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Case Studies

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CASE STUDIES

Case studies

Caring for a person with a mental illness - Christian

Question 1

For a start, Christian has chronic schizophrenia. Thus, he requires psychosocial, psychological,

and medical inputs. At the moment, these are not provided, and being a sole case manager I may

not be in a position to provide the three inputs because they require experts in the fields. Failure

to provide the three inputs poses a serious risk to him (Frankenburg, 2017). A further concern is

that Christian hardly ever stays in the room. Thus, administering his oral medication is always a

problem. This, coupled with the fact that his place of residence is extremely and perpetually

untidy, poses additional health concerns such as lung diseases, cardiovascular diseases, diabetes,

and obesity, which are very common to neglected schizophrenic patients (Pillinger, et al., 2017).

These are some of the risks that I have to deal with at the very start.

Question 2

The first thing to do as a manager in Christian’s case will be to acknowledge that management of

patients suffering from chronic schizophrenia requires familiarity with antipsychotic medications

(Millar, Sands, & Elsom, 2014). These include familiarity with physical healthcare, psychosocial

interventions, and side effect profiles. Due to Christian’s deteriorating health occasioned by poor

hygiene, poor eating habits, and indiscipline to his oral medication, I need to familiarize myself

with and address his physical health care. This includes monitoring his metabolic syndrome,

sexual health counselling, discussing with him to quit smoking, hyperprolactinaemia, and also

monitoring his movement behaviour since from the scenario it is clear that he doesn’t settle at his

place of residence (Leucht, Cipriani, & Spineli, 2013). Before thinking of any pharmacological

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care to administer to Christian, it would serve him well if I administer some non-

pharmacological treatment to him. He has already shown signs of developing auditory

hallucinations and also negative symptoms of schizophrenia such as apathy, social isolation and

withdrawal, lethargy and poor self-care (Schweewe, Backx, & Takken, 2013). Therefore, I

would procure the services of a psychologist to administer sessions of Cognitive Behavioural

Therapy (CBT) to him.

Improving Christian’s hygiene is another thing that I would do before engaging him in

medication. This also includes procuring the services of an energetic young man to assist me in

keeping him in his house instead of leaving him to wander alone in the streets. Helping him settle

down is one of the most important initial steps to the psychotic care. It would also help in

administering pharmacological care to him once he settles down (Amir, et al., 2013). I would

also engage the services of a dietician to manage his eating habits with a view to improving his

health. Exercising is also a very important measure for Christian because of his danger of

developing diabetes.

Question 3

The UN Principles of 1991 regarding mental health care have greatly influenced most Mental

Health Acts in Australia and beyond (Hastrup, et al., 2013). Based on those principles, mental

health patients are supposed to be handled in a manner that respects their human dignity and

culture. Mental health patients are supposed to be treated within their community and with

respect to their right to privacy, recreation, education, and communication. Principle 9 of these

principles contains the omnibus provision of respecting the rights of mental health patients

(Brayley, Alston, & Rogers, 2015). Some of the principles that guide the assessment and

treatment of mental health patients in Australia include recovery-oriented practice, culturally-

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informed practice, recognition of family and carers, and respect for human rights, careful

assessment of the patient to ensure that they understand the consequences of their decisions to be

treated (Freeman, et al., 2015).

Based on the above principles, Christian has a right to have an assessment of the highest quality

and a mental care that respects his human rights. These are the principles that will guide me in

the process of managing his case.

Question 4

For a start, Christian requires pharmacotherapy. He requires antipsychotic medication to address

the exacerbated schizophrenic symptoms that are coming up. The Olanzapine drug that he is

currently taking is not adequate in itself. He requires such other drugs as Ziprasidone,

Amisulpride, Aripiprazole, Paliperidone, and Clozapine, to name a few. He also requires depot

antipsychotics such as Haloperidol, Paliperidone palmitate, and Fluphenazine, to name a few. In

addition to the pharmacological treatment prescribed here, Christian also requires non-

pharmacological treatment such as Cognitive Behavioural Theraphy (CBT), checking of his

smoking status, weight monitoring, especially now that he hardly eats well, monitoring of his

blood pressure, monitoring of his cholesterol, lipids, and blood sugars, neurological examination,

eye examination, and liver function tests. One other important care is to monitor his diet and also

to initiate exercise sessions to ensure that he fights chances of developing diabetes or obesity.

This can be done by the case manager with assistance from the case management team that will

be selected within the first few days after taking over the case management. Most importantly,

the case manager will come up with a plan to tame him so that he stops wandering everywhere

listening to stereo and watching TV as these can be adverse to his hearing senses.

Question 5

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Many ethical and clinical dilemmas emerge when dealing with chronic schizophrenic patients.

