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CASE STUDY

Psychiatric Mental Health Comprehensive Case Study

Mia Bruno

April 8, 2023

Dr. Teresa Peck, DNP, MSN, RN

NURS 4842 Mental Health Nursing

Centofanti School of Nursing, Youngstown State University

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Abstract

The following case study describes the disease process of a patient with major depressive

disorder, bipolar disorder, and cluster B including all the treatments, interventions, and

care provided for this patient. The subject of this study is RM, a 24-year-old Caucasian

female that presented to the psych floor due to suicidal ideation. RM is being treated for

major depressive disorder, bipolar disorder, and cluster B. Nursing care provided on the

unit is focused on symptom management through pharmacologic methods, as well as

therapeutic group therapy sessions. Various academic journals were accessed and

researched to supplement the information in this patient’s case. The searches were done

using the MAAG library and Google Scholar online resources and the search engines EBSCO

and CINHAL were used to find related and relevant articles.

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CASE STUDY

Objective Data

Patient identifier RM

Age 24

Sex Female

Date of admission 1st admit: 1/21/23 2nd admit: 3/14/23

Dates of care 1/31, 3/14, 3/28

Psychiatric diagnosis Major Depressive disorder

Other diagnoses bipolar disorder, cluster B disorder, suicidal ideation

Behaviors on admission RM was admitted involuntarily to the psyche unit as she was

telling her brother that she was feeling suicidal and had the plan to hang herself. At this

time, RM was compliant with her meds which included lithium, Abilify, and Remeron. She

states that she often has “voices in her head” that tell her to do “scary things.” RM was

started on Haldol PRN for these hallucinations, and she claims the voices have stopped.

Behaviors on day of care 1/31: RM was cooperative and willing to speak with students on

the day of care. She had a flat affect and maintained very poor eye contact during
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conversation. RM had been on the unit for about 10 days and her physical appearance/

grooming had improved drastically since her first day on the unit. RM participated in both

morning and afternoon groups this day and was hopeful for a discharge to her brother’s

house soon. RM seems childlike in conversation and has a delayed developmental level,

inappropriate for her current age of 24. RM denied any auditory hallucinations since

starting Haldol and says she feels much better.

3/14: RM was home for about a month and was readmitted to the unit on the morning of

3/14. RM presented to the ED the night prior brought by her brother, with c/o suicidal

ideation and the same plan of “hanging herself.” She denies hallucinations at this time and

labs drawn show that she has been compliant with her meds and is therapeutic. On the day

of care, her physical appearance is disheveled and there is a drastic decline in her grooming

since discharge from her last admission. During the conversation, RM has a very flat affect,

is slow to respond, and states that she is “exhausted.” She attends only the afternoon group

on this day as she had testing done during the morning group. She shares that she thinks

her brother is scared of her and that’s why she is back here. Also noted in the chart, her

brother states that “it may be time for RM to go to a group home.”

3/28: RM is still on the unit since her second 3/14 admission. Her

appearance/grooming/dress has not improved, and she seems to be less involved in group

activities on the unit. She is still willing to talk, but she states she has started some new

meds, and “all she does is sleep lately.” These new meds include Wellbutrin and Cogentin.

RM requests not to be woken up for 7 AM meds and does not attend morning group

because of her tiredness. However, she is requesting Trazadone almost every night as a

sleep aid. She expresses she is anxious about discharge plans moving forward as she had a
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fight with her brother prior to this admission. Unsure if she is aware that he wants her to

go to a group home after this admission.

Safety and security measures Throughout the entire inpatient admission there were

many safety and security measures implemented per the entire unit. There were Q15-

minute patient visual checks, all doors to come into and out of the unit were locked and the

patient was not permitted off the unit. There were no hazardous or potentially harmful

objects permitted on the unit, such as shoestrings, belts, long telephone cords, bathroom

doors do not lock, and no razors or other miscellaneous personal belongings in the patient

rooms. The furniture on the unit is weighted and heavy so it cannot be picked up or used in

a dangerous way. Also, all medications were administered and verified by a nurse on the

unit.

