MENTAL HEALTH COMPREHENSIVE CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Marauka Santucci

April 11, 2023

Dr. Teresa Peck, DNP, MSN, RN

NURS 4842L Mental Health Nursing Laboratory

Youngstown State University

MENTAL HEALTH COMPREHENSIVE CASE STUDY

Abstract

RM is a 24-yer-old female patient who has been admitted to the inpatient psychiatric unit following

suicidal ideation. She has a psychiatric mental health diagnosis of major depressive disorder in

addition to bipolar disorder and cluster B. With her medication treatment that includes

antidepressants, antimanic and antipsychotics, and antihistamines for anxiety, the symptoms have

become manageable, but RM has not resumed to a functioning level of daily hygiene,

communication, or other daily activities. Nursing care provided on the unit is focused on symptom

management through pharmacologic methods, as well as group therapy and individualized therapy

sessions.
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Objective Data

Patient identifier RM

Age 24

Sex Female

Date of admission March 14, 2023

Date of care March 28, 2023

Psychiatric diagnosis Major Depressive Disorder

Other diagnoses Bipolar, Cluster B, suicidal ideation

Allergies Penicillin, Latex, Lamotrigine

Behaviors on admission RM was having an argument with her brother with whom she lives

with. The patient stated she wanted to hang herself and the patient’s brother decided to send the

patient back to Trumbull Memorial Hospital for admission to the psychiatric unit. Arguments

with her brother happen often, but the patient is reluctant to describe the arguments. Patient

states she still has not had contact with her father.

Behaviors on day of care RM was calm, cooperative, and willing to talk with me. She

participated in the 10:45 am group therapy session, but not the morning group therapy session.

Patient stated she hasn’t been sleeping well and is very unmotivated with a lack of interest in

activities of daily living. She stated she has been having racing thoughts and a lack of

concentration. RM was hallucinating and seeing shadows that she stated cause her some anxiety.

Since this patient has been on the unit for some time, I am able to see that she is not as outgoing
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as she previously has been. Her affect was congruent with her mood, and her posture was

slouchy. Her speech was slower and quieter, and she did not engage in lengthy conversation but

gave shorter responses to questions asked with minimal eye contact. Her mannerisms were calm

yet detached.

Safety and security measures During the inpatient admission there were visual safety checks

implemented around the clock every 15-minutes. The patient was also not permitted out of the

unit, and staff was present at all times. Any and all possible hazardous items such as shoelaces,

razors, pencils, and pens were not permitted on the unit, and only markers were used for writing.

Medications were administered to the patient by the nurse, and the nurse verified all medications

were taken at the time of administration.

Laboratory results

Lab Value Result

Glucose 93
Sodium 135 ˄
TSH Normal
T4 Normal
RBC 5.45 ˄
Hbg/Hct Normal/46˄
WBC 10.8 ˄
BUN/Crea. Norm/Norm
QTc 403
Toxicology Negative
HCG Negative
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Psychiatric medications

Generic Name Trade Name Class/Category Dose/Frequency Reasoning

benztropine Cogentin Anticholinergic 1 tab (0.5 mg) Side effects of
BID Haldol
bupropion Wellbutrin Antidepressant 150 mg daily Depression
lithium Eskalith Antimanic 300 mg BID Mood
stabilization
mirtazapine Remeron Tetracyclic 15 mg QHS Mood
antidepressant stabilization
haloperidol Haldol Typical 5 mg Q6H PRN Mood
antipsychotic stabilization
hydroxyzine Vistaril Antihistamine 50 mg Q6H Anxiety
PRN

Summary of psychiatric diagnosis

Major depressive disorder is characterized by two weeks or more of a “depressed mood”

and “loss of interest or pleasure in nearly all activities” (Kennedy 2008). The additional

symptoms of major depressive disorder include anhedonia, or the inability to feel pleasure,

changes in weight (gain or loss), sleep (insomnia or hypersomnia), changes in energy,

concentration, decision-making, self-esteem, and goals. The degree of depression is related to

the person’s sense of helplessness and hopelessness. Depression symptoms can be mild to

severe and if untreated can last for a few weeks to months or years (Videbeck p. 663). RM

presented with multiple symptoms of major depressive disorder such as anhedonia, lack of

energy, lack of concentration, fatigue, low self-esteem, and weight loss due to a lack of appetite.

