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A young woman with Depression

SUBJECTIVE
Stefanie is a 32-year-old female from Puerto Rico who presents to your office today with complaints of difficulty sleeping. You learn that Stefanie can go for a few days with minimal sleep (about 3 hours/night), but does not seem to be fatigued the next day. Stefanie explains that after 3 days with minimal sleep, she “crashes” and has a good night’s sleep. She states that sleep will be “alright” for a few days, even a few weeks, and then she will have a similar issue with sleep.
You learn throughout the assessment process that Stefanie has had this problem for years. She noticed that it began in college and thought it was just because of the workload and academic demands. However, she found that it persisted after college. She also notices that she has periods where she will engage in increased amounts of goal-directed activity. She states that things will just “pile up” at work and she gets this burst of energy to “make everything right.” She states that these bursts will last most of the day. She states that these periods show up probably every 2 to 3 weeks.
Stefanie also confesses to problems with being “down in the dumps.” She states that when she has her episodes in which she endeavors to “make everything right,” she feels fantastic and on top of the world. However, when these periods of energy end, she reports that she feels “depressed”—but then states: “well, maybe not depressed, but I definitely feel sad and empty.” She also endorses feelings of fatigue and a decreased ability to concentrate when she is feeling sad. She finally tells you: “I have lived with this for so long, I have to admit that it is finally a relief to tell someone how I feel!”
OBJECTIVE
Stefanie is dressed appropriately to the weather. She has no gait abnormalities. Physical assessment is unremarkable. Gross neurological assessment is within normal limits.
MENTAL STATUS EXAM
Stefanie is alert and oriented × 4 spheres. Her speech is clear, coherent, goal directed, and spontaneous. Self-reported mood is “sad.” Affect does appear consistent with dysphoria. Eye contact is normal. Speech is clear, coherent, and goal directed. She denies visual or auditory hallucinations. No overt evidence of paranoid or delusional thought processes noted. She denies suicidal or homicidal ideation and is future oriented.
At this point, please discuss any additional diagnostic tests you would perform on Stefanie

Decision Point One

BASED ON THE INFORMATION PROVIDED IN THE SCENARIO ABOVE, WHICH OF THE FOLLOWING IS THE RIGHT DIAGNOSE

Bipolar I, current phase, depressed
Bipolar II, current phase, hypomanic
Cyclothymic disorder

Decision Point Two

BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:
Begin Depakote 250 mg orally three times daily
Begin Abilify 10 mg orally daily
Arrange to see Stefanie every 3 months for routine follow-up

Decision Point Three

BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.
Maintain current dose of Abilify
Increase Abilify to 15 mg orally daily
Discontinue Abilify

Also include how ethical considerations might impact your treatment plan and communication with clients and their family.

REFERENCES
American Nurses Association. (2014). Psychiatric-mental health nursing: Scope and standards of practice (2nd ed.). Washington, DC: Author. Standard 13 “Collaboration” (pages 78-79)
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2014). Kaplan & Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Philadelphia, PA: Wolters Kluwer.
Chapter 8, “Mood Disorders” (pp. 347–386)
Gabbard, G.O. (2014) Gabbard’s treatment of psychiatric disorder (5thed.). Washington, DC: American Psychiatric Publication.
Chapter 13, “Acute and Maintenance Treatment of Bipolar and Related Disorders”