect and rating on their depressive symptoms.

Psychotherapy Options for this Patient and Their Symptoms
Baldessarini, Tondo, and Vasquez (2018) write that the long-term treatment of adult bipolar disorder is limited by the lack of availability to comprehensive treatment programs that do not solely revolve around medications. This matches with the information shared by Swartz and Swanson (2014) that states pharmacology plans that focus on solely using medications usually only provide partial relief for patients (Abstract section, para. 1). This relief is considered to be partial by Swartz and Swanson because patients who only use pharmacologic interventions experience “low rates of remission, high rates of recurrence, residual symptoms, and psychosocial impairment” (Abstract section, para. 1). While medications for patients with bipolar disorder should be paired with other forms of intervention, however, Altshuler et al. (2017) write that antidepressants produce favorable results and lower rates of hypomania in patients with bipolar II disorder who are also using other forms of mood stabilizers as well.

Swartz and Swanson write that psychotherapy (which has been used as an intervention for bipolar disorder since the 20th century) is a treatment option that has shown to have equal to or better results than using psychopharmacologic interventions on their own. One of the bipolar-specific psychotherapy options is psychoeducation which can be delivered in an individual or family-based setting which can help patients see a decreases in the Hamilton Depression Rating Scale and the amount of relapses that are experienced as a result of their bipolar disorder’s symptoms. Psychoeducation involves the use of structured teaching sessions that provide patients information about their diseases, potential forms of treatment, and how to prevent relapses and any worsening of their conditions.

These sessions can also be done in groups, as group psychoeducation also involves teaching patients about stress management, avoiding substance abuse, learning how to detect when new episodes may be occurring, and other mood and temper management related topics (Swartz & Swanson, 2018). In all forms of education, assessments are used to keep track of students’ progress and ability to comprehend the information that is being given to them. Swartz and Swanson (2014) write that there may not be much of a difference in the effect of psychoeducation and other forms of psychotherapy. However, the use of memory-based assessments and introspective discussions may lead to higher levels of retention and memory performance. This, according to Bauer, Hautzinger, and Meyer (2017) may be a key to helping patients with either bipolar I and II disorder see improvements in their conditions. Bauer et al. write that the prevention and stress management strategies taught in psychoeducation sections may be more effective if the patients they are being taught to have a high level of recall ability. This means that the education itself is only detail related to the larger issue of ensuring that patients’ cognitive abilities can still perform at a high level when they are in adverse situations.

Community Support Resources for this Client
According to Yatham, Kennedy, Parikh, Schaffer, Bond, Frey et al. (2018), peer support resources and treatments have received a third-line treatment recommendation within the “Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder.” The 2018 guidelines suggest that the online locations of peer advocacy organizations such as the Depression and Bipolar Support Alliance, the Mood Disorders Association of Ontario, CREST.BD, MoodSwings, and Revivre all have methods for peers to keep in contact with and provide encouragement to one another. While peer support groups and advocacy organizations have been shown to have positive effects, this client should still use clinical psychoeducation treatments to help them manage their bipolar-related depression. This is because Yatham et al. note the risks of solely using peer support groups and relying on advice from members of the bipolar community who are not clinically trained to provide treatment and conduct research (Psychosocial Interventions section, para. 14-15).

Recommendations
Knowing this information, this patient needs to have weekly access to a non-profit mental health care facility that offers group psychoeducation sessions to low-income members of the community and also helps them with managing stress in social and professional environments. This patient’s love for their art can be turned into a career if they have the proper preparation and connections, so it may also be in this patient’s best interest to take graphic design or business courses at their local community college so they can learn how to use their creativity as a trade instead of a hobby. Along with taking courses at a local college, this client should also be connected to a peer advocacy organization that has an online forum where they can stay connected to peers who are experiencing the same difficulties in life that they are. While it is possible for them to use their art as a tool for therapy and income, interventions must also be made that involve getting the patient’s family to see these possibilities as well.

Swartz and Swanson (2014) write that family focused therapy sessions are interventions where a patient and their family member are educated on topics related to “psychoeducation, communication enhancement training, and problem-solving skills training” (Family Therapy section, para. 1). These lessons on problem solving and communication may improve the relationship that this patient has with their family. Also, it may give the patient’s family members a new understanding of how their criticism affects their loved one and causes them to enter into extreme bouts of depression.

    References
  • Altshuler, L. L., Sugar, C. A., McElroy, S. L., Calimlim, B., Gitlin, M., Keck, P. E… & Suppes, T. (2017). Switch rates during acute treatment for bipolar II depression With lithium, sertraline, or the two combined: A randomized double-blind comparison. American Journal of Psychiatry, 174(3), 266-273. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/28135846
  • Baldessarini, R. J., Tondo, L., & Vasquez, G. H. (2018). Pharmacological treatment of adult bipolar disorder [Abstract]. Molecular Psychiatry. doi: 10.1038/s41380-018-0044-2. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29679069
  • Bauer, I. E., Hautzinger, M., & Meyer, T. D. (2016). Memory performance predicts recurrence of mania in bipolar disorder following psychotherapy: A preliminary study. Journal of psychiatric research, 84, 207-213. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/27764692
  • LaRossa, J. M. (2017). Rating Scales and Safety Measurements in Bipolar Disorder and Schizophrenia – A Reference Guide. Psychopharmacology bulletin, 47(3), 77-109. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5546554/
  • Muneer A. (2016). The Treatment of Adult Bipolar Disorder with Aripiprazole: A Systematic Review. Cureus, 8(4), e562. doi:10.7759/cureus.562. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4859817/
  • Swartz, H. A., & Swanson, J. (2014). Psychotherapy for Bipolar Disorder in Adults: A Review of the Evidence. Focus (American Psychiatric Publishing), 12(3), 251-266. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4536930/
  • Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. … Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar disorders, 20(2), 97-170. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5947163/