Target Sx:

• The primary symptoms to target with treatment adjustments include:

o    Significant mood swings linked to hormonal changes

o    Irritability and mood elevation before menstruation

o    Depression occurring primarily during non-working periods

o    Anxiety sleep disturbances are a cyclic course of exacerbation and relief related to her menstrual cycle symptoms that could be treated pharmacologically and non-pharmacologically, along with medication adjustment in an attempt to get overall mood stability and quality-of-life improvement.

Medication Considerations:

• The patient is currently prescribed the following medications:
  • Lamotrigine (100 mg) as a mood stabilizer to manage bipolar symptoms, particularly effective for mood swings in bipolar I disorder.
  • Remeron (7.5 mg) to aid in sleep, which can be disrupted due to depressive and anxious episodes.
  • Prozac (40 mg) to regulate mood and alleviate depressive symptoms, especially during the premenstrual phase, which may benefit from cyclic dosing or dose adjustments based on symptom severity.
  • Propranolol (10 mg as needed) to manage anxiety symptoms, particularly during episodes of high stress or anxiety.

Lamotrigine is generally well-tolerated and effective for reducing bipolar-related mood swings. Remeron provides support for sleep disturbances commonly associated with depressive episodes. Prozac, a selective serotonin reuptake inhibitor (SSRI), is effective for mood regulation and may be particularly beneficial for her premenstrual dysphoric disorder symptoms with targeted dosing adjustments. Propranolol effectively manages situational anxiety without significant cardiovascular concerns, as evidenced by her stable vitals (American Psychiatric Association, 2022).

• • Blood pressure: 145/84 mm Hg
  • Heart rate: 113 bpm
  • Respiratory rate: 16 breaths per minute
  • Temperature: 97.2 °F
  • WT 178.6 LBS
  • BMI 27.15

These are signs of tachycardia and hypertension that may require follow-up. Usually, anxiety is well-controlled by Propranolol; this observation may signal the need to reevaluate the dosage or additional interventions for better stabilization of cardiovascular functions in the current treatment.

Rating Scale(s):

• • Young Mania Rating Scale (YMRS): This scale will be useful in describing the intensity of manic symptoms, mainly during the premenstrual weeks, when the patient describes elevated mood and increased irritability. Regular assessments of YMRS should have been done in order to quantify symptom fluctuation and track the effectiveness of any medication adjustments.
  • Hamilton Depression Rating Scale (HDRS): The HDRS will measure the intensity of depressive symptoms, with a particular emphasis on those that occur during the low-activity periods. This measure ensures that the current dosage level of SSRI is matched to her intensity of depressive symptoms and assists in making decisions regarding whether any adjustments in the cyclic or dose level are necessary.

Using both scales will allow for tracking changes over time, establishing a symptom baseline, and providing concrete measures of treatment efficacy.

Previous Test done on the previous visit:

o   PHQ-9: The score is 22/27, indicating severe depression. Thus, close observation and potential adjustment of the antidepressant dose are indicated.

o   The MDQ, or Mood Disorder Questionnaire, has positive responses that confirm the bipolar trends and hence justify further use of mood stabilizers, adding an antipsychotic for better mood regulation.

Labs: 

• • Baseline liver function tests to monitor any potential side effects of Lamotrigine, as mood stabilizers can impact liver function over time.
  • Thyroid function tests to assess Prozac’s effects and investigate potential endocrine contributions to depressive symptoms, especially during the premenstrual phase.
  • A complete metabolic panel to evaluate the patient’s overall health and detect any imbalances associated with her current medications.

Regular lab tests will ensure that her medications are not contributing to adverse effects, allowing for prompt adjustment if necessary.

ROS:

• • Neurological: Reports significant mood and behavioral changes tied to her menstrual cycle, suggestive of premenstrual dysphoric disorder.
  • Endocrine: Given the cyclical nature of her mood symptoms, there may be a hormonal influence, particularly in the luteal phase of her menstrual cycle.
  • Cardiovascular: Stable cardiovascular function indicates that Propranolol is effectively managing situational anxiety without notable side effects or cardiovascular concerns.

This review reflects the broad impact of her symptoms across multiple systems, confirming that mood symptoms are cyclical and linked to hormonal changes.

o   Bipolar Disorder, Current Episode Depressed, Moderate (F31.64): This diagnosis represents her cyclic depressive and manic-like symptoms. The current depressive episode consists of low mood, irritability, and crying spells, especially during non-working periods (National Institute of Mental Health, 2024). Symptoms are considered to be moderate in that they interfere with daily activities but remain manageable.

o   Adjustment disorder with Anxiety (F43.12): This is regarding situational anxiety that might have been heightened through life events or stress. There is heightened anxiety at specific times, such as during the premenstrual phase of her menstrual cycle.

o   Insomnia Disorder (F51.05): Characterized by difficulty initiating or maintaining sleep, this sleep disorder may contribute to fatigue and emotional instability. The sleep disturbance is associated with mood disturbance and may be exacerbated during depressive or anxious states (Kaur et al., 2023).

