Ms. B, an inmate recently incarcerated in a Texas jail system aged 51 years, presented to the psychiatric pharmacist complaining of hearing voices, feeling depressed, and exhibiting suicidal thoughts and verbalizations. As a result of her complaints the pharmacist referred the patient to the attending psychiatrist, who immediately placed Ms. B on closed behavioral observations.
Ms. B had been incarcerated for possession of crack cocaine. She reported a 15-year history of crack cocaine use, with her last date of use being the day before her arrest for possession.
The patient reported that she engaged in crack cocaine use two to three times per week,“sometimes” daily; alcohol use three to four times per week, “sometimes” daily; and marijuana use daily.
Ms. B’s past medical history was significant for hypertension, gastroesophageal reflux disease (GERD), bronchitis, and a penicillin allergy that caused a rash. Her social history consisted of a marriage lasting 29 years that produced one son.
The patient’s past psychiatric history consists of follow-up for psychosis related to cocaine withdrawal, as well as a history of depression and mania. Ms. B also had a history of two suicide attempts, with the last being 10 to 15 years prior.
The patient self reported that her past psychiatric medication trials in the free world consisted of lithium, which she stated was “too strong;” valproic acid (Depakote, AbbVie), which was “helpful;” aripiprazole (Abilify, Otsuka); haloperidol; and a selective serotonin reuptake inhibitor (SSRI). The strength and daily dosages of these past prescriptions are unknown.
Prior to her current incarceration, Ms. B was taking escitalopram (Lexapro, Forest Laboratories) 20mg daily and venlafaxine (Effexor, Pfizer) 75mg daily. The patient reported a modest treatment benefit for mood disturbances. Laboratory assessments were performed with no abnormalities identified.
Ms. B had a Global Assessment of Functioning (GAF) score of 50-55 on assessment in accordance to DSM-IV guidelines, as she was admitted before publication of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). This score indicates moderate symptoms, and moderate difficulty in social and occupational functioning.
Diagnosis and Treatment
Ms. B was diagnosed with bipolar disorder with psychotic features and auditory hallucinations, comorbid depression, and crack cocaine and alcohol dependence.
Bipolar disorder affects about 1% of the general population, but is ranked the world’s eighth leading cause of medical disability. Approximately 20% of individuals with the disorder attempt suicide at least once in their lifetime. Concurrent history of substance-use disorders is common among patients with bipolar disorder, affecting an estimated 41% to 46%.
Patients with bipolar disorders can present clinically with four types of mood episodes: major depressive, manic, mixed and hypomanic.
Major depressive episodes are marked by depressed mood, marked decrease in pleasure or interest in all activities, increased need for sleep, low energy and psychomotor retardation. Manic episodes consist of abnormally and persistently elevated and expansive mood, and irritability, with severe episodes resembling paranoid schizophrenia.
Hypomanic episodes consist of less severe forms of mania, whereas mixed episodes feature symptoms of both manic and major depressive episodes, and must occur nearly every day for at least a one-week period.
Diagnostic criteria include a hallmark episode of acute mania lasting at least one week, and the presence of at least three of the following symptoms:
- Flight of ideas
- Subjective racing thoughts,
- Decreased need for sleep
- Inflated self-esteem or grandiosity
- More talkative than usual or pressured speech
- Increase in goal-directed activity
- Psychomotor agitation
Nonpharmacological therapy for bipolar disorder consists of supportive therapy and psychotherapy (individual, group or family). Educating the patient about the psychosocial and physical stressors that precipitate episodes, recognizing the signs and symptoms of mania and depression, and the importance of complying with treatments are essential components of therapy. Electroconvulsive therapy (ECT) may be considered for severe cases.
Pharmacological treatment options include lithium, carbamazepine, valproic acid, lamatrogine, topiramate, and oxcarbazepine. Several atypical antipsychotics are FDA approved for treating acute mania and/or mixed mania. These include aripriprazole, risperidone, olanzapine, quetiapine, ziprasidone, and asenapine.
In this case, Ms. B was started on aripiprazole 15mg once daily for her bipolar disorder and citalopram 20mg once daily for depression, with renewal of both medications to be assessed at 90-day follow-up.
She was also prescribed thiamine 100mg daily for 30 days to provide dietary supplementation for depletion associated with alcohol-use disorder and to manage potential alcohol withdrawal symptoms, and rantidine 150mg twice daily for persistent acid reflux and heartburn associated with GERD.
Abimbola Farinde, PharmD, MS, is a clinical staff pharmacist at Parkland Hospital in Dallas, Texas.
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