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.

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 5^th 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 5^th 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 5^th edition when the 4^th 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)

                                                              i.      Provide internet address for personal access if desired – www.psychologytools.org.

                                                            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.

a.       Use http://www.heretohelp.bc.ca/wellness-modules (8 modules)

                                                              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 [7^th 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	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

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