Laboratory results

Lab Value Result

Glucose 135; Low
TSH Normal
T4 Normal
RBC 5.45; High
Hbg/Hct Hgb;
Normal
Hct 46; High
WBC 10.8; High
BUN/ Norm/Norm
Creatinine
QTc 403; Normal
Toxicology Negative
HCG Negative
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Psychiatric medications

Generic Name Trade Name Class/Category Dose/ Reasoning

Frequency
lithium Eskalith Antimanic 300 mg PO BID Mood
Agent Stabilization
(bipolar)
haloperidol Haldol Antipsychotic 5 mg PO Q6H Acute psychotic
(Typical/1st PRN behavior/
gen) mood
stabilization
mirtazapine Remeron Tetracyclic 15 mg PO QHS Mood
Antidepressant stabilization
(depression)
Trazadone Trazodone Antidepressant/ 50 mg QHS PRN Sleep aid
Sedative
benztropine Cogentin Anticholinergic/ 0.5 mg PO BID Prophylactic
Anti-Parkinson for EPS- side
effects of
antipsychotics
bupropion Wellbutrin Antidepressant 50 mg PO Daily Mood
(NDRI) stabilization
(depression)

Summary of psychiatric diagnosis

Major depressive disorder A major depressive episode lasts at least 2 weeks, during

which the patient feels a depressed mood or loss of pleasure in nearly all activities.

Symptoms include changes in eating habits, hypersomnia, insomnia, impaired

concentration, impaired decision-making or problem-solving, inability to cope with daily

life, feelings of worthlessness, hopelessness, or guilt, thoughts of death and/or suicide,

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overwhelming fatigue, anhedonia, and pessimistic thinking with no improvement.

Treatment includes cyclic antidepressants, MAOIs, SSRIs, and atypical antidepressants.

(Videbeck, 2023)

Bipolar disorder bipolar disorder is diagnosed when a person’s mood fluctuates to

extremes of mania and/or depression, as described in major depressive disorder. Mania is

a distinct period during which mood is abnormally and persistently elevated, expansive, or

irritable. Typically, this period lasts about one week (unless the person is hospitalized and

treated sooner), but it may be longer for some individuals. Manic episodes often contain

behaviors like grandiose or persecutory delusions, hallucinations, decreased sleep, flight of

ideas, and increased activity. These hallucinations are experienced by 18-50% of those who

experience auditory hallucinations (Rudnick, 1999), and they are usually command

hallucinations, telling the patient to either harm themselves or to harm others. Their mood

may be excessively cheerful and euphoric or irritable when they are questioned or told no.

People with bipolar may experience a normal mood in between extreme episodes of

depression or mania. (Videbeck, 2023) In the case of RM, she has Bipolar II, which means

she has mostly major depressive episodes accompanied by some hypomanic periods. When

I have seen RM on the unit, she usually swings toward the depressive stage and her affect

reflects that as well.

Cluster B disorder Cluster B is a combination of 4 personality disorders: Antisocial,

Borderline, Histrionic, and narcissistic personality disorder. The predominant pattern or

behavior of this combination diagnosis is erratic or dramatic behavior. People with

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personality disorders are often described as “treatment resistant.” (Morey, Benson, &

Skodel, 2016) Common behaviors and characteristics of cluster b include:

Identification of stressors and behaviors precipitating current hospitalization

RM states that she has many stressors in her life, with her family relationships

taking top priority. RM shares that her mother passed away about 3 years ago and that this

is something that she still feels sad about every day. RM states that she was her mother’s

caregiver while she was sick and until she passed away. She states that because of this, she

wants to be an STNA, but she has taken no steps to enroll in schooling or move forward

with this goal in any way. RM recognizes her current situation, but her developmental stage

is delayed. She also has physical characteristics of fetal alcohol syndrome although nothing

is confirmed, this is just objective data that may explain her developmental delays and

child-like behavior/speech. Since staying with her adult brother and being admitted to the

unit twice, she states she has not spoken to her dad. She admits to being manipulative and

lying to her family often, but she is hopeful that she can still have a relationship with her

dad. RM doesn’t open up much about this in conversation.

