Introduction
While Ms. P is currently seeking treatment for symptoms of depression, it is essential to consider the possibility of bipolar disorder as a potential diagnosis. Bipolar disorder is characterized by episodes of depression and mania, with periods of normal mood in between. It is estimated to affect approximately 2.8% of adults in the United States. Several factors may suggest the possibility of bipolar disorder in Ms. P. Firstly, her history of moderate major depressive disorder and recent breast cancer diagnosis may increase her risk for developing bipolar disorder. Research has shown that individuals with a history of major depressive disorder are at an increased risk of developing bipolar disorder.
Additionally, the onset of depression in Ms. P may have been preceded by a hypomanic or manic episode, a hallmark symptom of bipolar disorder. A hypomanic episode is characterized by elevated or irritable mood, increased energy, decreased need for sleep, and increased productivity, among other symptoms (Vaidyam et al., 2019). Her breast cancer diagnosis and subsequent treatment may have overlooked or overshadowed this. It is also important to note any family history of bipolar disorder or other mental health conditions, as there is a genetic component to the development of the bipolar disorder (Marzani & Neff, 2021). Finally, certain medications, including some used in breast cancer treatment, may increase the risk of mood disturbances and bipolar disorder. This evaluation aims to assess the patient’s symptoms, mental status, and psychosocial history to determine the most appropriate diagnosis and treatment plan. Additionally, the evaluation will consider the patient’s medical and family history to identify potential risk factors that may contribute to her symptoms.
History of Present Illness
Ms. P’s reported symptoms of depression increased energy, and risky behaviors suggest the possibility of a bipolar disorder diagnosis. The symptoms of depression she is experiencing are consistent with her previous diagnosis of MDD (Marzani & Neff, 2021). Still, her reports of increased energy, decreased need for sleep, racing thoughts, and engaging in risky behaviors suggest the possibility of bipolar disorder. To further assess the possibility of bipolar disorder, a thorough evaluation of Ms. P’s current symptoms and history is necessary. Assessing her mood, behavior, and thought patterns during depressive and manic/hypomanic episodes can provide valuable information for diagnosis. During the interview, it would be essential to ask Ms. P about the duration, frequency, and severity of her depressive and manic/hypomanic episodes. It is also important to inquire about any other symptoms present during these episodes, such as changes in appetite, psychomotor agitation or retardation, feelings of guilt or worthlessness, and suicidal thoughts (Marzani & Neff, 2021).
Additionally, the patient’s history of previous episodes, including the age of onset, duration, and triggers, can provide helpful information for diagnosis. It would also be essential to assess for any comorbid conditions contributing to the patient’s symptoms, such as anxiety or substance use disorders. A family history of psychiatric disorders, especially bipolar disorder, can also increase the likelihood of a bipolar diagnosis. A comprehensive medical evaluation is also crucial to assess for any medical conditions contributing to the patient’s symptoms, such as thyroid disorders or neurological conditions.
Past Psychiatric History
Ms. P’s history of the major depressive disorder suggests that she may be more susceptible to mood disorders. However, her previous diagnosis of MDD does not necessarily indicate a diagnosis of bipolar disorder. While MDD and bipolar disorder share some symptoms, bipolar disorder is distinguished by manic or hypomanic episodes. It is possible that Ms. P’s previous diagnosis was accurate, and her current symptoms continue her previous major depressive episode. However, given her recent report of symptoms of increased energy, decreased need for sleep, racing thoughts, and risky behavior, it is essential to consider the possibility of bipolar disorder (Antony & Barlow, 2020). A thorough evaluation is needed to diagnose accurately and determine the most appropriate treatment plan.
Medical History
Ms. P has a history of bilateral breast cancer and is currently in remission. She reports no other significant medical history. The presence of a medical condition, such as breast cancer, can be a significant stressor and can contribute to the development of psychiatric symptoms. Research has shown that individuals who have experienced a major medical illness are at an increased risk of developing depression and anxiety (Antony & Barlow, 2020). Ms. P’s history of breast cancer, which she is currently in remission from, may have contributed to developing her depressive symptoms. It is also important to consider the potential impact that cancer treatment, such as chemotherapy or radiation, may have had on her mental health. It is important to note that individuals with bipolar disorder have also been found to have an increased risk of developing certain medical conditions, such as heart disease and diabetes. Therefore, it will be essential to consider Ms. P’s medical history and current physical health as part of her overall evaluation and treatment plan.
Family History
Ms. P reports a family history of depression and anxiety but is unsure about a history of bipolar disorder. A family history of depression and anxiety can increase the risk of developing mood disorders such as major depressive disorder and bipolar disorder. However, without more information about her family members’ mental health history, it is difficult to definitively say whether there is a genetic predisposition to bipolar disorder in her family (Antony & Barlow, 2020). Ms. P may benefit from further exploring her family history to identify potential risk factors for bipolar disorder.
