PS440 Unit 5 Mood Disorder Case Analysis Example

The Good Weeks Were Part of the Illness: A PS440 Unit 5 Mood Disorder Case Analysis

[Student Name]

Purdue University Global

PS440: Psychopathology

Unit 5 Mood Disorder Case Analysis

[Instructor Name]

[Date]

The guest, her family and the crisis center are composite; the manual, screening study and reviews cited are real.

The Case

Renee is a 34-year-old labor and delivery nurse in Rapid City, South Dakota. She walked through our front door at 2 a.m. after driving for three hours with no destination. She told staff she had slept about three hours a night for a week, could not stop her thoughts, felt hopeless and had thought about driving into a ditch. She agreed to stay.

Three weeks earlier her family physician had restarted sertraline for what appeared to be her third major depressive episode. The first came at 22, during nursing school, and the second at 29, after a miscarriage. Both times an antidepressant seemed to help within a couple of months.

When the center's psychiatric nurse practitioner asked about periods when her mood had been unusually good, Renee described what she called her good weeks. Two or three times a year, for five to eight days, she needs only four hours of sleep, feels sharp and confident, talks fast, starts projects and spends more than she should. During one such week she bought a nine-thousand-dollar horse trailer for a horse she did not own. She has always enjoyed these weeks and never mentioned them to a doctor, because no one asked and she did not consider them a problem. Her husband sees them differently. He told the nurse practitioner by phone that he dreads them, because she becomes impatient, sleeps in the barn office working on plans and spends money they then argue about for months. Her maternal uncle has bipolar I disorder, and her mother had what the family called nervous breakdowns.

Diagnosis

The DSM-5-TR defines bipolar II disorder by at least one major depressive episode and at least one hypomanic episode, with no history of full mania (American Psychiatric Association, 2022). Hypomania is a shift others can see: for four days in a row or longer, mood runs high, expansive or irritable and energy climbs, joined by changes such as sleeping little without feeling tired, talking fast, jumping between ideas or spending recklessly. Unlike mania, it stops short of marked impairment, psychosis or a hospital stay.

Renee's good weeks meet those criteria. They last five to eight days, involve reduced sleep, rapid speech, increased activity and impulsive spending, and her coworkers have noticed them. They have not led to hospitalization or psychosis, which distinguishes them from mania. Her current state, with depressed mood and hopelessness combined with racing thoughts, little sleep and restlessness, suggests a depressive episode with mixed features. On the chart, the nurse practitioner wrote bipolar II disorder, noting that the present depression carried mixed features.

Renee's good weeks were not a break from her illness; they were the part of it that no one had asked about.

Why It Was Missed

Bipolar II disorder is often diagnosed late, after years of treatment for depression. People seek help when they are depressed, not when they feel unusually well, and hypomania may be experienced as productivity rather than illness. Clinicians who do not ask specifically about past elevated periods may never learn about them.

Screening tools were developed partly for this reason. The Mood Disorder Questionnaire, introduced by Hirschfeld et al. (2000), fits on one page. Its thirteen yes-or-no items cover the signs of past elevated periods, from needing less sleep to unusual spending, and two short follow-ups record whether those signs clustered in time and how serious the consequences were. Tested with psychiatric outpatients, it identified most patients with bipolar disorder and correctly screened out most of those without it. Renee completed it at the crisis center and endorsed eleven of thirteen symptom items as having occurred together. A brief screen like this at either of her earlier depressions might have changed her care.

Why the Diagnosis Matters for Treatment

For major depressive disorder, antidepressants are an established treatment. Cipriani and colleagues pooled 522 trials in a network meta-analysis and found every one of the 21 drugs they compared outperformed placebo in adult major depression, by margins that were modest and differed from drug to drug (Cipriani et al., 2018)., 2018). Renee's first two courses of sertraline were consistent with that evidence for the diagnosis she had at the time.

Bipolar disorder is different. Geddes and Miklowitz (2013) reviewed the treatment of bipolar disorder and noted that evidence for antidepressants in bipolar depression is weak, and that antidepressants given without a mood stabilizer carry concerns about switching into hypomania or mania and destabilizing mood. They reviewed stronger evidence for lithium, certain anticonvulsants such as lamotrigine and some atypical antipsychotics for acute episodes and long-term prevention, and for psychological treatments, such as psychoeducation, family-focused therapy and interpersonal and social rhythm therapy, added to medication.

Renee's agitation on sertraline may reflect the risk the review describes. The nurse practitioner stopped the sertraline and started a mood stabilizer in consultation with a psychiatrist, and planned close follow-up.

Psychosocial Factors

Several features of Renee's life bear on her illness. Her work involves rotating twelve-hour shifts, including nights, and disrupted sleep is a well-known trigger for mood episodes in bipolar disorder. Interpersonal and social rhythm therapy, one of the treatments the review discusses, targets exactly this by stabilizing daily routines. Her family history may help her accept the diagnosis, since she has seen her uncle stabilize on treatment, but it may also frighten her. As a nurse, she may worry about what the diagnosis means for her license and her colleagues' view of her, which will need attention in treatment.

Plan

The plan has four parts. Medication changes are managed by a prescriber, with follow-up within a week. She will also see a therapist who uses interpersonal and social rhythm therapy, to address her shift schedule and sleep. Psychoeducation for Renee and her husband covers early warning signs of both depression and hypomania, including spending. Finally, the center's counselor will help her talk with her nurse manager about a schedule without rotating nights, if she chooses to disclose.

Conclusion

Renee's case shows why the course of a mood disorder matters as much as the current episode. Her good weeks were hypomanic episodes that changed her diagnosis from recurrent depression to bipolar II disorder, and that change reverses the role of antidepressants and adds treatments aimed at stability and rhythm. A screening question about good weeks, asked years earlier, might have spared her the drive at 2 a.m.

References

American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

Cipriani, A., Furukawa, T. A., Salanti, G., Chaimani, A., Atkinson, L. Z., Ogawa, Y., Leucht, S., Ruhe, H. G., Turner, E. H., Higgins, J. P. T., Egger, M., Takeshima, N., Hayasaka, Y., Imai, H., Shinohara, K., Tajika, A., Ioannidis, J. P. A., & Geddes, J. R. (2018). Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: A systematic review and network meta-analysis. The Lancet, 391(10128), 1357-1366. https://doi.org/10.1016/S0140-6736(17)32802-7

Geddes, J. R., & Miklowitz, D. J. (2013). Treatment of bipolar disorder. The Lancet, 381(9878), 1672-1682. https://doi.org/10.1016/S0140-6736(13)60857-0

Hirschfeld, R. M. A., Williams, J. B. W., Spitzer, R. L., Calabrese, J. R., Flynn, L., Keck, P. E., Jr., Lewis, L., McElroy, S. L., Post, R. M., Rapport, D. J., Russell, J. M., Sachs, G. S., & Zajecka, J. (2000). Development and validation of a screening instrument for bipolar spectrum disorder: The Mood Disorder Questionnaire. American Journal of Psychiatry, 157(11), 1873-1875. https://doi.org/10.1176/appi.ajp.157.11.1873