DSM-5 Dx with Specifiers and ICD-10 Code:

• • Bipolar I Disorder (ICD-10: F31.9): The diagnosis is based on her cyclical mood swings, manic-like symptoms (such as elevated mood and rapid speech), and depressive episodes that primarily occur during times of low activity.
  • Premenstrual Dysphoric Disorder (PMDD) (ICD-10: N94.3): The diagnosis is indicated by her significant mood swings and irritability, which intensify in the luteal phase and affect her daily life and social interactions (Jain & Mitra, 2023).

DSM-5 Rule-Out Dx and ICD-10 Code:

• • Major Depressive Disorder (ICD-10: F32.x): While depressive symptoms are present, they appear episodic and tied to hormonal fluctuations, aligning more closely with PMDD than a persistent depressive disorder.
  • Generalized Anxiety Disorder (ICD-10: F41.1): Anxiety symptoms are episodic, situational, and effectively managed with Propranolol, indicating they may be secondary to her primary mood disorder rather than a standalone diagnosis.

• • Medication:
    Lamotrigine (Lamictal) 150 mg daily. Increase dosage by 50 mg to improve symptom control as necessary, with regular monitoring for adverse reactions.
  • Prescription Information:
    Take 150 mg daily, with monitoring to assess effectiveness and any potential side effects, particularly skin reactions.
  • Side Effects:
    Common side effects include dizziness, drowsiness, headache, and risk of skin reactions. Patient education will cover recognizing and reporting symptoms to prevent complications.
  • Rationale:
    Lamotrigine is effective for managing manic and depressive phases of bipolar disorder, helping stabilize mood and reduce extreme fluctuations. Adjusting the dose gradually allows for symptom control with a low risk of adverse reactions, which is especially valuable for managing cyclic depressive and manic phases.
  • An adjunct antipsychotic:

For augmentation of mood stabilization with Lamotrigine, consider adding the antipsychotic Aripiprazole. It is one of the more common adjuncts to mood stabilizers in bipolar disorder and may offer additional symptomatic control of mania.

• • Dosage:

Initiate at 5 mg daily, titrating as necessary.

• • Side Effects:

It is a sedative; it also induces restlessness and GI problems.

• • Rationale:

Aripiprazole can be continued, as it has a relatively good side effect profile and has a lower risk of metabolic side effects compared to the rest of the antipsychotics; thus, it is suitable for long-term management.

2^nd Medication Choice with Prescription Information, Side Effects, and Rationale:

• 2nd Medication Choice:
  • Medication:
    Prozac (Fluoxetine) 40 mg with potential cyclic dosing or dose increase during the luteal phase. Cyclic dosing has shown benefits in targeting premenstrual symptoms.
  • Prescription Information:
    Continue 40 mg daily or increase dosage during the luteal phase if premenstrual symptoms persist.
  • Side Effects:
    Possible side effects include gastrointestinal distress, headache, changes in sleep, and appetite alterations.
  • Rationale:
    Prozac effectively treats both depressive and premenstrual symptoms, particularly in cases of premenstrual dysphoric disorder. Increasing the dose during premenstrual phases may enhance symptom control, focusing on cyclic mood swings and irritability while avoiding continuous high-dose exposure.
• Additional Recommendations:
  • Non-pharmacologic strategies: Implement Cognitive Behavioral Therapy (CBT) to support emotional regulation, mood stability, and coping mechanisms during low-activity periods.
  • Endocrinology Referral: A referral to an endocrinologist is recommended to evaluate potential hormonal imbalances contributing to mood instability.
  • Monitoring and Follow-Up: Schedule a follow-up appointment in 4-6 weeks to evaluate medication efficacy, adjust dosages if necessary, and monitor for side effects. Consistent mood tracking with rating scales will help establish symptom patterns, providing a foundation for future treatment adjustments.

·         Patient/Family Education

• • Adherence to Medication: Emphasize the importance of taking medication regularly and explain that this is a prescription by the doctor. Instruct on the use of Lamotrigine for mood stabilization and the addition of any new antipsychotic medication for the management of bipolar symptoms (Bauer et al., 2019).
  • Adverse Effects: Instruct the patient and family members on the potential adverse effects of Lamotrigine and antipsychotics, such as but not limited to somnolence, nausea, or restlessness, and the importance of reporting severe reactions as soon as possible.
  • Lifestyle and Support Strategies: The maintenance of healthy habits includes regularity in sleep, management of stress, and proper nutrition, and all these play a huge role in maintaining stability. The family needs education on the recognition of depressive and manic episodes so that timely support can be provided and help sought when needed.