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Psychopharmacology Map
Mercy Kollek
Stony Brook University School of Nursing
HNG-517-C13 Advanced Theory and Clinical Practice in Psychiatric/Mental Health I
Professor/Kim Backman PMHNP BC
November 30, 2022
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Introduction
J.D. is an outpatient of The Child Center of New York. She is a 21-year-old female,
currently an undergraduate student at CUNY College. She is independent, living with her
roommate and supporting herself by working 3-part time jobs. She is of Asian descent and was
diagnosed with Moderate Bipolar II Disorder in full remission (F31.81), 296.89. The patient's
symptoms met the required criteria indicated in the Diagnostic and Statistical Manual of Mental
Disorders, Fifth Edition (DSM-5(TM)), 2013). According to DSM-5 Bipolar II Disorder is a
“lifetime experience of at least one episode of major depression and at least one hypomanic
episode ”. In other words to satisfy required Criteria A-C of MDD and Criteria A-F of
Hypomanic Episode). The first signs of depression were recorded at the age of 13, and the
ongoing conflict with her parents was established as the contributing factor. Over the course of
the next 8 years (2014-2022), she was admitted 2 times to an inpatient psychiatric unit at
Bellevue Hospital for a period of 3 weeks at each hospitalization time. Suicidal ideation was the
main reason for her hospitalizations. The latest medication regimen consists of Quetiapine XR
350 mg PO daily.
Typhon Case ID: 1753-20221102-001
Major DSM-5 Dx (1)
Moderate Depressed Bipolar II Disorder in full remission (F31.81) 296.89
Diagnosis: Patient meets all required criteria (A-C) for a current or past major depressive
episode as well as criteria (A-F) for past hypomanic episodes. Current medication: Quetiapine
XR (Seroquel) 350 mg PO 1x/day
Differentials
Borderline Personality Disorder 301.83 (F60.3)
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Cyclothymic Disorder 301.13 (F34.0)
Recurrent Severe Major Depressive Disorder 296.33 (F33.2)
Symptoms to target
Major Depressive Episode
Patients reported or displayed symptoms such as (1) consecutive 2-weeks of sadness and
hopelessness; (2) suicidal ideation without intent or plan; (30 hypersomnia during
depression episodes; (4) feeling of worthlessness and misunderstood; (5) disinterested in
doing things that normally would bring joy; (6) occasionally symptoms that cause her to
be upset with professors at school, but not serious enough to cause any disturbances; (7)
her symptoms are not attributed to physiological effects of any substance or another
medical condition. Symptoms are meeting depression episodes criteria outlined in DSM5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5(TM)),
2013).
Hypomanic Episode
Reports of (1) lasting 4-5 days significant energy increase; (2) she displays talkativeness
(pressured speech), goal-directed activities (such as masturbation multiple times per day);
(3) irrational spending on impulse Amazon purchases; (4) mood changes noticeable by
her close family and friends; (5) these symptoms do not cause inappropriate disturbances
in social relations or needs for hospitalization; (6) lastly, the mentioned symptoms are not
contributed by any medication or drug abuse (Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition (DSM-5(TM)), 2013)
Medications
QuetiapineXR 350 mg/day
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Generic: Seroquel XR
Classification: Antipsychotics, 2nd Generation; Antimanic Agents
Not prescribed but possible alternative if needed: LaMICtal (lamotrigine); Eskalith,
Lithobid (lithium); combination of ZyPREXA (olanzapine) plus Prozac or Rapiflux or Sarafem
or Selfemra (fluoxetine)
Rationale for Medication Decisions
Patient’s current prescription consists of Seroquel XR 350 mg PO per day. I am advising
the patient to stay with the current medication for the next 3-6 months instead of changing to
Lithium as the preceptor recommended. Her history of present illness information indicates
taking Abilify 30 mg and a lower dose of Seroquel IR. A recent dose increase of Seroquel XR
from 300 mg to 350 mg is well tolerated by the patient. Patient is able to maintain good grades as
a college student and successfully hold 3 part-time jobs simultaneously. For the past months, she
has been trying (with no success) to get an appointment to see her PCP, mostly because of her
busy school/work schedule. Additionally, final exams in school are advancing and busy hours on
her retail job with the Christmas season approaching rapidly make it impossible to have time to
go see her PCP or a local lab for blood work. These obstacles pose risks during medication
change to Lithium that requires scheduled blood testing and lithium levels monitoring
(pregnancy test, Lithium Levels, BUN, eGFR, Serum electrolytes, TSH, and CBC). Additionally,
November is the anniversary of her first suicidal ideation that led to hospitalization, which could
be heightening her anxiety and depression symptoms. I also recommend increasing her therapy
sessions to weekly and during her monthly session in January to revisit her medication
adjustment options if her mood depressive episodes will not improve. Quetiapine helps improve
concentration needed in school, helps to think more clearly and positively about herself, feel less
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nervous, and be more active in her everyday life. It contributes to sleep, appetite, and energy
level improvement. Quetiapine can help prevent and decrease the frequency of severe mood
swings. Quetiapine has minimal risk of causing EPS because it is a weak D2 receptor blocker
with a high 5-HT2A/D2 blockade. Also, it has a sedating agent that should help her during
hypomanic episodes.