Social History
Ms. P’s social history reveals that she is married with two children and works full-time as a teacher. Her job appears to be a source of stress for her due to the job’s demands and difficulty with coworkers. It is important to note that workplace stress can contribute to developing mood disorders, such as bipolar disorder. Ms. P denies any history of substance abuse, an essential factor to consider as substance use can also contribute to the development of bipolar disorder or worsen existing symptoms (Marzani & Neff, 2021). It is important to note that substance use can also interfere with the effectiveness of medications used to treat bipolar disorder. Overall, Ms. P’s social history provides some insight into potential stressors that may contribute to her symptoms of depression and possibly bipolar disorder. It is essential to address these stressors as part of her treatment plan to help improve her overall functioning and mental health.
Mental Status Examination
Appearance
Ms. P presents as well-groomed and appropriately dressed for the occasion. Based on the information provided, Ms. P consistently presents herself with what would be expected for a psychiatric evaluation. She is described as well-groomed and appropriately dressed for the occasion, which suggests that she is aware of social norms and can adhere to them. Additionally, her appearance does not suggest any signs of distress or impairment.
Mood and Affect
Ms. P reports feeling sad and hopeless. Her affect is congruent with her reported mood. The term “affect” refers to the observable emotional expression of a person. In this context, “congruent” means that Ms. P’s affect matches her reported mood, i.e., she appears sad and hopeless as she reports feeling sad and hopeless. This is an important observation because it is one of the symptoms used to diagnose depression. A person with depression may appear sad or “flat” (lack of emotional expression) even when discussing neutral topics, and their affect may not match the conversation context. In contrast, a person with bipolar disorder may have affective instability, meaning that their emotional expression can change rapidly and may not match the conversation context (Marzani & Neff, 2021).
Thought Process and Content
Ms. P reports experiencing racing thoughts during her periods of increased energy. This is a common symptom of bipolar disorder. This may indicate a manic or hypomanic episode (Antony & Barlow, 2020). However, she denies any suicidal or homicidal ideation, which suggests that her thought content is not currently disturbed. It is important to continue to assess her thought process and content throughout the evaluation to ensure her safety.
Speech
Ms. P’s speech is normal in rate, volume, and tone. Everyday speech is typically described as fluent, clear, and easily understood. An appropriate rate, volume, and tone characterize it. In the context of Ms. P’s evaluation, her speech was expected, which suggests that she can communicate effectively and is not experiencing any significant disruptions in her ability to express herself (Vaidyam et al., 2019). This positive finding suggests that her symptoms of depression and possibly bipolar disorder are not significantly impacting her ability to communicate with others.
Cognition
Ms. P reports some difficulty with memory and concentration, which she attributes to her symptoms of depression. During the evaluation, she exhibited no confusion, disorientation, or perceptual disturbances. She could provide detailed and coherent responses to questions and appeared to have intact comprehension and communication abilities. However, she did report difficulty completing tasks and making decisions, which suggests some cognitive impairment (Marzani & Neff, 2021). These symptoms are consistent with depression and may contribute to her functional impairment at work and other areas of her life. It will be essential to monitor her cognitive functioning as she undergoes treatment to determine if there is improvement in this area.
Insight and Judgment
Ms. P has good insight into her symptoms and their impact on her life. Her judgment appears intact. Based on the information provided, it appears that Ms. P has good insight into her symptoms of depression and how they have impacted her life. She was able to provide a detailed description of her symptoms and how they have affected her mood, energy level, and daily functioning. Additionally, she recognized the negative impact her symptoms have had on her relationships and work performance. Ms. P’s judgment also appears to be intact. Aside from the occasional shopping sprees during periods of increased energy, she did not report engaging in any behaviors that would be considered dangerous or harmful to herself or others (Marzani & Neff, 2021). Overall, Ms. P appears to understand her symptoms and their impact on her life and demonstrates appropriate judgment and decision-making abilities.
Patient Instructions/ Follow Up
After completing the evaluation, it is essential to develop a treatment plan that addresses Ms. P’s symptoms of depression and potentially bipolar disorder. She is recommended to return to the clinic in 15 days for a follow-up appointment to monitor her symptoms and adjust her treatment plan as needed. In addition to pharmacotherapy, individual or group psychotherapy should be started to help manage her symptoms and address underlying stressors. It is essential that Ms. P takes all medications as prescribed and follows up with appropriate medical physicians as needed to manage her medical conditions.