First, case managers find themselves having to tell half-truths to their schizophrenic patients so

that they don’t run the risk of losing them for good. Oftentimes the case manager has to withhold

the truth about the health of their patients so that they keep them under watch and medication

(Noordsy, 2016). This may compromise their ethical values. Secondly, the case manager must

sometimes put up with the urge of supporting risky ambitions of the schizophrenic patient to

keep them under watch and also to keep them under medication. For example, Christian may

start considering advancing his education even before fully recovering (Kane, Robinson, &

Schooler, 2015). As his case manager, I should support this ambition because it is meant to

improve the quality of his life, even though it will make him sacrifice a lot at the expense of his

life. In addition to this, sometimes a case manager finds themselves in a position of having to ask

their schizophrenic patients about their wishes regarding their medication (Roberts & Kim,

2015). Whereas this enables their patients to make decisions regarding their health, the decisions

the patients make may not be healthy because of their health condition. They are, however,

decisions that must be made after all. Finally, there are grave ethical and clinical repercussions

when a psychiatrist has to make a decision relating to the life of the patient. Although these

decisions are hard to make, they have to be made after all. The case manager must, however,

make sure that the decisions they make are the best at that particular time and given the

circumstances (Sekar, Bialas, & de Rivera, 2016).

Question 6

As the new case manager, I should be mindful of my own health and welfare, even as I manage

Christian’s case. This way, I will manage this case alongside other specialists like a physical

therapist, psychologist, and medical specialist, among others (Mueser, Deavers, & DL, 2013).

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This will provide me with an opportunity to pursue my welfare and career and at the same time

manage Christian’s case. Another reason for managing the case as a group is that Christian’s

health has deteriorated a lot. He is also bordering on having a serious mental condition that could

prove unmanageable if it is not addressed early enough. This, coupled with the fact that he is

becoming verbally and physically abusive to his managers makes a case for a shared

management of the case.

Tiffany

Question 1

Tiffany’s mother was only 16 years old when she gave birth to her. The mother even developed

postnatal depression following the birth. She was born with a low birth weight of 2200 gms., at

35/40 gestation and nursed in intensive care for the first few days due to respiratory distress

syndrome. These are clear risk factors that might have precipitated the development of a mental

health issue. Additionally, Tiffany doesn’t know her father. Her biological father moved away

from his relationship with her mother in her infancy (Kane, Robinson, & Schooler, 2015). This,

coupled with the fact that her subsequent step-fathers have had a history of domestic violence

with her mother and in the process harming her, might have fuelled her chances of developing a

mental health concern. She is prone to developing a Post-Traumatic Stress Disorder as a result of

seeing her mother being harassed by the step-fathers that she has been relating with. The decision

by her step-father to advise her to start dieting on the basis that she was becoming “beefy”

further fuelled her chances of developing a mental health condition (Millar, Sands, & Elsom,

2014). The diet she is undergoing has not been prescribed by a nutritionist and she is, therefore,

denying her body very valuable nutrients. As a result, she has lost self-esteem and confidence in

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her body and sees herself as worthless. These, among others, are the key risk factors that have

led to Tiffany developing a mental health disease.

Question 2

Resilience is the ability of a patient suffering from a psychological condition to adapt well to the

said condition. The condition could be a mental disease, trauma, stress, or depression. Tiffany is

suffering from a psychological condition from which she requires resilience. There are certain

protective factors that can facilitate her desire to develop resilience at the midst of the trauma

mental condition that she is undergoing (Leucht, Cipriani, & Spineli, 2013). For a start, she is a

high performer at school and has a group of close friends with whom they engage in co-

curricular and social activities with happiness. This social group and her willingness to

participate in social and co-curricular activities will drive away the mental disease. Secondly, she

is in a religious affiliation and attends church service regularly. She is also a member of the

youth group (Frankenburg, 2017). Such social grouping and membership to a religious group is a

protective factor that can easily drive away any chances of her developing the mental disease. In

addition to this, her teachers have noted her sudden change in behaviour and weight and have

taken an early step to talk to her. In particular, her guidance officer is seized of the matter and is

handling it with all the importance and attention that it disserves. The decision by the guidance

officer to take over the role to address Tiffany’s problems comes at a very critical time and may

act as the solely important step in warding off any risks of her developing the mental disease

(Mueser, Deavers, & DL, 2013).

Question 3

Tiffany is suffering from Anorexia Nervosa, a mental health condition whereby a person keeps

their body weight as low as possible. The anorexic patient usually restricts the amount of food

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they eat, as a result of an anxiety regarding their body shape (Amir, et al., 2013). People with

anorexia have a habit of concealing their condition from their family members and friends. This

is exactly what Tiffany is doing. She is wearing oversize clothes to conceal her condition and is

eating a meal a day so that she becomes thinner. She is also very busy at the gym, is underweight

at 43Kg, proceeds to purge after eating the evening meal so that she doesn’t gain weight, and

also uses laxatives such as diet pills and aperients to reduce her weight. She has sleep

disturbances and also has fainted a couple of times after waking up from sleep (Walker, 2014).

All these are symptomatic of Anorexia Nervosa, the medical health condition she is suffering

from.