One aspect of her admissions that I would like to narrow in on is the concept of

secondary gain. Secondary gain is an external advantage derived from an illness, such as

rest, personal attention, and release from responsibility. For RM, I believe she experiences

secondary gain when she is here on the unit. She states being suicidal and that her plan is

to hang herself, however, she has no past attempts or any self-directed harm at all. Because

of her cluster b diagnosis, we know that RM uses manipulation to get what she wants. She

has learned that this behavior will lead to her being admitted to the floor again. When she
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is here, she experiences comfort that she does not get at home. She has activities to do like

group therapy and crafts, people to relate to, warm meals, and a sense of stability that she

cannot get elsewhere. She has learned that stating she is suicidal and has a plan will get her

these comforts, but she has not true suicidal intent.

Patient and family history of mental illness

RM states that she was first diagnosed with major depressive disorder after her

mother’s passing. This is prevalent because mental illness can often come to the surface

after a major loss in life. The combination of disorders that she has includes bipolar, major

depressive, and cluster b. RM is on a combination of medications (listed above) to control

all the symptoms associated. Because her dad is no longer involved in her life and her adult

brother is trying to take a step back, we don’t have much information on the family’s

history of mental illness.

When questioned about family, RM states that she does not have good family

relationships. Her mother passed away three years ago due to sickness, and RM states she

was her caregiver. She stares very little about her father and only that they do not stay in

contact at this point. When asked about her relationship with her brother, she says that

they are not close because he doesn’t trust her, and she is manipulative towards her loved

ones. She does believe though that he is her support system, and he has always been there

for her. The adult brother has no history of mental illness that we are aware of. He is

married and has taken on RM as his responsibility in the last year due to the lack of

parental support.
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Psychiatric evidence-based nursing care provided

During RM’s stays on the inpatient unit, she received care from several nurses,

doctors, and therapists of a variety. The nurses assigned to RM each day would use the

evidence-based nursing process to assess, plan, implement, and evaluate outcomes based

on RM’s progress. There was a medication nurse that would administer all her daily

scheduled medications and PRNs throughout the day. The medication nurse was required

to watch her take all medications and make sure they were not being pocketed/saved for

later use due to the risk of an overdose attempt.

RM is currently on an antipsychotic, antidepressants (tetracyclic and NDRI), and

lithium which is an antimanic agent. These medications provide mood stabilization and

decrease any psychotic symptoms the patient is experiencing, such as auditory

hallucinations. The medication nurse will educate RM on side effects, and specific teaching

points about each medication and why she is taking them. The nurses are aware that

neuroleptic malignant syndrome is a severe adverse reaction to antipsychotics, and RM

taking Haldol is at risk for development of this serious condition.

Ethnic, spiritual, and cultural influences

RM is a single, Caucasian woman. She stated her mom worked in healthcare when

she was living and that her family was middle-class growing up. She did not disclose her

father's career, although her parents were together when her mother passed. RM states

that she grew up going to a Christian church, and she does still carry those same beliefs.

Ever since her mother’s passing, she has not been actively practicing though. She states that
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“she doesn’t understand why God would take my mom away.” She doubts the religious

beliefs that she grew up with because of this major loss in her life.

Evaluation of patient outcomes

Some outcomes that we would expect for RM with the diagnoses of bipolar, cluster

b, and major depressive disorder include mood stabilization, reorientation to reality,

remaining free from injury to self or others, prioritizing self-care activities, encouraging

expression of feelings, learning about medications to increase medication compliance after

discharge, and participation in group activities on the unit.

RM did meet most of these outcomes by the time of discharge during her first

admission. RM was showering daily and had the motivation to complete her self-care

activities which was a major improvement from her initial admission.

RM did not meet the majority of these outcomes on the day of care during her

second admission. She was started on new medications and stated she was “too tired to

even think about showering.” She had a drastic decline in appearance. She has maintained

medication compliance as evidenced by her therapeutic lithium levels. She is reoriented to

reality but is not prioritizing working on herself. RM has stated that she enjoys going to

group but when questioned, she cannot state any new coping mechanisms she has learned

throughout her admissions.

