2 packs of yam noodles
3 chicken thighs
6 potatoes - baked, cooled, cut into small dice.
3 cloves garlic
1 medium onion
1 medium bell pepper
1 large bag of peas (frozen)
salt to taste
dried spice mix - see soup seasoning recipe previously posted (can use Bragg's seasoning if safe for you)
1 cup celery chopped.
stew chicken thighs in crock pot for all day on high with water and spices.
Pick chicken into stew pot. Add crockpot broth. Add enough water to fill pot. Add all other ingredients. Cook on medium low for 40 minutes.
Makes about 9 quarts of soup.
NOTE - YAM NOODLES DO NOT FREEZE. SO, can do all the other stuff but the noodles and freeze it. When re-heating, add noodles and simmer for 30 minutes.
http://www.amazon.com/Oriental-Noodle-Ingredient-Potato-Starch/dp/B007AWOBLU - these are yam noodles.
This is a blog where whatever comes to mind will find its way onto the screen. Hopefully, there will be bits and pieces you enjoy or can use. And, when something neither appeals to you nor applies to you, you are most welcome to skip that post or comment on your own point of view. I hope you are looking forward to this as much as I am.
Tuesday, December 31, 2013
New Year's Eve
I suppose it says something about me - I get more excited about the turn of the year than I do about all other holidays and events combined. Birthdays - no big deal. Religious holidays - joy and stress. Family holidays and national events (4th of July)... mainly stress. No, for me the biggie is New Year's.
It is not the ball dropping or any of the glitz. Hey, I do not even have a television hooked up to cable (my TV is for DVD purposes only). There are no television channels in my life. No, for me it is the potential that hangs with great presence over the turning of the year.
Season's change do the same for me in a small degree. But, it is New Year's Eve that makes me all shivery with excitement. Much the same as Christmas did when I was small. Now, I review the previous year and find great anticipation of the possibilities of the coming year.
And, New Year's Eve has a wonderful present ... the first day of a new calendar. I find such delight in looking at the blank squares and knowing it is up to my choice as to how I fill those days. Sometimes, I seek to rectify poor behaviors of the past. However, I find more and more, as I grow older, that I seek to focus on where I am going instead of where I have been. The past has relevance - it would be foolish to imagine that it did not. However, it is the future that thrills me. Each moment of that expanse of time can be written by choice and by action. And, what a wonderful, heady thought that is to me.
So, my wish for each and every one is this:
May your New Year be the one you write for yourself. May it see you become a better person than you were yesterday. May you find joy and happiness and meaning. May you be the blessing on the world that you have the potential to be. And, when looking back upon the year, may you find peace and certainty that the year could not in any way have been lived to a better or fuller degree.
It is not the ball dropping or any of the glitz. Hey, I do not even have a television hooked up to cable (my TV is for DVD purposes only). There are no television channels in my life. No, for me it is the potential that hangs with great presence over the turning of the year.
Season's change do the same for me in a small degree. But, it is New Year's Eve that makes me all shivery with excitement. Much the same as Christmas did when I was small. Now, I review the previous year and find great anticipation of the possibilities of the coming year.
And, New Year's Eve has a wonderful present ... the first day of a new calendar. I find such delight in looking at the blank squares and knowing it is up to my choice as to how I fill those days. Sometimes, I seek to rectify poor behaviors of the past. However, I find more and more, as I grow older, that I seek to focus on where I am going instead of where I have been. The past has relevance - it would be foolish to imagine that it did not. However, it is the future that thrills me. Each moment of that expanse of time can be written by choice and by action. And, what a wonderful, heady thought that is to me.
So, my wish for each and every one is this:
May your New Year be the one you write for yourself. May it see you become a better person than you were yesterday. May you find joy and happiness and meaning. May you be the blessing on the world that you have the potential to be. And, when looking back upon the year, may you find peace and certainty that the year could not in any way have been lived to a better or fuller degree.
Quick and easy mashed potatoes: The perfect use of a Ninja...
When your hands hurt - or you have a stomach bug and allergies enough you cannot take advantage of instant potatoes... Here is a great way to make quick and easy homemade mashed potatoes.
Rinse several potatoes.
Put on glass baking dish. Set into oven. Turn onto 400 degrees Fahrenheit. Let bake at least a hour. Done when soft to the touch.
Pull glass dish with baked potatoes out of oven. Using silicon mitt to protect your hands, split the potatoes and squish out the insides into a bowl. Either set the skins aside later for baked cheese skins or dispose of the skins.
Into Ninja (I used the small pitcher and the dough blade), dump the tater insides. Add butter and milk to taste. I used about 1/3 cup milk, 3 medium potatoes, and 2 tablespoons butter. Put the lid on and process like you would dough. Scrape down the sides once or twice if needed. Add salt, garlic, sour cream, etc. to suit yourself.
The actual work time for this - about 6 minutes all told. The total time from start to eating... about 1 1/2 to 2 hours. For me, with a stomach bug today... I took a nap for the time it was taking to bake the potatoes.
Even better - the dishes all went into the dishwasher... so no fuss, no mess, and something gentle on the tummy.
Rinse several potatoes.
Put on glass baking dish. Set into oven. Turn onto 400 degrees Fahrenheit. Let bake at least a hour. Done when soft to the touch.
Pull glass dish with baked potatoes out of oven. Using silicon mitt to protect your hands, split the potatoes and squish out the insides into a bowl. Either set the skins aside later for baked cheese skins or dispose of the skins.
Into Ninja (I used the small pitcher and the dough blade), dump the tater insides. Add butter and milk to taste. I used about 1/3 cup milk, 3 medium potatoes, and 2 tablespoons butter. Put the lid on and process like you would dough. Scrape down the sides once or twice if needed. Add salt, garlic, sour cream, etc. to suit yourself.
The actual work time for this - about 6 minutes all told. The total time from start to eating... about 1 1/2 to 2 hours. For me, with a stomach bug today... I took a nap for the time it was taking to bake the potatoes.
Even better - the dishes all went into the dishwasher... so no fuss, no mess, and something gentle on the tummy.
Sunday, December 29, 2013
A quick update :)
Well, it has been a while since I last blogged. My life changed significantly and I had to take time to adjust to the changes.
I graduated from Capella in October. I now have my Master of Science in Mental Health Counseling degree. I got a job at EHS Support Services providing mental health support services to clients in Giles, Christiansburg, Radford, and areas in between. Currently, I have 7 clients. I really enjoy what I do and the people (both clients and coworkers) with whom I work. I find my clients to be challenging, changeable, and delightful. My coworkers are supportive and professional. It is nice not to have to do politicking when I am at the office.
The transition from student to employed person required more adjustment than I had ever imagined. I am working a 40-55 hour work week. I was trying to take a Capella class also in order to obtain a certificate in Addiction Counseling. However, I simply could not find balance between work and school and life. So, I dropped the class. Just recently I decided to drop the certificate program entirely.
Brian and I moved. We now have a lovely little place. However, the difference between communal living and independent living was unlike my expectations. Brian and I have a huge backyard (a bit over 2 acres) in which the dogs love to run and play. It is peaceful here with gorgeous sunsets.
