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Case review with 4 p'sDate of Current Episode: 14/10/24 Diagnosis: BPAD Alert/Risk/Practice Protective Issues Mental state stable, ongoing dysthymia in the context of her manic episode resolving Ongoing elevated risks of vulnerability, harm to reputation when unwell. High acute and chronic risks of treatment noncompliance, reduced insight to and insistence on treatment cessation Protective factor son Minsoo Supportive GP . 1. Formulation: (Include age, marital status, dependents, schooling, occupation, age of illness onset, standing diagnosis, factors complicating illness [eg: poor insight, poor compliance, substance abuse], number of admissions, date of first & last admissions, referral reason). Background Mija (Preferred to be called Chole) is a 60-year-old woman mother of two (from a previous relationship) and immigrated from South Korea several years ago. Mija has a diagnose of BPAD, with an onset of manic symptoms beginning this year, current managed on under CTO Mija h

How many pages

Case Review

Date of Current Episode:

14/10/2024

Diagnosis:

Bipolar Affective Disorder (BPAD)

Alert/Risk/Practice:

Protective Issues

Mija's mental state is currently stable, but she is experiencing ongoing dysthymia as her manic episode is resolving. There are ongoing elevated risks of vulnerability, particularly concerning harm to her reputation when she is unwell. Additionally, there are high acute and chronic risks regarding treatment noncompliance, as well as reduced insight into her condition, leading her to insist on treatment cessation.

Protective Factors

Support from a caring GP, Minsoo.

1. Formulation

Background

Name: Mija (Preferred name: Chole)
Age: 60 years
Marital Status: Mother of two from a previous relationship.
Dependents: Two adult children.
Schooling: Educated in South Korea.
Occupation: Currently unemployed but has had various roles prior to her health issues.
Age of Illness Onset: The onset of her manic symptoms occurred in the year 2024.
Standing Diagnosis: Bipolar Affective Disorder (BPAD).

Complicating Factors

Mija's condition is complicated by several factors:

Poor Insight: There is a notable lack of insight into her condition, which contributes to her treatment noncompliance.
Poor Compliance: Historical patterns of noncompliance with treatment regimens have been observed, particularly during fluctuating mental states.
Substance Abuse: There are no current indications of substance abuse; however, previous episodes have seen various forms of self-medication as a coping mechanism.

Admissions History

Number of Admissions: Mija has been admitted a total of 3 times since the onset of her current illness.
Date of First Admission: March 2024, due to her first acute manic episode.
Date of Last Admission: September 2024, again related to the acute presentation of manic symptoms.

Referral Reason

Mija was referred for psychiatric evaluation and ongoing management under a Community Treatment Order (CTO) due to her recent manic episodes and the need for close monitoring of her mental health status. Her treatment is aimed at stabilizing her mood, improving insight, and enhancing compliance with her treatment plan.

Current Management

Mija is currently managed under the CTO to ensure she adheres to her medication plan and receives adequate support. Regular evaluations will help in monitoring her mental state, and ongoing collaboration with her GP will be crucial for her long-term recovery. Treatment interventions focus on psychoeducation, mood stabilization, and exploring her reluctance to engage with treatment.

In summary, Mija's case requires a nuanced approach that takes into account her ongoing struggles with BPAD, the challenges she faces regarding compliance and insight, and her valuable support systems. Regular reviews and adjustments to her treatment plan will be essential to ensure her continued stability and overall well-being.