In depression, researchers have found that the neurotransmitters norepinephrine and

serotonin are decreased, therefore, treatment and control of depression is done with
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antidepressant medication such as MAOIs, SSRIs, and atypical antidepressants. Which

medication is used is determined by the patient’s symptoms, age, physical health, other

medications they are currently prescribed, and medications that have worked or not worked

previously. If the client with depression is also presenting with psychotic symptoms, an

antipsychotic is used in combination with the antidepressant (Videbeck p. 664). RM is

prescribed bupropion, and mirtazapine for depression, and she is prescribed haloperidol as an

antipsychotic. Other medical treatment options for depression include electroconvulsive therapy

and psychotherapy. Electroconvulsive therapy (ECT) is used in clients who do not respond to

antidepressant medications or those who have intolerable side effects. ECT involves the

application of an electrical current to the patient’s scalp that will deliver electrical impulses to

the brain in order to provoke a generalized epileptic seizure. The purpose is to alleviate psychotic

and depressive symptoms (Leiknes et al., 2012). This stimulates the brain to produce

neurotransmitters which help to balance the brain’s chemical imbalance resulting in decreased

symptoms of depression (Videbeck p. 674). Psychotherapy in combination with medications is

considered the most effective treatment for major depressive disorders. The goal is symptom

remission, restoration of psychosocial skills, and prevention of relapse. Psychotherapy includes

interpersonal therapy, behavior therapy, and cognitive therapy, all of which RM is receiving

during her stay at Trumbull Memorial Hospital.

Suicidal thoughts are common in people with mood disorders, especially with depression.

Psychiatric disorders such as depression, bipolar disorder, schizophrenia, substance abuse,

PTSD, and borderline personality disorder increase the risk for suicide. Environmental factors

that are associated with increased risk of suicide include isolation, recent loss, lack of social

support, unemployment, and family history of depression or suicide (Videbeck p. 721). Factors
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that put RM at risk include isolation, recent loss, and lack of social support. Because of the

safety risks of clients with major depressive disorder, nurses and physicians need to assess the

client for suicidal ideation, plans, and thoughts of hurting themselves or others. It is important to

implement safety measures on the unit and to monitor the patient’s whereabouts and behavior

frequently. Providing consistency, therapeutic communication, and building rapport can help the

client to feel safe sharing any thoughts of harming themselves to staff members on the unit.

Since RM frequently comes to the hospital because of threatening suicide and suicidal ideation,

all safety measures are priority and implemented to keep her safe. Clients who begin taking

antidepressants will continue to have an increased risk for suicide in the first few weeks of

medication therapy. This is because they might experience an increase in energy, but still feel

depressed which will make them more likely to carry out suicidal ideas. Patient education on

medication is very important as well as close monitoring during this time.

This patient’s second psychiatric diagnosis is bipolar disorder. Bipolar disorder, also

known as bipolar affective disorder, is one of the top 10 leading causes of disability worldwide.

Bipolar disorder is characterized by chronically occurring episodes of mania or hypomania

alternating with depression and is often misdiagnosed initially (Jain & Mitra, 2023). Bipolar

disorder is diagnosed when a person’s mood fluctuates to extremes of mania and/or depression.

During a depressed phase, the mood, behavior, and thoughts are the same as previously

described for major depressive patients and is characterized by two weeks or more of a sad mood

or lack of interest in life activities. Mania is a period of abnormally elevated or irritable mood.

This period can last for one week but can be longer for others. Manic episodes include inflated

self-esteem and grandiose delusions; decreased sleep; pressured, rapid, and loud speech; flight of

ideas or racing unconnected thoughts; and distractibility. A person’s mood can also be
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excessively cheerful and enthusiastic. They often deny any problems, placing blame on others.

RM presented with more depressive symptoms than manic symptoms during this encounter.

Previous encounters with this patient consisted of a happier more stable mood. The treatment or

control of bipolar disorder involves lifelong regimens of medications such as antimanic or

anticonvulsant medications. RM is currently prescribed lithium for mood stabilization in bipolar

disorder.

This client’s third diagnosis is called cluster B personality disorder. Cluster B personality

disorder is characterized by dramatic, emotional, and unpredictable thinking or behavior. It

includes antisocial personality disorder, borderline personality, histrionic personality disorder,

and narcissistic personality disorder. The way cluster B is diagnosed is by an in-depth interview.

A health professional will ask the person about clinical history, experiences, emotions, and

behaviors as well as possibly speaking with the person’s family, or others who are close.