We have Chai Chi (a rescue pup). Chai is probably about 7 months old and is probably some sort of whippet mix. Being young, Chai has more teeth than brains. He loves to chew - so on days Brian and I are out of the house for long periods, Chai and Inky go to my parents' house for pet-sitting.
Brian had a sleep study done. He was diagnosed with circadian rhythm disorder and restless legs syndrome. While he does not stop breathing enough to meet criteria for sleep apnea (have to stop 5 times per hour), he does stop breathing (10 times in 6 hours). We have a follow up appointment to see what that means. Until then, he was prescribed Ambien for the sleep issues. Since starting that, his sleep is normalizing a bit.
Brian has been struggling with his mood disorder (officially mood disorder NOS, I think he has bipolar I disorder with rapid cycling). He had a moment of catharsis and epiphany. Those changes plus the medication has resulted in his moods stabilizing for the first time in 7 years... a HUGE RELIEF for us all.
Working has me out and about in the community. Exposure to allergens is common. So, I am working on ways to minimize my exposure. Fortunately, I am not reacting as badly to each exposure, but by the end of the day I am definitely having some allergic reactions. So, I am taking benedryl each day and minimizing what I can. This is letting me work... and I am hoping the trend continues.
I am still creating recipes and doing beadwork. And, as I find balance with my new life structure, I am starting to return to the things most important to me - friends, blogging, reading, learning. Life is good!
I graduated from Capella in October. I now have my Master of Science in Mental Health Counseling degree. I got a job at EHS Support Services providing mental health support services to clients in Giles, Christiansburg, Radford, and areas in between. Currently, I have 7 clients. I really enjoy what I do and the people (both clients and coworkers) with whom I work. I find my clients to be challenging, changeable, and delightful. My coworkers are supportive and professional. It is nice not to have to do politicking when I am at the office.
The transition from student to employed person required more adjustment than I had ever imagined. I am working a 40-55 hour work week. I was trying to take a Capella class also in order to obtain a certificate in Addiction Counseling. However, I simply could not find balance between work and school and life. So, I dropped the class. Just recently I decided to drop the certificate program entirely.
Brian and I moved. We now have a lovely little place. However, the difference between communal living and independent living was unlike my expectations. Brian and I have a huge backyard (a bit over 2 acres) in which the dogs love to run and play. It is peaceful here with gorgeous sunsets.
We have Chai Chi (a rescue pup). Chai is probably about 7 months old and is probably some sort of whippet mix. Being young, Chai has more teeth than brains. He loves to chew - so on days Brian and I are out of the house for long periods, Chai and Inky go to my parents' house for pet-sitting.
Brian had a sleep study done. He was diagnosed with circadian rhythm disorder and restless legs syndrome. While he does not stop breathing enough to meet criteria for sleep apnea (have to stop 5 times per hour), he does stop breathing (10 times in 6 hours). We have a follow up appointment to see what that means. Until then, he was prescribed Ambien for the sleep issues. Since starting that, his sleep is normalizing a bit.
Brian has been struggling with his mood disorder (officially mood disorder NOS, I think he has bipolar I disorder with rapid cycling). He had a moment of catharsis and epiphany. Those changes plus the medication has resulted in his moods stabilizing for the first time in 7 years... a HUGE RELIEF for us all.
Working has me out and about in the community. Exposure to allergens is common. So, I am working on ways to minimize my exposure. Fortunately, I am not reacting as badly to each exposure, but by the end of the day I am definitely having some allergic reactions. So, I am taking benedryl each day and minimizing what I can. This is letting me work... and I am hoping the trend continues.
I am still creating recipes and doing beadwork. And, as I find balance with my new life structure, I am starting to return to the things most important to me - friends, blogging, reading, learning. Life is good!
Labels:
allergies,
Bipolar Disorder,
blessings,
Capella,
challenges,
EHS,
friends,
mental health,
work
Tuesday, September 10, 2013
Helping a Friend out.
Hey Ya'll - Got a friend who is going through a very difficult time right now. I know everyone has tight finances. So, if you are shopping on amazon anyway, could you shop there through this link: Amazon Link to Help a Friend
It would really help my friend out... and won't cost you a bit.
UPDATE 12-2013
My friend was killed by her estranged husband who also shot and killed their 14 year old son. The man then committed suicide. Their younger children are with family.
It would really help my friend out... and won't cost you a bit.
UPDATE 12-2013
My friend was killed by her estranged husband who also shot and killed their 14 year old son. The man then committed suicide. Their younger children are with family.
Sunday, September 8, 2013
IEP helpful hints/suggestions.
http://www.friendshipcircle.org/blog/2012/01/19/top-ten-most-ridiculous-comments-heard-at-an-iep-meeting/
For all parents who need to know more about IEPs in order to successfully advocate for their children.
RE: IEPs versus Response to Interventions
http://www.specialeducationadvisor.com/wp-content/uploads/2010/08/RTI-Memo-OSEP.pdf
For all parents who need to know more about IEPs in order to successfully advocate for their children.
RE: IEPs versus Response to Interventions
http://www.specialeducationadvisor.com/wp-content/uploads/2010/08/RTI-Memo-OSEP.pdf
Webinar about the use of Ketamine for Bipolar Disorders
http://bbrfoundation.org/meet-the-scientist-august-2013
I attended this webinar. I am not sure what I think about using substances which are also illegal street drugs, but... For some of the people whom I have worked with who have resistant and uncontrolled bipolar disorder - anything might be better than the status quo.
I attended this webinar. I am not sure what I think about using substances which are also illegal street drugs, but... For some of the people whom I have worked with who have resistant and uncontrolled bipolar disorder - anything might be better than the status quo.
Resource for Disability Hearings - Help with knowing what to log and tips on how to talk about it all
http://www.bothwellhamill.com/index.php/site/hearing_prep_video/
Resource for Disability Hearings - Help with knowing what to log and tips on how to talk about it all.
Resource for Disability Hearings - Help with knowing what to log and tips on how to talk about it all.
Dehydrating Watermelon, doing household tasks, putting up broths.
Today - dehydrating watermelon and dehydrating pear sauce (makes fruit leathers). -
Unhappy moment of the weekend - I think I am starting to react to cinnamon. Tried several different sources and all cause mouth burning and twinge my head. So, cinnamon is on the no-go list for a couple months. Will try it again about Christmas time/January 2014.
BROTH
CHICKEN
VENISON - Same with the venison broth.
TINY STORAGE OPTION FOR BROTH:
You can reduce further, spread on the liquid tray of the dehydrator and dehydrate to store in smaller containers
USES FOR BROTH:
Then, Take the broth and use it to cook beans that you have soaked. Once done, remove the beans and eat those. Then use the leftover broth for making dumplings. (I make grain free dumplings).
All broths from cooked veggies and meats can be AWESOME to save to increase nutritional value of your foods.
THE DAY'S SCHEDULE ... AND THE NEXT COUPLE OF DAYS
Happy Moment - Got the things packed from the kitchen. So, when I find a job, and start having money, a little more packing is done for moving out. YAY!
Today's list - laundry and hanging out clothes, Coursera Class starting (free class, topics of interest to me...) Global Health. Dishes. Freezing Chix broth and venison broth. Packing a couple boxes of books. giving the dog a bath.
We will see how far I get!
Monday - final signatures for internship and submitting the final paperwork. Job interview.
