Bipolar disorder refers to a mental disorder that causes alternating changes in the mood, concentration, activity level, energy, and the ability to carry out various day-to-day tasks. The National Alliance on Mental illness indicates that over 10 million individuals in the United States are affected by bipolar disorders each year. Bipolar disorders range from mild, manic, and depressive (Jann, 2014). The main indicative symptom is mood episodes which tend to get worse. Reviews indicate that the rates of suicide among bipolar individuals is 10-30 times higher than among the general population (Phillips & Kupfer, 2013). Several treatments are always offered to patients in this case to stabilize their moods. The case study shows a young man with bipolar disorder, having suicidal thoughts. The problem is that he is suicidal by overdosing with the medication prescribed for his treatment, creating some side effects that land him in the Emergency room. This paper explores the problem in the case study, outlining the issues and implications for various stakeholders, and providing recommendations to resolve the case.
The scenario is a suicidal 28-year old male in the emergency room for overdosing with Clonazepam, sodium valproate, and quetiapine. The patient, John, has bipolar disorder and is currently referred on a Form 1A of the Western Australia Mental Health Act 2014. Throughout the night, he has been drowsy, restless, and agitated. When he communicates, he sometimes has delusional content and appears confused. He is most likely experiencing a delirium caused by the overdose. The nurse in charge keeps checking his blood pressure, temperature, heart rate, saline levels, and the Q-T interval after every four hours to ensure that they are within the normal limits. In the last eight hours, he has shown an intravenous line of normal saline 1 liter. In the last four hours, the Q-T interval seems to be lengthening, and he is booked for an ECG at 10:00 am. The blood pressure and body temperature seem to be within the normal range, and he is undergoing neurological observations that will be reviewed by the medical team. Throughout the night, his behavior has not been problematic but when he presented to the ER, he showed severe agitation such that the Aggressive incident & security team had to respond. John is not to be given any form of medication unless he shows agitation. He is considered to be at risk due to his fluctuating sensorium and therefore action is needed to ensure his protection. The Consultation-Liaison psychiatry team is on its way to review him. He is likely to become more alter, distressed and agitated in the next few hours. When the night duty RN hands over the documents with all this information to the daytime shift nurse, she comments saying that “I don’t know why we are wasting our time looking after a woman who wants to kill herself when there are plenty of sick people out there who need hospital beds.”
The problem, in this case, is that the patient has attempted suicide through overdose and hence experiencing delirium which has impaired his cognition and consciousness, caused by the drug overdose. As indicated above, patients with bipolar disorder tend to have suicidal thoughts, explaining John’s overdose. Agitation is one of the symptoms in patients with bipolar disorder (Raja, M., & Azzoni, 2012). The drugs that John used to overdose himself are bipolar disorder medication. Clonazepam is a benzodiazepine that is used in the treatment of sleep disorders, mania, and anxiety as it is a central nervous depressant and therefore slows brain function (Goodwin, Haddad, Ferrier, Aronson, Barnes, Cipriani, & Young, A. H. (2016). When taken in large amounts, Clonazepam causes drowsiness, confusion, impaired coordination, loss of consciousness, and in severe cases, death. Sodium valproate is used in the treatment of bipolar disorder and is effective in manic states. When taken in large amounts, valproate tends to cause symptoms of feeling dizzy, nausea, and headaches (Fontana, Mandolini, Delvecchio, Bressi, Soares, & Brambilla, 2020). Quetiapine on the other hand is used in the regulation of manic episodes. When taken in large amounts, it can lead to seizures, delirium, agitation, and Q-T prolongation (Hayes, Marston, Walters, Geddes, King, & Osborn, 2016). Research done by scholars on valproate and quetiapine overdosereveals that it results in benign outcomes whereby the level of consciousness of an individual becomes impaired, such that one may require transfer to the Intensive Care Unit. In another study by Huang and Hua Wei (2013), bipolar patients treated with quetiapine showed almost zero chances of developing delirium. However, when quetiapine is prescribed as an adjunct to valproate for mania, the patients reported developing delirium (Huang, & Wei, 2013). When sodium valproate is taken together with clonazepam, the effect is that it causes drowsiness (Muneer, 2015). On the other hand, when clonazepam is taken together with quetiapine, the side effects are confusion, drowsiness, difficulty in concentration, and dizziness.