Possible Medication Side Effects
There is a long list of adverse side effects. Most common side effects of using Seroquel
are: elevated diastolic blood pressure; increased triglycerides; headache; somnolence; increase
total cholesterol; increased appetite; constipation; tremors and more. Patient does not report any
major side effects.
Medical Interventions/Labs
My medical intervention recommendation consists of visiting her PCP doctor and local
lab for blood work as soon as possible and to forward the result of her visit to The Child Center
of New York. Prescribed blood testing to rule out pregnancy, fasting glucose/hemoglobin A1c,
creatinine, BUN, eGFR, serum electrolytes, TSH w/reflex to T4, lipid panel, CBC with
differential and lithium level. All mentioned tests are baseline, before starting Lithium.
Major DSM-5 Dx (2)
Bipolar I Disorder 296.53 (F31.4)
Diagnosis: The patient displays symptoms that meet Criteria A-C of Major Depressive
Episodes of the DSM-5 guidelines associated with Bipolar I disorder and, to some degree,
Criteria B and D of Manic and A-F criteria of Hypomanic Episodes of the same 296.53 (F31.4)
diagnosis.
Differentials
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Recurrent Severe Major Depressive Disorder 296.33 (F33.2)
Moderate Depressed Bipolar II Disorder in full remission (F31.81) 296.89
Generalized Anxiety Disorder 300.02 (F41.1)
Symptoms to target
Patients presented and reported (1) during the same 2- weeks sadness and despair, (2)
have passive thoughts of ending her life, but without a plan and true intentions. Patient has
reported a longer sleeping schedule of 12 hours per day. (4) For the past 14 days, she has been
feeling undervalued, underappreciated, misunderstood, and (5) her interest in her favorite
activities creative writing has diminished. (6) Her school work and social relations occasionally
cause minor upset, or she simply does not show up, but it does not cause any significant distress
after all. (7) Lastly, all her symptoms are not caused by medical conditions or their side effects,
or drug abuse. Reported symptoms and severity Hypomanic/Manic Episodes' require detailed
consideration. Need to discern Manic or Hypomanic episodes with certainty is the pivoting point
in diagnosing the patient. The patient displays (1) talkativeness (but interruptible) and anxiety
during the conversation, (2) reports an increase in sexual desires or a burst of intense school
studies. Her mom (3) reports noticeable out-of-normal behavioral changes during hypomania
episodes, J.D. (4) showed increased energy and overall activities that last 3-4 days. (5) The
symptoms are NOT persistently elevated, extended, or irritable. Her hypomanic moods are short
and DO NOT require hospitalization or emergency intervention. Finally, all elevated mood
symptoms are not caused by any other medical issues, medication, or drug-induced. According to
R. J. Boland et al., “Impaired judgment is a hallmark of manic patients.”, they often drink
alcohol excessively and about 75 percent are assaultive or threatening at some time. (2021). J.D.
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is very much aware of her condition, drinks only socially, and never reported assaultive or
threatening behavior.
Based on my analysis, the length and intensity of the elevated energy moods CAN NOT
be considered manic episode symptoms. They are in line with hypomanic symptoms described in
DSM-5 Bipolar II criteria (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
(DSM-5(TM)), 2013).
