COUC 546 Week 3 Case Study 1 Example

Case Study 1: A Real Estate Agent's Depression, His Unnoticed Highs and a Bio-Psycho-Social-Spiritual Plan for Bipolar II Disorder

Case Summary

Ryan, a 34-year-old married real estate agent, came to counseling at his wife's urging after six weeks of low mood, sleeping ten hours a night, poor concentration, loss of interest in work and church, and a recurring thought that his wife and children "would do fine" without him; he denied a plan or intent. When asked about past periods of unusually good mood, he described three episodes in the last five years, each lasting four to six days, when three or four hours of sleep felt like plenty, his speech sped up, he launched several business ventures and he spent $6,000 on equipment he never used. Coworkers called him "on fire," and he was never hospitalized. His father had "big ups and downs," and a paternal uncle died by suicide. Ryan has increased his drinking to four or five beers most evenings during the current episode. He attends a Baptist church and said he feels guilty that he cannot "pray his way out of this."

Key Issues

Four issues stand out. First, safety: passive suicidal thoughts, a family history of suicide and increased drinking raise risk and must be addressed immediately. Second, the history of elevated mood has never been recognized, and treating his depression with an antidepressant alone could risk destabilizing his mood. Third, alcohol use has increased during the episode and may be self-medication. Fourth, shame related to his faith may keep him from accepting help.

Diagnostic Impressions

The provisional diagnosis is F31.81, bipolar II disorder, with the present episode depressed and of moderate severity (American Psychiatric Association, 2013). Ryan meets criteria for a current major depressive episode, since for well over two weeks he has had low mood, lost interest, oversleeping, trouble focusing, a sense of worthlessness and repeated thoughts about death, and his work has suffered. Each earlier high lasted four days or more and brought short sleep without fatigue, fast talk, a burst of new projects and spending he regretted; others noticed the change, but he never needed hospital care, so these periods fit hypomania rather than mania. Alcohol use disorder, mild, should be assessed further.

Major depressive disorder was ruled out because of the hypomanic history, and cyclothymic disorder was ruled out because Ryan has had full major depressive episodes. A substance-induced mood disorder is unlikely, since the hypomanic episodes occurred before the increase in drinking. Kring et al. (2016) describe the bipolar disorders as defined by episodes of mania or hypomania in addition to depression, so the diagnosis depends on history the client may not volunteer. People usually seek help during depression and may remember hypomanic periods as their best times, which is exactly what happened here: Ryan had never mentioned them to his physician.

Treatment Recommendations

Biological

Ryan should be referred to a psychiatrist for medication evaluation, with the counselor sharing the history of hypomania so that the prescriber can weigh a mood stabilizer rather than an antidepressant alone. Geddes and Miklowitz (2013) describe lithium as the best-established long-term treatment for bipolar disorder and recommend combining medication with psychological treatment. A physician should also evaluate his alcohol use and sleep, and laboratory tests appropriate to any medication chosen should be arranged. The counselor should ask the psychiatrist how to recognize side effects so that Ryan can be supported in staying on treatment.

Psychological

Counseling should begin with a safety plan and then include psychoeducation about bipolar disorder, mood and sleep monitoring, and a structured psychotherapy. In a randomized trial of 293 outpatients with bipolar I or II depression, Miklowitz et al. (2007) found that patients receiving up to 30 sessions of family-focused therapy, interpersonal and social rhythm therapy, or cognitive behavioral therapy recovered faster and at higher rates over a year than those receiving brief collaborative care. Judd et al. (2003) found that patients with bipolar II spent about half of all weeks with depressive symptoms and only a small fraction with hypomanic symptoms, so the long-term plan must focus on preventing and managing depression while watching for early signs of hypomania. Motivational interviewing can address his drinking, since alcohol can worsen depression and interfere with mood stabilizers.

Social

Ryan's wife should be involved, with his consent, so that she can learn the warning signs of both depression and hypomania and help with sleep routines. Family-focused therapy would formalize this support. Work demands should be reduced temporarily, and the couple may need help with debts from past spending. A financial safeguard, such as a joint agreement to delay large purchases for forty-eight hours, could protect them during any future hypomanic period. Ryan's coworkers do not need to know his diagnosis, but a trusted colleague could help him pace his workload.

Spiritual

Ryan's faith can become a source of support rather than shame. With his permission, the counselor can explore his belief that he should be able to pray his way out of depression, and help him see treatment as consistent with his faith. Scripture describes Elijah, exhausted and asking to die under a broom tree, receiving rest and food before being given a new task (English Standard Version Bible, 2001/2016, 1 Kings 19:4-8), a passage that may help him see care for his body as part of God's care for him. His pastor could be included in his support network if he wishes.

Collaboration

Ryan's recovery depends on a team in which the counselor coordinates information, the psychiatrist manages medication, the physician monitors health, and his wife and church provide daily support. With signed releases, the counselor would share the mood history with the psychiatrist, review progress with the whole team monthly and update the safety plan as needed.

Conclusion

This case shows how a depressed client can carry an unrecognized bipolar history and how asking about past highs changes the diagnosis and treatment. A collaborative plan that combines medication, structured psychotherapy, family involvement and respectful attention to faith gives Ryan the best chance of recovery.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

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

Judd, L. L., Akiskal, H. S., Schettler, P. J., Coryell, W., Endicott, J., Maser, J. D., Solomon, D. A., Leon, A. C., & Keller, M. B. (2003). A prospective investigation of the natural history of the long-term weekly symptomatic status of bipolar II disorder. Archives of General Psychiatry, 60(3), 261-269. https://doi.org/10.1001/archpsyc.60.3.261

Kring, A. M., Johnson, S. L., Davison, G. C., & Neale, J. M. (2016). Abnormal psychology: The science and treatment of psychological disorders (13th ed.). Wiley.

Miklowitz, D. J., Otto, M. W., Frank, E., Reilly-Harrington, N. A., Wisniewski, S. R., Kogan, J. N., Nierenberg, A. A., Calabrese, J. R., Marangell, L. B., Gyulai, L., Araga, M., Gonzalez, J. M., Shirley, E. R., Thase, M. E., & Sachs, G. S. (2007). Psychosocial treatments for bipolar depression: A 1-year randomized trial from the Systematic Treatment Enhancement Program. Archives of General Psychiatry, 64(4), 419-426. https://doi.org/10.1001/archpsyc.64.4.419