In this case study, the patient overdosed using the drugs, hence explaining the extreme side effects. The drowsiness during the night can be explained by taking valproate, together with clonazepam, and the mix of clonazepam with quetiapine. The delusional content in his conversation is caused by the reaction of clonazepam overdose, which causes impaired coordination in his speech. The confusion is caused by the reaction of the overdosed drugs, causing delirium. Patients with delirium tend to be agitated, and therefore the reason for his overnight agitation and restlessness (Clough, Henry, & Ekelund, 2014). The combination of these drugs does not affect his temperature and blood pressure, and hence falling within the normal range. The lengthening of the Q-T interval shown from the last ECG is a result of the side effect of quetiapine overdose. The patient is probably suffering from manic depressive episodes, and hence the instruction not to give him any medication unless he is severely agitated. The Center for Substance Abuse Research indicates that the good effect created by bipolar disorder pharmacology is such that the drug tolerance causes people to find the need to increase the dosage so that they can achieve the effects formerly received from a smaller amount of medication. John’s case may be intentional, to achieve this effect, or accidental, since he is currently a referred on a Form 1A of the Western Australia Mental Health Act 2014. Form 1A refers to a referral issued under the Mental Health Act of 2014 which indicates that an individual should have an examination by a psychiatrist. It contains information on what one’s rights are and what they can expect once in the Form 1A referral (Taylor & Vallianatou, 2016). John had probably consulted ‘The Consultation-Liaison’, who will review his progress. The patient needs the four hourly checkups of his blood pressure, temperature, heart rate, and Q-T interval to avoid developing any associated complications from the overdose. The increased agitation on presentation to the Emergency room can be explained by the delirium from the overdose. Patients with delirium tend to experience elevated levels of disorientation and confusion, causing the patient to refuse to comply with certain procedures (Hayes, Marston, Walters, Geddes, King, & Osborn, 2016). Delirium may also cause neurologic signs hence the need for monitoring. The patient is therefore negatively impacted by the side effects, and without monitoring can get worse, or even be suicidal.
Attempted suicide among individuals with bipolar disorder is a common occurrence. Statistics reveal that up to 25 to 30% of these individuals attempt suicide every year and of this 8 to 19% die (Frey & Hunt, 2018). This not only has an implication on the patient but also the family. Bipolar disorder tends to be genetic and in most cases, treatment only becomes effective if an individual has family support. Family members may fail to recognize the symptoms of a suicidal bipolar individual due to lack of knowledge or many other factors (Frey & Hunt, 2018). Attempting suicide can cause distress to the family not only in terms of the care given but also the stress, worry, and financial constrain. Some patients commit suicide for reasons such as the denial of treatment and that they have the disease. The family may not effectively care for the patient and therefore require a caregiver, causing financial strain. The family may also constantly worry about the individual that they may attempt suicide or display aggressive behaviors that they may be unable to handle (Mondimore, 2014). A specialist is needed to take care of such individuals with serious and constant mood disorders. Research reveals that the management of suicidal thoughts in patients with bipolar disorders represents a clinical challenge. Research in the field also shows that individuals who have attempted suicide before are more likely to attempt another one compared to bipolar individuals who have not (Mondimore, 2014). The family may also feel guilty that they did not take care of their relative well to identify the suicidal signs early enough. In John’s case, he requires admission into psychiatry to ensure that he undergoes therapy needed to help him stabilize and control his moods, to avoid suicidal thoughts and aggression.
The case also informs the nursing profession in various ways. For instance, the comment from the night duty registered nurse about wasting time looking after a patient who wants to kill himself while there are many sick people who need beds says a lot about the care given to bipolar individuals with suicidal thoughts (Schaffer, Isometsä, Azorin, Cassidy, Goldstein, Rihmer, & Yatham, 2015). Nurses have the ability to ensure the successful care of these individuals. They have a responsibility of providing a safe environment, improving self-esteem, meeting the patient’s physiologic needs, and guiding the patient towards socially acceptable behavior. Patients who are in the manic phase are more energized, elated, and easily agitated and quickly irritated and are more likely to cause self-injury due to their inherent distress. (Latalova, Kamaradova, & Prasko, 2014). Despite being aware of these responsibilities, nurses, just like the nurse on night duty neglect their responsibilities. Giving such negative thoughts and comments can push the patient to commit suicide again. Nurses should therefore take on their responsibilities by giving perspective and hope for the future for the clients.