Tuesday - Job Fair, meeting with pastors of youth groups.
Wednesday - depending on how I am feeling, hiking or maybe just level ramblings about the outdoors.
- Cut the watermelon into strips.
- Pour the pear sauce (pears from neighbors trees, cinnamon, all spice, nutmeg, honey, water - cooked 24 hours on low in the crockpot, processed through the ninja, sieved of chunks/skin/etc; makes pear sauce. Same can be done with any fruit) into a liquid tray of a food processor.
- Dehydrate both for 16-24 hours on 110. Makes very tasty fruit leathers and pieces of watermelon "leather".
Unhappy moment of the weekend - I think I am starting to react to cinnamon. Tried several different sources and all cause mouth burning and twinge my head. So, cinnamon is on the no-go list for a couple months. Will try it again about Christmas time/January 2014.
BROTH
CHICKEN
- Cook Chicken in a VERY LARGE stock pot with onion, garlic, salt, other seasonings as preferred.
- When chicken is pull off the bone tender, remove chicken.
- Boil the broth left down to 1/3 of the level it was when you removed the chicken.
- Put in fridge overnight.
- Skim off fat if you want to.
- Bag in ziplocs or in freezer storage containers.
- Freeze.
- Good for 6 months in a deep freezer.
VENISON - Same with the venison broth.
TINY STORAGE OPTION FOR BROTH:
You can reduce further, spread on the liquid tray of the dehydrator and dehydrate to store in smaller containers
USES FOR BROTH:
Then, Take the broth and use it to cook beans that you have soaked. Once done, remove the beans and eat those. Then use the leftover broth for making dumplings. (I make grain free dumplings).
All broths from cooked veggies and meats can be AWESOME to save to increase nutritional value of your foods.
THE DAY'S SCHEDULE ... AND THE NEXT COUPLE OF DAYS
Happy Moment - Got the things packed from the kitchen. So, when I find a job, and start having money, a little more packing is done for moving out. YAY!
Today's list - laundry and hanging out clothes, Coursera Class starting (free class, topics of interest to me...) Global Health. Dishes. Freezing Chix broth and venison broth. Packing a couple boxes of books. giving the dog a bath.
We will see how far I get!
Monday - final signatures for internship and submitting the final paperwork. Job interview.
Tuesday - Job Fair, meeting with pastors of youth groups.
Wednesday - depending on how I am feeling, hiking or maybe just level ramblings about the outdoors.
Saturday, September 7, 2013
What it means to be a help object - by Rachel Cohen-Rottenberg.
http://www.disabilityandrepresentation.com/2013/09/03/what-it-means-to-be-a-help-object/
by Rachel Cohen-Rottenberg
This is very much important to read - especially if you are able-bodied. And if you are not able-bodied, this is also important because it puts to words what is often unspoken.
It is my hope that all who read this look for ways to even out the experience of privilege and to make the world a bit fairer to all!
Laura
by Rachel Cohen-Rottenberg
This is very much important to read - especially if you are able-bodied. And if you are not able-bodied, this is also important because it puts to words what is often unspoken.
It is my hope that all who read this look for ways to even out the experience of privilege and to make the world a bit fairer to all!
Laura
Tuesday, September 3, 2013
Case Study Treatment Plan (Capella Assignment) - Bipolar/mood disorder NOS
For this assignment, complete the
Assessment Process section of your project, which consists of the following
segments:
·
The presenting problem.
·
Previous treatments.
·
Strengths, weaknesses, and social
support systems.
·
Assessment.
·
Diagnosis.
To assist you in completing this
assignment, please click Case Study Treatment Plan in the
Resources area to access the Case Study Treatment Plan template.
Use these guidelines to format your case study.
Refer to the Case Study Treatment
Plan project description for detailed instructions regarding this assignment.
Note: Your
instructor may also use the Writing Feedback Tool to provide feedback on your
writing. In the tool, click on the linked resources for helpful writing
information.
Resources
Identifying Information
This section will describe pertinent information relative to the
client.
*For the purposes of this case study, the identifying information will be the case study description.
*For the purposes of this case study, the identifying information will be the case study description.
Stella
is a 38 year-old biracial (African American and Native American) woman. She is married to Doug (her high school
sweetheart, for the last 18 years) and has one child who is a teenager. She lives in a small city (150,000
population) and has maintained her current employment for 3 years.
Presenting Problem
Identify the primary problem(s), the precipitating factors for the
client to seek treatment, and whether or not this is a voluntary client (vs.
being compelled by another person or outside agency). Briefly describe these
factors in paragraph form.
Stella has chosen to attend counseling based on the requests of both her employer and her husband. Her employer has put her on FLMA so that she has time to resolve her emotional crisis. Her husband has changed his work schedule so that he is more available to help her through this time. There is no legal or other mandated requirement for Stella to attend counseling.
The precipitating event which created current need for counseling is an emotional breakdown where co-workers found Stella “sobbing uncontrollably”. She was hospitalized (voluntarily) where her medications were changed by the hospital psychiatrist. She has been referred to counseling with the community mental health agency.
Previous Treatments
Identify previous treatments and whether or not they were successful.
Is the client currently participating in any self-help group?
Stella
has been in and out of counseling since late adolescence. Twice, suicide attempts prompted seeking
mental health assistance. She has been
on at least two medications in the past.
Currently she is on a third (prescribed by the hospital
psychiatrist). The previous pattern for
mental health counseling is that once improvement begins, Stella has disengaged
from treatment. For the last therapist,
treatment ended with the therapist moving out of area. There is no indication from Stella’s previous
records that therapy successfully reached goals and concluded in planned
termination.
Stella
is not currently participating in self-help or support groups. Further, Stella’s family is not participating
in support groups. There is no
indication that Stella or her family have ever attempted group work.
Strengths, Weaknesses and Social Support Systems
Make note of any factors that will potentially impact treatment
success, both positively and negatively. For example, the client may have a
supportive family, which would be a positive factor. On the other hand, the
client may have co-occurring disorders which could complicate treatment.
Overview:
Stella
is was adopted as an infant in a closed adoption and her adoptive parents are
now deceased. No biological family
information is available other than her mother may have been 16 years of age
when Stella was born and that her pregnancy may have been the result of rape.
Stella
lives in a small city (pop. 150,000) and has held the same job for 3 years
(bookkeeper of a meatpacking plant).
Stella attributes the longevity of this position to the
"kindness" of her boss. Prior
to this job Stella has had a series of jobs which have lasted a year or
less. Currently, Stella is on FLMA to
give her time to stabilize her moods.
She has
been married to the same man (Doug) for 18 years. The marriage is reported by the client as
having had trouble but with both being committed to staying in the marriage. Doug is an over-the-road trucker and often
away for 14 days, home for 3-4 days, and then away for 14 days again. Due to Stella's mental health, Doug has
recently changed routes and will be away no longer than 4 days at a time. He is very interested in what he can do to
help Stella stabilize her mood disorder.
Strengths:
·
Family
that is willing to work through these problems.
o
Son
is willing to help with medication
o
Husband
has stayed through infidelity and through suicide attempts. Is currently willing to change job routine
and help with stabilization.
o
Sister-in-law
is have volunteered to go walking on a regular basis with Stella each evening.