Plans for discharge

After her first admission on 1/21, RM was discharged about 2 weeks later to her

adult brother’s house in Vienna. After this second admission on 3/14, there are comments
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in RM’s chart stating that her brother feels it may be time for RM to go to a group home.

Her brother is married with a few pets at home, and he and his spouse both work full-time

jobs. He doesn’t believe he can trust her at the house, and he is also afraid for her safety due

to her constant suicidal vocalization.

As stated earlier in the identification of stressors section, after her mother’s passing,

it seems as if her mental illness peaked, and her father is trying to relinquish all ties with

RM. As far as I know, we don’t have all the information regarding her father as he lives in

Dayton, and he does not contact RM or answer her calls. On the last day of care 3/28, RM

stated she was very anxious about her discharge plans. As she now knows her brother feels

the best decision would be a group home for RM. She did not disclose if this is something

she is okay with, but just expressed a lot of stress around the situation and did not want to

talk about it.

Prioritized nursing diagnoses

The following are prioritized nursing diagnoses for RM:

1. Risk for suicide related to ongoing suicidal ideation and plan of action.

2. Risk for self-harm related to depression as evidenced by suicidal ideation and intent.

3. Total self-care deficit related to major depressive episodes as evidenced by observation

of poor hygiene.

4. Interrupted family processes related to manipulative behaviors as evidenced by

dysfunctional relationships with dad and brother.

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5. Ineffective individual coping related to insufficient ability to make decisions as

evidenced by destructive behavior towards self or others.

6. Anxiety related to discharge plans as evidenced by brothers’ suggestion for a group

home living situation.

Potential nursing diagnoses

1. Ineffective health maintenance

2. Deficient knowledge

3. Impaired verbal communication

4. Hopelessness

5. Impaired social interaction

6. Chronic low self-esteem

7. Risk for self-mutilation

8. Grieving

9. Disturbed Thought Processes

10. Social isolation

Conclusion

Concluding this case study; cluster b is a combination of personality disorders that

are characterized by erratic and dramatic behavior, intense or toxic relationships, very

labile moods, and social manipulation. Bipolar II consists of mostly major depressive

episodes with cycles of hypomanic episodes and euthymic periods in between. Lastly major
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depressive disorder in RM’s case ties in directly with bipolar II and is characterized by long

periods of major depression. The combination of these mental illnesses and the treatments

that go along with them can pose a risk of noncompliance for RM.

In RM’s case, our main goal is to encourage medication compliance and stabilize her

mood through the use of pharmacologic measures, individual and group therapies, and

inpatient treatment. For best control of illness, RM needs to successfully recognize her

illnesses and take major steps forward to decrease her dysfunctional thought processes

and behaviors in an effort to maintain a functional life.

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References

Videbeck, S. L., & Miller, C. J. (2023). Psychiatric-Mental Health Nursing. Wolters Kluwer. 

Townsend, M. C., & Morgan, K. I. (2020). Essentials of Psychiatric Mental Health Nursing:

Concepts of care in evidence-based practice. F.A. Davis Company. 

Cailhol, L., Pelletier, É ., Rochette, L., Laporte, L., David, P., Villeneuve, É ., Paris, J., & Lesage, A.
(2017). Prevalence, mortality, and health care use among patients with cluster B
personality disorders clinically diagnosed in Quebec: A provincial cohort study, 2001-
2012. The Canadian Journal of Psychiatry, 62(5), 336–342.
https://doi.org/10.1177/0706743717700818 

Won, E., & Kim, Y.-K. (2017). An oldie but goodie: Lithium in the treatment of bipolar
disorder through neuroprotective and neurotrophic mechanisms. International
Journal of Molecular Sciences, 18(12), 2679. https://doi.org/10.3390/ijms18122679 

Rudnick, A. (1999). Relation between command hallucinations and dangerous

behavior. Journal of the American Academy of Psychiatry and the Law, 27(2), 253–257.