There are various solutions that fit in this case including finding therapy that can help change the patient’s behavior. There are various forms of therapy that can be offered in mental institutions such as cognitive behavioral therapy (Cosoff and Hafner, 2018). The patient can also be referred to a psychiatrist once he is stable so that his behavior is constantly monitored. Moreover, he can also get community and family support, which will aid the treatments offered.
Conclusion and Recommendation
In conclusion, suicidal attempts among individuals with bipolar disorders are a common occurrence. In the case above, the patient overdosed using his prescriptions, causing him to have fluctuating sensorium, among other effects as explained in this paper. Overdosing with these drugs can cause death or delirium as seen in John. Suicidal attempts among individuals with bipolar disorder affect the family and also impact the nursing profession, based on the care offered. In this case, the night duty nurse does not fulfill her responsibility to the patient as she feels that it is a waste of time and this reflects on the care given to these patients. The best approach for the wellbeing of the patient is by enrolling in therapy where they can be taught to manage their behavior through cognitive behavioral therapy, which is the best intervention for individuals with mood disorders.
Clough, Z., Henry, R., & Ekelund, A. (2014). Delirium associated with therapeutic levels of lithium in bipolar disorder. Progress in Neurology and Psychiatry, 18(2), 10-12.
Cosoff, S. J., & Hafner, R. J. (2018). The prevalence of comorbid anxiety in schizophrenia, schizoaffective disorder and bipolar disorder. Australian and New Zealand Journal of Psychiatry, 32(1), 67-72.
Fontana, E., Mandolini, G. M., Delvecchio, G., Bressi, C., Soares, J. C., & Brambilla, P. (2020). Intravenous valproate in the treatment of acute manic episode in bipolar disorder: A review. Journal of affective disorders, 260, 738-743.
Frey, L. M., & Hunt, Q. A. (2018). Treatment for suicidal thoughts and behavior: A review of family‐based interventions. Journal of marital and family therapy, 44(1), 107-124.
Goodwin, G. M., Haddad, P. M., Ferrier, I. N., Aronson, J. K., Barnes, T. R. H., Cipriani, A., … & Young, A. H. (2016). Evidence-based guidelines for treating bipolar disorder: Revised third edition recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 30(6), 495-553.
Hayes, J. F., Marston, L., Walters, K., Geddes, J. R., King, M., & Osborn, D. P. (2016). Lithium vs. valproate vs. olanzapine vs. quetiapine as maintenance monotherapy for bipolar disorder: a population‐based UK cohort study using electronic health records. World Psychiatry, 15(1), 53-58.
Huang, C. C., & Wei, I. H. (2013). Unexpected interaction between quetiapine and valproate in patients with bipolar disorder. General hospital psychiatry, 32(4), 446-e1.
Jann, M. W. (2014). Diagnosis and treatment of bipolar disorders in adults: a review of the evidence on pharmacologic treatments. American health & drug benefits, 7(9), 489.
Latalova, K., Kamaradova, D., & Prasko, J. (2014). Suicide in bipolar disorder: a review. Psychiatria Danubina, 26(2), 0-114.
Mondimore, F. M. (2014). Bipolar disorder: A guide for patients and families. JHU Press.
Muneer, A. (2015). Pharmacotherapy of bipolar disorder with quetiapine: a recent literature review and an update. Clinical Psychopharmacology and Neuroscience, 13(1), 25.
Phillips, M. L., & Kupfer, D. J. (2013). Bipolar disorder diagnosis: challenges and future directions. The Lancet, 381(9878), 1663-1671.
Raja, M., & Azzoni, A. (2012). Valproate and quetiapine overdose with benign outcome: A case report. International journal of psychiatry in clinical practice, 6(3), 173-174.
Schaffer, A., Isometsä, E. T., Azorin, J. M., Cassidy, F., Goldstein, T., Rihmer, Z., … & Yatham, L. (2015). A review of factors associated with greater likelihood of suicide attempts and suicide deaths in bipolar disorder: Part II of a report of the International Society for Bipolar Disorders Task Force on Suicide in Bipolar Disorder. Australian & New Zealand Journal of Psychiatry, 49(11), 1006-1020.
Taylor, D., & Vallianatou, K. (2016). Clinically Significant Interactions with Mood Stabilizers. In Applied Clinical Pharmacokinetics and Pharmacodynamics of Psychopharmacological Agents (pp. 423-449). Adis, Cham.