·
Work
o
Boss
is “kind”
o
Work
put Stella on FLMA and encouraged her to seek help.
o
Stella’s
boss has worked with her through her mood changes.
o
3
years employment
o
Her
boss has requested her to continue treatment consistently
·
Mental
Health & Emotional strengths
o
Willingness
to engage in therapy
o
Willingness
to utilize medication to manage moods
o
Desire
to regain health and wellness
o
Practice
in mood management
Opportunities
to Grow:
·
Social
o
No
social group is described in the case study/intake information.
o
No
passions – church, social, political, artistic, etc. are described.
o
All
support is described as family or work.
This suggests imbalance.
·
Support
groups
o
None
are mentioned at this point as having been attended.
·
Insight
o
There
have been 2 previous suicide attempts and 3 previous hospitalizations. This suggests that Stella is not able to
recognize danger points, that she may recognize them but cannot intervene, or
that she may recognize them and chooses not to intervene before the depressed
mood becomes suicidal crisis. It is
important which one is accurate and that this pattern of behavior/opportunity
for growth is addressed.
·
Treatment
failure
o
There
have been multiple counselors, multiple medications, and multiple psychiatrists
involved in Stella’s care. However,
there has not been satisfactory progress in managing and resolving Stella’s
mental health needs. This may suggest
that there are factors which may not have been addressed. Further, it suggests that medication may
require additional effort to find a medication or a combination of medications
that will be effective.
o
Stella
has prematurely ended therapy previously.
This is a risk factor that threatens successful therapy this time. A strength balancing this is that her boss is
encouraging her to maintain consistent therapy attendance.
·
Suicide
o
The
two previous suicide attempts are risk factors for additional suicide
attempts. That the second attempt was
more lethal in potential than the first is especially troubling. This suggests that safety planning and
resilience building may need to be addressed quite early in therapy and then
revisited throughout therapy.
·
Interpersonal
o
It
is possible that Stella will need training in interpersonal relationship skills
as suggested by her statement that it is easier to work with numbers than with
people.
Either/or
·
Guilt
and Negative Feelings associated with Mental Health Influenced Actions
o
Mental
health consequences have been involved in Stella’s life for the majority of her
life. How Stella views these actions and
the consequences thereof must be explored.
Her response to her views may be either opportunity to grow or strength.
·
Systems
o
Stella’s
mental health has impacted her family in multiple ways. These ways are both explicit and
implicit. It will be essential to
determine how the family structure has accommodated Stella’s mood disorder, how
people in the family conceptualize the mood disorder and their roles in the
family, and where the family wants to go from here. When one member of the family has mental
health issues, trying to treat that person without regard to the family system
is often ineffective.
·
Cultural
Considerations
o
Stella
is biracial and her adoptive parents were Caucasian. Determining how Stella views her cultural
heritage and the legacies she takes from that heritage will be important in
developing culturally appropriate therapy.
There will be both strength and opportunity to grow in this area.
Assessment
Describe the process you will use to complete a clinical
assessment for this client. If you intend to use specific instruments, state
what they are. Provide a rationale for each of your choices, including any
concerns with the relevance and biases of potential assessment tools with
multicultural populations. If you plan to refer your client to another mental
health professional for all or parts of the assessment, identify who that will
be and what you will ask that professional to assess.
Previous
diagnoses would be assessed for current validity. The current case study does not explicitly
state what previous diagnoses Stella might have, however, it does imply
something within the range of mood disorders.
The
antidepressant that Stella was prescribed in late adolescence triggered what
seems to be mania. When a mood
stabilizer was added to the antidepressant, the manic symptoms seemed to abate. While there is enough information to
tentatively diagnose depressive disorder, bipolar disorder may or may not be
accurate given the manic symptoms may have been induced by medication and that
hypomanic states are difficult to diagnose accurately/
Considering
the resources of a Free Clinic are limited and assessments are limited to what
can be obtained without charge, the most appropriate tool to assess and
diagnose Stella’s specific mental health disorder would be a structured
clinical interview. Further, a structured
clinical interview can be tailored to fit Stella’s multicultural background,
her functional capacity of the given day, and her personal concerns. Rich information can be obtained from such an
interview and will provide confirming data or rule-out data for specific mood
disorders.
Diagnosis
Complete a multi-axial diagnosis (Axes I – V). Include any
elements of the client's current mental status that the case study allows.
Axis I: Mood disorder NOS
r/o Bipolar Disorder
Axis
II: Deferred
Axis
III: None
Axis
IV: Deferred
Axis
V: GAF: Current: 40
GAF: Within the last
week: 30
Treatment Plan Annotated Bibliography
Based on your diagnostic impression, develop an annotated
bibliography of resources describing suggested treatments for the disorder(s)
identified. You should describe each source in your own words, not simply use
the provided abstract. You will utilize a minimum of five current articles from
peer-reviewed journals in the counseling or related professions from the
Capella Library. Cite and reference the resources using APA 6th edition guidelines.
You may utilize your textbook, but it does not count as one of your five
scholarly resources. You are also encouraged to utilize more than five
resources if they aid in developing a comprehensive treatment plan.
Annotated Bibliography
Altamura,
A. C., Moliterno, D., Paletta, S., Buoli, M., Dell'Osso, B., Mauri, M. C.,
& Bareggi, S. R. (2012). Effect of Quetiapine and Norquetiapine on
anxiety and depression in major psychoses using a pharmacokinetic approach: A
prospective observational study. Clinical Drug Investigations, 32(3),
213-219.
Basco, M. R.
(2006). The bipolar workbook: Tools for controlling your mood swings.
New York, NY: Guilford Press.
This
is a CBT-based self-help workbook apparently targeted to a more basic and
barebones understanding of bipolar disorder.
The language seems to be less complex and accessible to a lower
comprehension level than the other two workbooks. Of the three workbooks I have used with
clients, the layout of the workbook is cleaner, with more white space, fewer
graphics, and larger print than the other two. While one client preferred this workbook, others
have indicated that they felt "talked down to" when reading the
book.
Bauer, M. S.,
Kilbourne, A. M., Greenwald, D. E., Ludman, E. J., & McBride, L. (2008). Overcoming
bipolar disorder: A comprehensive workbook for managing your symptoms &
achieving your life goals. Oakland, CA: New Harbinger Publications, Inc.
This
is a self-help workbook with excellent tracking graphs embedded within the
chapters. Of particular interest are
the trackers for the Personal Mania Profile (p. 74) and Personal Depression
Profile (pp. 136-137), and the very specific progressive relaxation directions
(pp. 164-165). This workbook has more graphs,
trackers, and logs than the other two.
Clients report feeling increased sense of self-mastery after utilizing
the tools from this workbook.
Berk, M.,
Hallam, K., Malhi, G. S., Henry, L., Hasty, M., Macneil, C., . . . McGorry,
P. D. (2010). Evidence and implications for early intervention in bipolar
disorder. Journal of Mental Health, 19(2), 113-120.
This
article suggests a stage model for treatment of bipolar disorders. Please see appended items for a psychoeducational
chart based on this stage model.
Bourne, E. J.
(2010). The anxiety and phobia workbook [5th Ed.]. Oakland, CA: New
Harbinger Publications, Inc.