Medications
Lithobid ER introduction of the medicine 300 mg PO 1x/day at the bedtime for 14 days
Generic: Lithium XR
Classification: Antimanic Agents
Rationale for Medication Decisions
My recommendation is to gradually taper off currently prescribed Seroquel XR 350 mg
Also, I recommend introducing Lithium ER 300 mg PO at bedtime (HS).
Lithium's exact mechanism of action is still unknown, however, the benefits are clear, it
works especially for Bipolar Disorders. Provides robust effects in treating and preventing both
mania and depression. In addition, it has a proven record of reducing suicidal ideations.
According to Heldt lithium decreases 7-fold “the risk of suicide for bipolar patients taking a
therapeutic level of the drug” (2017).
Possible Medication Side Effects
Lithium Therapeutic Index (TI) is very low therefore lithium blood level needs to be
closely monitored to prevent lithium toxicity (Lithium: Drug Information, n.d.). Common side
effects are hand tremors, increased dilute urination, mild thirst, nausea, diarrhea, vomiting,
drowsiness, muscular weakness, and lack of coordination. Lithium can cause acute kidney injury,
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chronic kidney disease or nephrogenic diabetes insipidus. Lithium also increases the incidence of
hypothyroidism 6-fold. (Cafer, 2020)
Medical Interventions/Labs
Patient must urgently see her PCP medical doctor for a routine checkup as well as
evaluation. She also must obtain prescribed baseline complete blood cell counts with differential
(CBC with diff); urinalysis; blood urea nitrogen; creatinine; serum calcium levels; thyroid
function tests; and a pregnancy test. Her lithium toxicity must be checked frequently. When a
stable dose is obtained, monitoring can subside every 3 to 6 months with an emphasis on
monitoring lithium levels; renal and thyroid function; and urinalysis. When PCP visit and testing
are completed the results must be forwarded to The Child Center of New York for the record.
Preceptor Validation
My Psychopharmacology Map was validated by my preceptor as truthful and accurate
based on his knowledge of the case. He agrees with my synthesis of the patient’s symptoms as
accurately correlated with the DSM-5 Criteria and correctly diagnosed as Bipolar II Disorder in
full remission (F31.81) 296.89. Preceptor validated my point of view regarding continuing
treatment with Seroquel 350 mg PO 1x/day for the next 3 months and scheduling tapering off
Seroquel and introducing Lithium after that. Preceptor agreed that changing the medication while
her school's final exams are on the way, plus her work retail demands at the Christmas season
may negatively impact the outcome of the medication changes.
Preceptor pointed out some areas for improvement. He recommended taking into
consideration the broader spectrum of differential DX's before establishing the final diagnosis.
Perhaps the less common choices would require additional questioning or closer observation of
the patient, however, it would allow one to have a better perspective of the patient's case. The
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second feedback is to resist creating opinions based on other physicians or NP notes. Attempt to
establish independent thought that is based on your therapeutic relation with the patient, inperson interviews, and observations.
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References
Boland, R. J., Verduin, M. L., & Ruiz, P. (2021). Kaplan & sadock’s synopsis of psychiatry
twelfth edition (12th ed.). Wolters Kluwer.
Cafer, J. (2020). Cafer’s psychopharmacology: Visualize to memorize 270 medication mascots
(1st ed.) [PDF]. CaferMed.
Diagnostic and statistical manual of mental disorders, fifth edition (DSM-5(TM)) (5th ed.).
(2013). American Psychiatric Publishing.
Heldt, J. (2017). Memorable psychopharmacology (1st ed.) [PDF]. CreateSpace Independent
Publishing Platform.
Lithium: Drug information. (n.d.). UpToDate. Retrieved November 14, 2022, from
https://www.uptodate.com/contents/lithium-druginformation?search=lithium&source=panel_search_result&selectedTitle=1~149&usage_t
ype=panel&kp_tab=drug_general&display_rank=1
Seroquel, Seroquel XR (quetiapine) dosing, indications, interactions, adverse effects, and more.
(2022). Medscape. https://reference.medscape.com/drug/seroquel-xr-quetiapine-342984