Safety Plan
To ensure her safety, a safety plan was discussed with Ms. P, including telling a friend, calling the office, calling 911, or going to the nearest ER if she develops thoughts of self-harm or others or symptoms of psychosis (Antony & Barlow, 2020). Orders were placed for CBC CMP, TSH T3, Liver Panel Test, Renal Panel Test, Urine drug test, Urinalysis, and EKG to evaluate her medical condition further. Ms. P does not meet the criteria for an immediate inpatient hospitalization, but continued outpatient care is necessary. Continued outpatient care is essential for Ms. P to ensure she receives ongoing support and treatment for her bipolar disorder (Vaidyam et al., 2019). This includes regular check-ins with a healthcare provider and ongoing monitoring of her symptoms and medication management. By staying connected with a mental health professional, Ms. P can receive guidance and support to help manage her symptoms and reduce the risk of relapse.
The safety plan is also essential to Ms. P’s care, as it outlines specific steps she can take if she experiences a mental health crisis. This helps ensure that she has the plan to address any immediate concerns and can seek help if needed. The orders for additional medical testing are important to ensure that no underlying medical conditions contribute to her symptoms and to monitor any potential medication side effects (Antony & Barlow, 2020). It is also important to note that Ms. P does not meet the criteria for an immediate inpatient hospitalization, which indicates that she can safely receive treatment on an outpatient basis. This can help to reduce the potential for additional stress and disruption in her life and allows her to continue to work and care for her family while receiving the care she needs (Vaidyam et al., 2019). Overall, the combination of ongoing outpatient care, a safety plan, and appropriate medical monitoring can help to support Ms. P’s mental health and improve her quality of life.
Ms. P has been advised to abstain from all illicit drugs, alcohol, or mind-altering substances. The risks, benefits, treatment alternatives, and medication side effects have been explained to her. Her E-FORCSE was reviewed, and there is no evidence of misuse of controlled substances. Ms. P has provided informed consent for the treatment documented in this clinical note, and she understands her mental condition and the need for treatment (Vaidyam et al., 2019). Her concerns regarding diagnosis and prognosis were addressed, including accuracy and projection over time. The patient understands that greater than 50% of the session is on counseling and care coordination. Ensuring that Ms. P is fully informed about her treatment options and understands each option’s potential risks and benefits is crucial. By explaining the risks, benefits, and potential side effects of medication and discussing treatment alternatives, Ms. P can make informed decisions about her care that align with her individual preferences and goals (Antony & Barlow, 2020). Informed consent is a critical aspect of the patient-provider relationship and is necessary to establish a collaborative and trusting therapeutic alliance.
Ms. P’s E-FORCSE was reviewed to assess for any misuse of controlled substances, which could impact her treatment plan and overall well-being. The absence of evidence of controlled substance misuse allows for greater confidence in prescribing medication as part of her treatment plan. The patient’s concerns regarding her diagnosis and prognosis were also addressed, which can help to alleviate any potential anxiety or uncertainty surrounding her condition. Counseling and care coordination are integral to the treatment plan for mental health conditions. By ensuring that more than 50% of the session focuses on counseling and care coordination, Ms. P can receive the necessary support and guidance to manage her symptoms and improve her overall functioning (Antony & Barlow, 2020). A collaborative approach to treatment can also improve treatment adherence and outcomes.
Conclusion
Based on the evaluation, Ms. P appears to be experiencing symptoms consistent with bipolar disorder. Given her history of depression and anxiety and the reported presence of racing thoughts during periods of increased energy, this diagnosis is likely. A treatment plan has been developed, which includes starting psychotherapy, individual or group, taking prescribed medications as directed, and following up with appropriate medical physicians as needed. Ms. P has been advised to abstain from all illicit drugs, alcohol, or mind-altering substances, and her safety plan has been discussed. Orders were placed for several tests to evaluate her medical condition further. Although Ms. P does not meet the criteria for an immediate inpatient hospitalization, continued outpatient care is necessary. The risks and benefits of medications, alternative care, and treatments were reviewed and discussed with Ms. P. She has provided informed consent for the treatment documented in this clinical note. It is essential to closely monitor Ms. P’s symptoms over time and adjust her treatment plan to ensure the best possible outcomes for her mental health. With the proper care, Ms. P can manage her condition and improve her quality of life.
References
Antony, M. M., & Barlow, D. H. (Eds.). (2020). Handbook of assessment and treatment planning for psychological disorders. Guilford Publications.
Marzani, G., & Neff, A. P. (2021). Bipolar disorders: Evaluation and treatment. American family physician, 103(4), 227-239.
Vaidyam, A. N., Wisniewski, H., Halamka, J. D., Kashavan, M. S., & Torous, J. B. (2019). Chatbots and conversational agents in mental health: a review of the psychiatric landscape. The Canadian Journal of Psychiatry, 64(7), 456-464.
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