This
is a workbook and psychoeducational source for increasing wellness and
resiliency for people who experience anxiety and phobia. It is an excellent resource for ANYONE
coping with the effects of anxiety and mood disorders. The focus is holistic and wellness
based.
However, with that said, the 5th
edition has a chapter on Acceptance and Commitment Therapy (ACT). ACT does not completely align with my
counseling orientation, although there are some aspects I do find useful. The 5th edition also has an
updated chapter on current medications, which is quite valuable for people
considering medication. If
recommending this book to clients, it may not be worth the additional money
to purchase the 5th edition when the 4th edition has
essentially the same information (other than the two aforementioned
chapters).
McGoldrick,
M., Carter, B., & Garcia-Preto, N. (2011). The expanded family life
cycle: Individual, family, and social perspectives [4th ed.]. New York,
NY: Allyn & Bacon (Pearson).
This
source helps explain specific family interactions and patterns. Considering research has identified circles
of support as being prominent in the efficacy of treatment or lack thereof,
it is important to consider how the family interacts and what tweaks can be
done to enhance the wellness of that system.
This text provides a basic background to most family patterns and
suggests additional resources for exploring specific patterns.
McGoldrick,
M., Gerson, R., & Petry, S. (2008). Genograms: Assessment and
interventions [3rd ed.]. New York, NY: W.W. Norton & Company.
This
source allows clients to start to build maps of genetic trends, physical
health, mental health, behaviors, supports, and other factors which impact
quality of life. A genogram is the
start of behavioral awareness. Turning
the genogram into an ecomap allows for systems of support to be illustrated
and expanded. Further, genograms can
provide rich and valuable information about family inheritance, which can
help expand the possibilities of treatment and can indicate potential
complications.
Miklowitz, D.
J. (2011). The bipolar disorder survival guide: What you and your family
need to know [2nd Ed.]. New York, NY: Guilford Press.
This
is a wonderfully accessible books for people with mood disorders and for
their families. While it is
specifically for bipolar disorder, it is also applicable to people who have
unipolar depression or mood disorder NOS.
Information is presented in a factual, non-blaming manner. Terminology is accessible and avoids jargon
(terms essential to psychoeducation are clearly defined). Additional resources are presented in
subject delineated format. The
suggested resources are affordable and easily accessible via internet/public
library.
I have often recommended this
source to clients and on occasion lent out extra copies I keep on hand for
clients who are unable to afford to purchase their own copy. This is my go-to resource for clients
coping with mood disorders.
Russell, S.
J., & Browne, J. L. (2005). Staying well with bipolar disorder. Australian
and New Zealand Journal of Psychiatry, 93, 187-193.
This
article provides some specific measures for working around the challenges of
bipolar disorder or any mood disorder for that matter. Some of the information is dated, however,
the wellness focus is supported via the body of literature. The advantage of this resource is that it
is short (versus the Miklowitz book) and has concrete iformation.
Sagman, D.,
& Tohen, M. (2012). Comorbidity in bipolar disorder. Psychiatric Times,
30-32.
This
article mentions some specific medical conditions which are often comorbid
with bipolar disorder. Knowing which
specific physical conditions are likely to be comorbid allows the
psychiatrist to tailor medication protocols and track medication side
effects. For example, knowing that
metabolic conditions are likely to be comorbid with bipolar disorder might
help the psychiatrist decide to pay closer attention to the common side
effect of weight gain.
The Lancet.
(2013). Bipolar disorder: At the extremes. The Lancet, 381, 1597.
This
commentary has some excellent points:
Primarily that treatment of bipolar disorder is really treatment of
the person; requires supporting the person and the family of the person; and mandates
planning for the waxing and waning of the disorder. At a single page and with easily accessible
language, it provides an excellent psychoeducational introduction to
normalization and destigmatization of bipolar disorder.
Goals, Objectives and Timeline
List five treatment goals, the objectives (or steps) for each goal
and an estimated timeline for meeting each objective. Then indicate the
specific interventions you will use to help the client reach each goal. This
should include a plan to minimize relapse symptoms and occurrence. You should
also include any adjunct services you would like your client to receive, such
as relaxation training, or exercise. Be sure to include any community services
and organizations (such as NAMI) that will support the treatment goals and any
referrals you plan to make.
Treatment
Plan:
I.
Physical Health
a.
Physical
Health - Immediate
i.
Screening
for comorbid disorders (heart disease, cholesterol levels, insulin resistance,
hormonal levels)
ii.
Complete
physical including basic blood work
iii.
Complete
family history for medical and physical conditions
iv.
Food
Allergy consideration
II.
Crisis
Management – First week: Four appointments
for the week. Two sessions for crisis
management planning, one family crisis management planning session, and one
session of psychoeducation for client and family.
a.
Safety
Planning – FIRST SESSION - Individual
i.
Provide
safety planning packet and develop a safety plan in session. With previous suicide attempts, safety
planning is the most important need.
Also, it will be essential to obtain client AND family buy-in to the
safety plan. As self-awareness develops
(through use of trackers and psychoeducation), the safety plan will need to be
reassessed and refined.
1.
See
Appended items for Safety Plan Packet
ii.
Crisis
Information
1.
Provide
to client and to family ALL local crisis numbers and information, including at
least ACCESS, RAFT, and Police Crisis Intervention Team (CIT) contact.
b.
Mania
Protocol Planning – SECOND SESSION
i.
Utilize
The Bipolar Disorder Survival Guide and Overcoming Bipolar Disorder to develop
these plans and protocols. Tracking
sheets used over time will help to identify triggers and pre-mania symptoms.
ii.
Smart
Phone Apps may be helpful. Discuss
available free and paid options.
c.
Depression
Protocol Planning – SECOND SESSION
i.
Utilize
The Bipolar Disorder Survival Guide and Overcoming Bipolar Disorder to develop
these plans and protocols. Tracking
sheets used over time will help to identify triggers and pre-mania
symptoms.
ii.
Smart
Phone Apps may be helpful. Discuss
available free and paid options.
d.
Over
the course of treatment, these plans will be reviewed and modified. Mood tracking and suicidal ideation tracking
will occur at each session.
III.
Distress
Reduction – 6 session progression
a.
Psychology
Tools – Distress Reduction Self-Help Modules (4 modules)
ii.
Print
each module and provide one per session.
iii.
Review
previous session’s module.
1.
Practice
skills taught in the module.
2.
Discuss
ways to apply the module to current life.
a.
Track
application of the module over the week.
Session 1
|
Session 2
|
Session 3
|
Session 4
|
Session 5
|
Session 6
|
Provide Module 1
|
Review Module 1
|
Review
application of Module 1
|
Review
application of Module 1 & 2
|
Review
application of Module 1-3
|
Review
application of Module 1-4
|
|
Practice Skills
taught in the module
|
Review Module 2
|
Review Module 3
|
Review Module 4
|
|
|
Discuss ways to
apply the module - TRACK
|
Practice Skills
taught in the module
|
Practice Skills
taught in the module
|
Practice Skills
taught in the module
|
|
|
Provide Module 2
|
Discuss ways to
apply the module - TRACK
|
Discuss ways to
apply the module – TRACK
|
Discuss ways to
apply the module – TRACK
|
|
|
|
Provide Module 3
|
Provide Module 4
|
|
|
IV.