Symptoms of cluster B are specific to each disorder. The journal article Personality disorders

explains that symptoms of antisocial personality disorder include a disregard for others’ feelings

and needs, persistent lying, problems with the law and violation of others’ rights, aggressive

behaviors, disregard for safety of others or self, impulsiveness, irresponsibility, and a lack of

remorse. The article also states that symptoms of borderline personality disorder include

impulsive or risky behaviors, unstable or fragile self-image, unstable and intense relationships,

mood swings as a reaction to interpersonal stress, suicidal behavior or threats, intense fear of

being alone or abandoned, feelings of emptiness, frequent displays of anger, stress-related

paranoia. The third disorder included in cluster B is histrionic personality disorder and the

article clarifies that symptoms include consistently seeking attention, excessively dramatic and

provocative behavior, strong opinions, they are easily influenced, and shallow and rapidly
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changing emotions. Lastly, the article explains that symptoms of narcissistic personality disorder

include fantasies about power or success, exaggeration of achievements, expectation of praise

and admiration, belief that you’re special and more important than others, and envy of others or

believing others envy you (2016). Treatment for cluster B disorders includes medications,

psychotherapy, and behavioral therapies. RM presented with at least one symptom of each

disorder such as persistent lying, disregard for safety of self, impulsiveness, unstable

relationships, interpersonal stress, suicidal threats, seeking attention, and expectation of

admiration.

Identification of stressors and behaviors precipitating current hospitalization

Prior to admission, RM stated she was compliant with her medication and that she was

feeling good. Patient was living with her brother and his wife. She stated that she got into an

argument with her brother and threatened to hang herself. Her brother expressed that he is afraid

she will follow through with and carry out her plans for suicide. He also feels that it may be time

for her to live in a group facility when she is discharged, but the patient explains she wants to go

back to her brother’s home. In addition to her diagnosed mental disorders, it is safe to assume

that her risk for suicide is high and that she should be admitted when she is having thoughts and

ideas of suicide for observation. Because of her frequent admission to the unit due to the same

complaints, we can assume that the patient is presenting with malingering and benefitting from

primary and secondary gain. Malingering is the intentional production of false or grossly

exaggerated physical or psychological symptoms (Videbeck p. 914). People who malinger

typically have no physical symptoms and greatly exaggerate any minor symptoms. Because of

the argument with her brother, which we often receive no context regarding, she states she is
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going to commit suicide and she is admitted to the psychiatric unit. On the unit, the patient

receives food and water, she can avoid responsibilities of everyday life that she otherwise could

not, she avoids ADLs for a limited time, she is receiving medications routinely, and most

importantly, she isn’t arguing with her brother. This leads us to believe she is benefiting from

primary and secondary gain. Primary gain is the relief of anxiety that is achieved by avoiding a

specific anxiety-driven behavior, such as staying in the house to avoid anxiety of leaving a safe

place. Secondary gain is the attention received from others as a result of these behaviors

(Videbeck p. 539). For example, the patient states she will hang herself and she is admitted to

the unit where she receives attention from staff workers, nurses, and physicians who are

concerned about her threats of suicide and is able to avoid responsibilities of everyday life. In

the three weeks since she has been back to the unit, we noticed a decline in self-care and attitude.

On the 21st of March, the patient seemed as though she had performed ADLs, brushed her hair,

eaten food, slept well, and taken medications. On the 28 th of March, the client seemed to regress

back to her status from admission. This is possibly due to almost being discharged from the

facility. When a client does not want to leave, they can regress back to a state of instability

which can extend their stay and again we can assume secondary gain.

Patient and family history of mental illness

RM has a psychiatric mental health diagnosis of major depressive disorder in addition to

bipolar disorder and cluster B. It is unknown when she was diagnosed with each disorder, but

the patient stated that within the last couple years she attended Highland Springs Mental Health

Facility in Cleveland, Ohio. It is unknown whether there is any history of mental illness in her

family. Patient stated her mother passed away about three years ago and that she was the one
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who took care of her mother. She does not have contact with her father who lives out of town,

and we are unaware of if her brother suffers from any mental illness.

Psychiatric evidence-based nursing care provided

During her stay on the inpatient psychiatric unit, RM received nursing care from the

mental health nursing staff. RM was assigned a nurse each shift with whom she was able to

build a relationship with. The nurse would then use the nursing process to assess, diagnose, plan,

implement, and evaluate RM every day to ensure she was receiving necessary treatment. The

nurse would also administer daily medications and ensure that the patient was not pocketing her

pills for later use. RM was prescribed two new medications. She was prescribed an

anticholinergic mediation called benztropine, and bupropion as an antidepressant. RM also takes

lithium, an antimanic medication; mirtazapine, an antidepressant; and haloperidol, a typical

antipsychotic, for mood stabilization. She also is prescribed hydroxyzine for anxiety. The

nurses that provide care for this patient are aware of what each of the medications are used for,

common side effects, and signs and symptoms of neuroleptic malignant syndrome, a rare but

serious condition that may develop from the use of antipsychotics.

Another component of the treatment RM received while she was inpatient was daily

group sessions that she was encouraged to attend. The unit provided a structured schedule that

included mealtimes, times for personal care or phone calls, and structured groups run by nurses,

social workers, and the psychiatrist on the unit. RM seemed to attend the later group therapy

sessions more often because she stated she is usually tired and wants to get more sleep during the

morning group session. She is reminded that regularly attending as many of these group sessions
MENTAL HEALTH COMPREHENSIVE CASE STUDY

as she can each day can help her complete treatment sooner. RM did state that she likes to attend

group therapy.

