The patient is a 38-year-old female who lives with her fiancé and two children. She is presenting for follow-up of her insomnia, and her chief complaint is that she is not doing well and is still not sleeping through the night. Patient is alert and oriented; appears to be in no acute distress; speech is clear; is able to follow commands. She presents with good hygiene and is well-dressed and organized. She reports feeling anxious and depressed. She also reports that she has not slept in 4 nights. She reports that the hydroxyzine she was previously prescribed for her insomnia is not helping her fall asleep. Patient claims that she was also previously prescribed Remeron to help her depression, but she stopped taking it because it was making her gain weight. She mentions that her appetite is good. She denies history of suicidal or homicidal ideation or history of self-harm. She denies any visual or auditory hallucinations, delusions, or psychotic symptoms.  Cognitive Behavioural Therapy For Anxiety And Related Disorders

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The diagnoses for this patient were determined to be bipolar II disorder, generalized anxiety disorder, and insomnia. Her treatment plan consisted of a prescription of Trileptal 900mg orally at bedtime to treat her bipolar II disorder and Gabapentin 100mg cap orally twice daily, and Doxepin 29mg orally once daily at bedtime to treat her anxiety and insomnia. Trileptal has been found to be an effective mood stabilizer in addressing manic episodes associated with bipolar disorder (Grunze et al., 2021). On the other hand, gabapentin boosts sleep efficiency and reduces the amount of spontaneous arousal that occurs during sleep, while Doxepin works by boosting the levels of several naturally occurring chemicals in the brain that are essential for maintaining mental equilibrium (Almasi & Meza, 2019). Among the medications discontinued in this patient include Mirtazapine (patient reports weight gain), Hydroxyzine (did not help the patient fall asleep), and Propranolol. Patient was educated on the side effects of the prescribed medications and the importance of adhering to the treatment regimen. She was also recommended to start CBT sessions to help with her anxiety. The goal of CBT is to put an end to detrimental patterns of behavior by analyzing the factors that contribute to an individual’s feelings of sadness, anxiety, or fear (Carpenter et al., 2018). Patient verbalized understanding of the treatment plan and is set to follow up in 2 weeks.

References

Almasi, A., & Meza, C. E. (2019). Doxepin. https://www.ncbi.nlm.nih.gov/books/NBK542306/

Carpenter, J. K., Andrews, L. A., Witcraft, S. M., Powers, M. B., Smits, J. A., & Hofmann, S. G. (2018). Cognitive behavioral therapy for anxiety and related disorders: A meta‐analysis of randomized placebo‐controlled trials. Depression and Anxiety, 35(6), 502-514. https://doi.org/10.1002/da.22728

Grunze, A., Amann, B. L., & Grunze, H. (2021). Efficacy of Carbamazepine and its derivatives in the treatment of bipolar disorder. Medicina, 57(5), 433.  Cognitive Behavioural Therapy For Anxiety And Related Disorders 

Discussion board of the most interesting client
USE THIS PATIENT INFO TO MAKE YOUR NARRATIVE AND ADD REFERENCES PLEASE. THANKS. Any info I don’t have here, just make it up. Thanks

Info – Taking meds as prescribed. Pt reports not doing well. Reports she is still not sleeping through the night and has not slept in 4 nights. State she stopped taking the Remeron because it was making her gain weight. States the hydroxyzine is not helping her fall asleep. States appetite is good. Denies any acute issues at this time. Denies any si, no injury to self, no psychosis.

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Supportive therapy appointment 5/3/22:
– She states she is out door dashing for the evening. Discussed following up in future scheduled visit. Pt agreed to this.
– Pt is not having si/hi/self-harm thoughts.

Past Diagnosis and Age of Onset
Bipolar II
GAD
Insomnia

Social Hx
Lives with fiancee and 2 kids. works as a phlebotomist

Dx
F31.81 – Bipolar II Disorder
F41.1 – Generalized Anxiety Disorder
F51.01 – Insomnia Disorder Cognitive Behavioural Therapy For Anxiety And Related Disorders
Treatment Plan
Bipolar 2 (stable)

– Trileptal 900mg po at bedtime
Anxiety/Insomnia (unstable)
Start Doxepin 29mg capn po qhs
Gabapentin 100mg cap po bid
d/c Mirtazapine 15mg tab po at bedtime (pt stopped taking it. States it makes her gain weight)
– d/c Hydroxyzine 25mg Tab po qhs
-d/c Hydroxyzine 10mg tab po bid prn for anxiety
-d/c Propranolol 10mg tab po BID

discussed s/e of meds, recommended therapy for anxiety sx, pt agreeable, referral in place. pt verbalized understanding, f/u in 2 weeks Cognitive Behavioural Therapy For Anxiety And Related Disorders