Wellness
– 3 sessions per topic with 8 topics = total of 24 sessions. Review topics as indicated by clients
throughout treatment in order to develop a holistic and individualized treatment
plan.
i.
Mental
Health Matters – This introduces aspects of health and wellness. Determine client preference for order of
topics and for relevance to client’s life.
Use mood graphs and descriptions handout (please see appended
documents).
ii.
Stress
and Well-Being
1.
Use
The Anxiety and Phobia Workbook as an adjunct to this module. Trackers for increased wellness are included
within the workbook. Teach “noting and
naming” and “belly breathing” during this module.
iii.
Social
Support
1.
Spirituality
– Discuss aspects of spirituality and the buffering effects of
spirituality. Also discuss the social
support offered by a spiritual group.
Multicultural care must be incorporated to ensure respect for various
religious and spiritual traditions.
2.
Consider
also ethnicity and family traditions and groups in this module.
3.
Utilize
local support groups for client AND for family.
4.
Include
ethnicity and traditional background in this module.
iv.
Problem-Solving
1.
Include
coping skills in this module. Use
PsychologyTools.org CBT skills and tracking logs, Anxiety and Phobia Workbook,
and The Bipolar Disorder Survival Guide for information on specific coping skills.
v.
Anger
Management
1.
For
this module incorporate concepts from distress tolerance. Discuss the feelings underlying anger and
work on developing an “emotional library”.
vi.
Getting
a Good Night’s Sleep
1.
Include
information from National Institute of Health National Heart Lung and Blood
Institute: PDF Healthy Sleep. Either print the PDF or obtain printed copies
of the booklet. (Source: http://www.nhlbi.nih.gov/health/public/sleep/healthy_sleep.pdf)
vii.
Eating
and Living Well
1.
Exercise
– Review exercise/physical activity. If
necessary develop list of physical activities and/or refer to Primary Care
Physician for Physical Therapy referral if physical conditions precluded
physical activities at this time.
2.
Review
especially caffeine intake (see appended document Seroquel for Constance) and
carbohydrate if insulin resistant or having high levels of cholesterol (common
comorbid conditions). If necessary, send
to PCP to set up referral to dietician.
viii.
Healthy
Thinking
1.
Include
information on Cognitive Biases from PsychologyTools.org to supplement this
module.
2.
Include
information on intellectual development and continuing education, if
appropriate to client goals.
b.
Include
any other aspects of wellness that the client feels important to her wellbeing
and personal goals.
V.
Psychoeducation
– Incorporate throughout each step and goal.
Utilize handouts, graphics, and large tablet drawing in sessions
a.
Stage
Model for bipolar disorder treatment
b.
Mood
pattern information sheet
c.
Communication
pathways for coping with mood disorders
d.
Genogram
and ecomap
VI.
Team
Development –
a.
Releases
for Health Professionals, Family, and client-indicated relevant supports
b.
Team
Members:
i.
Medical/Psychiatric/Psychological
Team Development
ii.
Family
Supports
iii.
Community
Supports
iv.
Work
Supports
v.
Other
as indicated by client or team members
c.
Arrange
one team meeting with client approved team members (health professionals and
family and client at the minimum) for initial planning, at one month, and then
as needed for follow-up.
Communication with Other Professionals
Identify other professionals that you anticipate will be involved
in the care for this client. Explain how you will arrange for communication
with them and what you are likely to communicate to each of them. Identify the
kind of information you will need from each source.
Team
Members:
I.
Required
a.
Primary
Care Physician – Responsible for physicals and screening for common comorbid
physical conditions, responsible for medical team coordination and referrals to
second-tier health professionals.
b.
Pharmacist
– Responsible for checking all medications for drug interactions and providing
information about possible side effects.
c.
Psychiatrist
– Responsible for prescribing psychotropic medications.
d.
Counselor
– Responsible for case management, team coordination, and assisting client
follow-up regarding client concerns.
Responsible for psychotherapy and teaching of skills.
e.
Client
– Responsible for compliance, for communication of needs/concerns
f.
Family
– Responsible for attending meetings, for communication
II.
Second-Tier
Professionals – as needed
a.
Dietician
b.
Physical
Therapist, Occupational Therapist, etc.
c.
Specialty
Medical Professional (neurologist, endocrinologist, etc.)
d.
Social
Worker
e.
Department
of Rehabilitative Services Professional
III.
Ancillary
People
a.
Support
group leaders
b.
Religious
leader
c.
Service
providers
How to
communicate:
While
the easiest method of communication would be email, at this time, regular email
is not secure for confidentiality. It
might be possible to use an encryption program.
Another communication method would be using conference calls. Conference calling would allow for immediate
problem solving, but has the problem of schedule synchronization. The simplest method of communication,
although the least effective method for problem solving would be faxes and
paper summaries of status of treatment.
Progress reports sent back and forth between the required health care
providers would maintain flow of communication.
Release of Information forms for each provider would be obtained during
the first session and updated as needed.
Medications
Identify the classification(s) that are most likely to be
prescribed for this client. What are the probable outcomes, side effects and counter-indications?
What factors would contribute to the client being non-compliant? What role
would you play in this aspect of your client's care? Why do you believe these
medications are appropriate for this client at this time?
Typical
medications used for Mood Disorder NOS include:
Antidepressants, anticonvulsants, antipsychotics (especially
second-generation antipsychotics), Lithium, and various other medications used
off-label to treat mania and/or depression (such as Ketamine). Each medication has side effects and
contraindications. Most side effects
involve cardiac, hormonal (metabolic syndrome or thyroid), blood pressure, or
neurological complications. Perhaps most
serious are the possible side effects of Tardive dyskinesia – which can be permanent
even when medication causing the effect is removed. Because medication for bipolar disorders and
for mood disorders NOS may be prescribed in combination (e.g., antidepressant
and medication to act as mood stabilizer), it is important to consider additive
effects and contraindications. A
pharmacist is invaluable in this endeavor.
Also useful is Preston, O’Neal, and Talaga’s (2013) Handbook of Clinical Psychopharmacology for Therapists [7th
ed.].
While
the psychiatrist would prescribe the medications, it is the role of the
counselor to provide psychoeducation about the function of the medication, to
help with medication compliance, and to assist the client in developing and
forming ways to express concerns. The
psychiatrist is a specialist; the counselor, a generalist. Further, the counselor has more extensive
contact with the client and is more likely to notice side-effects. Therefore, the counselor must be aware of which side-effects are possible with which
medication or combination of medications.
Close communication between counselor and psychiatrist and between
counselor and pharmacist furthers this awareness and benefits the client.
If the
client is diagnosed with bipolar disorder, medications may have a
neuroprotective effect. Lifelong
medication is typical treatment for bipolar disorder and can contribute to the
client being able maintain an acceptable quality of life. Using a stage model for bipolar disorder,
medication has specific roles for specific stages. While the data is not conclusive, it is
suggestive. Therefore, balancing side
effects of medication with possible protective outcomes with client preference
becomes essential.
Legal, Ethical and Other Considerations
Identify and discuss any ethical and legal ramifications relating
to the treatment you are considering. Be sure to indicate whether the
ramification is ethical or legal and cite the specific ethical standards or
laws that will guide your decisions. Explain how you will address these.