Ethnic, spiritual, and cultural influences

RM is a Caucasian, single woman. She is not employed and depends on her brother for

housing and financial assistance. RM stated she is Christian, but that she does not practice the

religion. She does not have any other cultural influences.

Evaluation of patient outcomes

Some of the outcomes that are desired for a patient with major depressive disorder,

bipolar disorder, and cluster B disorder include remining free from injury and self-harm; the

ability to verbalize feelings with congruent verbal and nonverbal messages; remaining oriented

to person, place and time; demonstrating the use of effective coping mechanisms; demonstrating

decreased anxiety; sleeping at least 6 hours per night; performing self-care activities; being free

from psychotic symptoms; and developing a schedule or routine that includes daily

responsibilities. On the day of care, RM was able to meet the outcomes of remaining free from

injury, remaining oriented, verbalizing feelings congruent with affect, and being free from

psychotic symptoms. She was unable to meet, but was progressing towards meeting, the

outcomes of demonstrating the use of effective coping mechanisms, demonstrating decreased

anxiety, and developing a daily schedule or routine. She was not meeting the outcomes of

sleeping at least 6 hours per night or performing self-care.

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Plans for discharge

Although there were no discharge plans set for this patient at the time, it is likely that RM

will return to her brother’s home when she leaves. RM will be discharged with instructions for

following her medication regimen, and any education that is needed will be verbally reviewed

with the patient along with information sent home with her that includes side-effects, and

adverse reactions that can occur. She will have follow-up appointments with her physicians and

will be expected to continue therapy and treatment. RM will be encouraged to regularly attend

and maintain her appointments, and to stay compliant with her medications.

Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for RM:

1. Disturbed sensory perception related to psychological stress as evidenced by visual

hallucinations.

2. Disturbed though processes related to mental illness as evidenced by non-realistic

thinking and delusions.

3. Risk for total self-care deficit related to lack of energy as evidenced by poor grooming

and appearance.

4. Anxiety related to discharge as evidenced by regression to state of instability.

5. Risk for suicide related to previous suicidal ideation and threats.

6. Risk for imbalanced nutrition related to lack of appetite, energy, interest in mealtime as

evidenced by verbal expression of loss of appetite and weight loss.

7. Ineffective coping related to suicidal threats as evidenced by anhedonia and insomnia.

MENTAL HEALTH COMPREHENSIVE CASE STUDY

Potential nursing diagnoses

1. Ineffective activity planning

2. Ineffective verbal communication

3. Ineffective health maintenance

4. Fear

5. Hopelessness

6. Impaired memory

7. Rick for falls

8. Impaired social interaction

9. Social isolation

Conclusion

Major depressive disorder, bipolar disorder and cluster B disorder are all very complex

illnesses. With these illnesses come many exacerbations and remissions of symptoms often

complicated by stress, change, lack of support, lack of routine, and non-compliance with

medications. During the exacerbations of these disorders, the patient can become a great danger

to themselves and others due to feelings of helplessness and hopelessness, anger, frustration, and

feelings of isolation. Additionally, there may be communication and self-care deficits during

exacerbations that may make hospitalization necessary until the patient can become reoriented to

reality and are able to care for themselves. Upon discharge, RM will continue to be at an

increased risk for suicide. She will hopefully continue treatment and therapy which will aid in

lessening exacerbations and keep her functioning at a stable and sustainable level.
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References

Jain, A., & Mitra, P. (2023). Bipolar disorder - statpearls - NCBI bookshelf. National .

Retrieved April 8, 2023, from https://www.ncbi.nlm.nih.gov/books/NBK558998/

Kennedy, S. H. (2008). Core symptoms of major depressive disorder: Relevance to diagnosis and

treatment. Dialogues in Clinical Neuroscience, 10(3), 271–277.

https://doi.org/10.31887/dcns.2008.10.3/shkennedy

Leiknes, K. A., Schweder, L. J., & Høie, B. (2012). Contemporary use and practice of

electroconvulsive therapy worldwide. Brain and Behavior, 2(3), 283–344.

https://doi.org/10.1002/brb3.37

Mayo Foundation for Medical Education and Research. (2016, September 23). Personality

disorders. Mayo Clinic. Retrieved April 8, 2023, from

https://www.mayoclinic.org/diseases-conditions/personality-disorders/symptoms-

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narcissistic%20personality%20disorder.

Videbeck, S. (2016). Psychiatric - Mental Health Nursing. Lippincott Williams & Wilkins.