Ethical
and legal considerations for working with Stella include confidentiality,
informed consent, and the principle of client independence. Confidentiality concerns exist because to
effectively treat Stella, her family must be involved. Also, there are multiple professionals who
will be involved in her care. To keep
confidentiality boundaries clear, it is necessary that release of information
forms are utilized, that clear and concise explanations are provided to Stella
so that she understands and consents to who has what information, and that care
is taken to make sure provided information is needed by the person receiving
the information (Corey & Corey, 2011) .
Suicidal
ideation (SI) may also become a factor in confidentiality. With two previous suicide attempts, Stella is
at risk for additional suicidal attempt.
This risk is complicated by her mood disorder. To avoid feelings of betrayal, the counselor
must carefully describe requirement to report (Virginia Board of Counseling, 2010) . Because SI is a possibility, it must be
tracked each session. To be most
beneficial to Stella, the counselor should develop a working alliance with
Stella using SI tracking and mood tracking as a platform for caring. The point at which the counselor reports SI
would be incorporated in Stella’s Safety plan and jointly determined by Stella
and her counselor.
There is
a tendency for family to want to assume control of the life of the family
member with SMI. In crisis situations,
clients (and families) are suggestible.
With these factors in mind, it is imperative the counselor ensure
Stella’s autonomy is protected. Her
prognosis is improved as her ability to maintain self-care and self-efficacy
increases. Striking a balance between
external supports and internal competence will be essential. This concept is intrinsic in the American
Counseling Association Code of Ethics (Corey & Corey, 2011) . One way to increase autonomy is to explain
the options for treatment to Stella and follow her preference treatment
order. Another method would be to
utilize client informed treatment, with Stella rating and evaluating treatment
as therapy progresses.
Aftercare
Identify the aftercare plan for this client. Will other
professionals and/or resources continue to be involved with this client after
you have completed your services? Include a plan for care in case of relapse.
Mood disorders
can be lifelong conditions. It is
possible that Stella will require continual therapeutic care. Therefore, aftercare may be a misnomer. Instead, it may be more accurate to consider
how to provide continual care, but at levels aligned with Stella’s need at that
time. Support groups can provide
long-term and continued care. Monthly
check-ins can provide access to care, if needed. For relapse, which is typical
of mood disorders, continually updated safety plans provide a blueprint for
crisis management. Ideally Stella and
her family will have the tools needed to navigate and manage mood swings and
crisis moments. Continued support will
simply provide a safety net for them as they live and grow.
Appended
files for purposes of academic evaluation and grading. These would NOT be attached to a formal
treatment plan.
STAGE MODEL FOR TREATMENT OF BIPOLAR DISORDER (Berk, et al., 2010; Kapczinski, et al., 2009)
STAGE MODEL FOR TREATMENT OF BIPOLAR DISORDER
Stage
|
Description
|
Treatment
|
Comments
|
Stage 0
|
Risk factors
exist, although symptoms do not.
|
Wellness
therapies,
Avoidance of
chemicals and other toxins,
Avoidance of
known triggers
|
|
Stage 1 –
Prodromal Stage
|
1a - Nonspecific
symptoms
|
CBT,
Family
Interventions,
Wellness
Therapies,
Possible
treatment with a mood stabilizer,
Psychoeducation
|
Intervening here
might change the course of the disorder.
However, it is very difficult to accurately identify symptoms at this
stage.
|
1b - Identifiable
symptoms, but still very mild
|
|||
Stage 2
|
First episode of
mania or hypomania
|
Energetic
intervention with medication and therapy
|
Medication at
this stage may provide neuroprotective effects.
May also prevent
chronicity of mood relapse/cycling.
|
Stage 3
|
3a –
Sub-threshold symptoms
|
Combination of
medications,
Functional
impairments exist,
Supportive therapies
|
This is where
most research is conducted.
It is possible
that CBT may not be an appropriate treatment after certain amounts of cycling
(12 depressive episodes and/or three manic episodes).
|
3b – Threshold
symptoms.
|
|||
3c – Rapid
cycling or repeated persistent relapse
|
|||
Stage 4
|
Treatment
resistant mood disorder,
Unremitting
symptoms
|
Heavy duty
medications, Electroconvulsive Therapy
|
Impairment
prevents clients from living independently.
|
MOOD
GRAPHS AND DESCRIPTIONS - - For graphics, please contact me at LauraAC@aol.com.
Flat affect
(emotion/mood) can be seen in people who are “emotionally numb” – like after
grief or after trauma
Normal affect is
when you have ups and downs, but they are reasonable, in response to events,
and under your control.
Cyclothymia is a
type of BD, between normal and BDI
Bipolar Disorder I –
has really big ups and really low downs… or it has really low downs mixed with
a little bit higher than normal ups – these are called mixed episodes
Bipolar Disorder II
– has ups higher than normal, but really low downs. The higher than normal ups are called
hypomania.
Mania is when you have really high ups,
maybe get to a normal baseline (or maybe even normal downs), and then go back
up again. With mania, you do not have
larger than normal downs.
Depression is
when you have really low downs and maybe get to a normal baseline or maybe
normal ups, but have no higher than normal ups.
Sometimes people think that ups and downs that are higher
and lower than normal occurring on the same day are “rapid cycling bipolar
disorder”. This is not true. Instead moods that are all over the place
within a short period of time are due to biological problem, substance use, psychotic
break, or mental health crisis. This is when people should be at the emergency
room.
PLEASE GO TO THE EMERGENCY ROOM IF YOU ARE A DANGER TO YOURSELF OR TO
ANYONE ELSE
Seroquel
for Constance
By: Laura Collins
Paper presented in
partial fulfillment of requirements for COUN 6302 – Practicum - February
24, 2013
Constance (name and
identifying information changed to protect client’s identity, Constance
approved the use of her case study for educational purposes, received a copy of
this paper) is a middle-aged female. She
has a long history of polysubstance use and a history of alcohol dependence
(30+ years). Records from previous
contacts with the agency are inconsistent with respect to history of
trauma. Constance has observable
symptoms of anxiety, a flat affect, and a drawn face. She reports multiple symptoms of depression. Sleep is reported as “not normal”.
She
is divorced, unemployed, and recently has been released from jail where she was
serving time for a probation violation.
When Constance was released from jail, she had prescriptions for Prozac,
Neurontin, and for Seroquel. Constance
has not consumed alcohol for 3 months and has not used marijuana for the same
time period (length of time spent in jail for probation violation).
Constance
reports previous outpatient treatment for bipolar disorder, depression, anxiety,
panic disorder, and obsessive-compulsive disorder. Previous records from the agency indicate a
past history of alcohol dependence and mood disorder NOS, and detail which
medications were prescribed for which purposes.
Constance
smokes cigarettes and drinks a large amount of coffee per day. Since her gastric bypass, she cannot eat
large amounts of food and often finds food unappealing. Before she was abstinent alcohol, she
consumed the majority of her daily calories through alcohol. Since abstinence, she consumes the majority
of her calories through coffee with cream and sugar.
Previous
medicinal history:
Mid 2000’s – Gastric
Bypass
Approximately 2 years
ago:
I. 5-18
·
Prozac
20 mg
·
Celexa
20 mg
·
Ativan
2 mg
·
Seroquel
100 mg Twice daily
·
Seroquel
400 mg at night
·
Antabuse
II. 9-7
·
Mobic
·
Prozac
20 mg p.o. Q. Day (Daily)
·
Seroquel
200 mg p.o. B.i.d. (Twice Daily)
·
Seroquel
400 mg p.o., Q.H.s (Nightly at bedtime)
·
Campral
666 mg p.o. T.i.d (3 x per day)
·
Ativan
1 mg p.o. B.i.d. (Twice Daily)
III. 9-20
·
Prozac
40 mg p.o. Q. Day (Daily)
·
Neurontin
800 mg p.o. T.i.d (3 x per day)
·
Loxapine
20 mg p.o., Q.H.s (Nightly at bedtime)
·
Campral
666 mg p.o. T.i.d (3 x per day)
·
Seroquel
200 mg p.o. B.i.d. (Twice Daily)
·
Seroquel
400 mg p.o., Q.H.s (Nightly at bedtime)
This Year:
I. February
·
Prozac
40 mg p.o. Q. Day (Daily)
·
Neurontin
800 mg p.o. T.i.d (3 x per day)
·
Seroquel
200 mg p.o. B.i.d. (Twice Daily)
·
Seroquel
400 mg p.o., Q.H.s (Nightly at bedtime)
The
Literature
The
literature regarding Seroquel is in its infancy. While Seroquel (Quetiapine) has been
available in the U.S. since 1997, it has had a troubled history (Sansone &
Sansone, 2010) . One specific problem is that the Food and
Drug Administration confronted the manufacturer of Seroquel about off-label
marketing. Per Kuchn (2009, p. 2082) , analysis of a large
commercial database of prescribing practices shows that “the most common
off-label uses for… [Quetiapine] were maintenance treatment for bipolar
disorder, depression, and dementia.”
Potential side-effects include Metabolic Syndrome, tardive dyskinesia,
and possible increased risk for sudden cardiac death. Quetiapine seems to be effective in reducing
anxiety symptom for most patients (Altamura, et al., 2012) . It only seems effective in reduction of
depressive symptoms in bipolar (mood disorder) patients.
A
possibly developing problem is that of Seroquel having potential for illicit
use and abuse. Quetiapine has a street
value of $3 to $8 for a 25 mg dose (Sansone & Sansone, 2010) . Per Sansone and Sansone (2010), this is
particularly troubling because Quetiapine is being considered as a treatment
for substance abuse (specifically cocaine, alcohol, polysubstance, cannabis,
and opioid use/abuse). Risk factors for
misuse/abuse include inpatient and prison settings, previous benzodiazepines,
and being part of the at-risk population of people with substance use/abuse
disorders (Sansone & Sansone, 2010) . Further, for patients with possibility of
hepatic impairment, oral use of Quetiapine may require extra caution (Keating &
Robinson, 2007) .
Drug
interactions may occur with some antifungals and some antibiotics (Keating &
Robinson, 2007) ,
caffeine, CNS depressants, SSRI antidepressants, and tricyclic antidepressants (Preston,
O'Neal, & Talaga, 2010) . People taking second-generation
antipsychotics (such as Quetiapine) should have their lipid levels, blood sugar
levels, and weight monitored. These
medications can promote weight gain, cause diabetic-type symptoms, and alter
lipid metabolism (Preston, O'Neal, & Talaga, 2010) .
Use
of Seroquel for Constance
Constance has taken Seroquel for
many years based on existing records and client reports. She reports taking Seroquel when needed for
anxiety and to help her sleep. Based on
existing records, no previous diagnosis of bipolar disorder can be found. Multiple diagnoses of mood disorder NOS and
depressive disorder have been located in previous records.
Regardless
of Seroquel use, Constance still presents with feelings of anxiety and
depression. The incomplete resolution of
Constance’s symptoms is of concern.
Seroquel has been the treatment of choice for several years – without
acceptable resolution of Constance’s symptoms.
This brings to question why this medication has been continued.
Weight
(over-weight and obesity) have been significant concerns for Constance. It seems counter-productive for her to take
medication which is known to cause weight gain.
Previous bypass surgery may indicate metabolic differences from people
without gastric bypass. Seroquel may
have metabolic consequences resembling those of diabetes. The history of alcohol use suggests possible
liver involvement. Seroquel may have
hepatic complications. At this point, no
mention has been made of Constance receiving regular blood tests to follow
blood sugar, lipid, and liver enzyme levels.
This is of significant concern.
Constance
reports that while she takes Seroquel when she needs it for anxiety, and that
daytime use of Seroquel causes sedation and mental confusion. It is possible that the levels of caffeine
(at least 150 ounces of coffee per day at 12 mg per ounce = 1800 mg caffeine
per day) Constance is consuming is causing the dose of Seroquel to be higher
than expected within her bloodstream (Preston, O'Neal, & Talaga,
2010) . This may result in increased side-effects of
the Seroquel and an increased risk of toxicity (Preston, O'Neal, & Talaga,
2010) . Caffeine also contributes to anxiety.
Constance
is concerned that stopping use of Seroquel will precipitate relapse into
alcohol and marijuana use. Her
therapists are concerned that Constance may have psychological and possibly
physical dependence upon Seroquel.
However, after consultation, her therapists concluded that any
dependence is already established and that prior to removal of Seroquel,
Constance will need to develop coping skills, have acceptable medical supports
(and medication) to manage intense anxiety and depressive symptoms, and be willing
to discontinue a medication she has taken for years.
During
the time that skill development is occurring, decreasing amounts of caffeine
while increasing intake of nutritionally balanced foods may result in decrease
of adverse symptoms from Seroquel.
Additionally, it may be possible to reduce the amount of Seroquel used
during the day, if multi-modal treatment and reduction of caffeine reduce the
symptoms of anxiety. Finally, it seems
appropriate to reconsider the use of Seroquel to manage Constance’s anxiety and
depression. There may be other
medications which present less risk and increased benefits.
References
Altamura,
A. C., Moliterno, D., Paletta, S., Buoli, M., Dell'Osso, B., Mauri, M. C.,
& Bareggi, S. R. (2012). Effect of Quetiapine and Norquetiapine on
anxiety and depression in major psychoses using a pharmacokinetic approach: A
prospective observational study. Clinical Drug Investigations, 32(3),
213-219.
Keating,
G. M., & Robinson, D. M. (2007). Spotlight on Quetiapine in bipolar
depression. CNS Drugs, 21(8), 695-697.
Kuchn,
B. M. (2009). FDA panel issues mixed decision on Quetiapine in depression and
anxiety. Journal of American Medical Association, 301(20), 2081-2082.
Preston,
J. D., O'Neal, J. H., & Talaga, M. C. (2010). Handbook of clinical
psychopharmacology for therapists [6th ed.]. Oakland, CA: New Harbinger
Publications, Inc.
Sansone,
R. A., & Sansone, L. A. (2010). Is Seroquel developing an illicit
reputation for misuse/abuse? Psychiatry, 7(1), 13-16.
SAFETY
PLAN PACKET
- For safety plan packet, please contact me at LauraAC@aol.com.
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