Question 5

A clinician requires certain skills to develop a therapeutic relationship with a mental health

patient. The very obvious one is that the clinician must have undergone the requisite training for

them to develop a lasting therapeutic relationship with their patients. This includes having

completed training as a clinician and acquired the requisite qualifications (Kane, Robinson, &

Schooler, 2015). Secondly, establishing a therapeutic relationship is a reflective skill. The

clinician must reflect on such issues as self-awareness, empathy, self-knowledge, and knowing

the boundaries of the professional role. Thirdly, the clinician must understand which level of the

relationship they are with the patient to understand the degree of therapeutic relationship they are

supposed to exercise. Further, the relationship must be consistent and not a one-off. Such skills

are very important for a clinician dealing with a mental health patient (Walker, 2014).

Daphne

Based on her comments at the regional hospital, Daphne poses a serious suicidal threat to herself.

The level of suicide threat is very high because she doesn’t see anything to live for. As a

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clinician dealing with Daphne’s case, I would take very serious the case of someone who doesn’t

see anything to live for and only asks those whom she is dealing with to “just let her die.”

Further, she sees no value left in her life after the death of her husband with whom they were

very close and who had been taking care of her medication. Thus, based on the data available in

the case study notes, I would place the case at a very high level of suicide risk so that I give it the

attention that it disserves. She is even not in a position to make decision regarding her own

health and mental condition. She is fatigued, worn out, and teary. Her depressive symptoms have

persisted even after being placed under medication and her treating team has diagnosed her with

Major Depressive Disorder. This kind of data is reminiscent of a person who is tired of life and

sees nothing to live for, especially after losing her husband with whom they had lived happily for

years. It is a very high risk suicide case and I would treat it as such.

Question 2

As a clinician dealing with a patient with a mental disorder, I am bound by the provisions of the

DSM manual on mental disorders. Thus, if I am in doubt as to Daphne’s diagnosis with a Major

Depressive Disorder, the first thing to do is to open the Manual and ascertain that the diagnosis

was correct. Axis IV of the Manual lists Major Depressive Disorder as one of the mental

disorders under that category and it results from, among other causes, important events in e

person’s life, including the death of a loved one (Heffner, 2017). Marriage is also listed as one of

the causes of the disorder. Looking closely at Daphne’s case, the biggest cause of her disorder is

the death of her husband with whom they had lived happily for years. Therefore, it is highly

likely that his death and that fact that she did not have anyone else to finance her medication and

give her the warm company she dearly needed perpetuated the development of the disorder. The

feelings arising from the loss of a loved one may be short-lived. However, when such feelings

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become persistent, this is the time that the person develops MDD with the symptoms that

Daphne shows as narrated in the case study notes. The main clinical symptoms of the disorder

are a persistent lack of interest in whatever someone is doing, a feeling of sadness and irritability

with the events of the day, loss of weight, lack of sleep, restlessness, and, above all, a high level

of suicide risk (Kerr, 2017). Daphne has shown all these symptoms and was, therefore, correctly

diagnosed with Major Depressive Disorder.

Question 3

Electroconvulsive therapy is sometimes referred to as “electroshock therapy” and it is carried out

under general anaesthesia. It is administered to people having highly severe and psychotic

suicidal depression like the one that Daphne is suffering from. It is very ideal for high-risk

suicide patients like Daphne and works very well within a short time. However, it is true that

ECT is associated with the side effects of memory loss as Daphne notes. The medication is

supposed to be given with the consent of the patient on whom it is being administered and, just

as is the case with most other types of medication, it should not be forced into someone who

doesn’t want it. However, in England and Wales, the medication can be administered under the

Mental Health Act if two medical doctors, another professional, and another independent

specialist not directly involved with the case determine that it is important for the welfare of the

patient. However, the specialists must also seek the consent of the family members of the patient.

In the case of Daphne, this consent has not yet been sought. Thus, I would take the extra step to

consult other medical specialists, an independent practitioner not directly involved with her case,

and also her immediate family members to determine the possibility of still administering the

medication.

Question 4

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It is well documented that sleep disturbances in depressed persons are hardly cured through

medical treatment (Emery, Wilson, & Kowal, 2014). Whereas some clinicians still apply

medication to depressed patients having insomnia, there is evidence to show that Cognitive

behavioural Therapy (CBT), when done well, increases the chances of the depressed patient

developing more consistent sleep patterns. Research has shown that an inability to sleep and also

oversleeping are some of the key symptoms of depression. Some clinicians use psychotherapy

comprising counselling and therapy to address sleep disturbance in depressed patients (Emery,

Wilson, & Kowal, 2014). Sometimes antidepressants are used to decrease sadness and

hopelessness to stimulate sleep. As a clinician, I would recommend administer a combination of

antidepressants, psychotherapy, and CBT.

Question 5

I would make use of a combination of behavioural and cognitive therapy on Daphne, noting that

her condition is getting complicated by the day. In behavioural therapy, such approaches as

classical conditioning, desensitizing, operant conditioning, and cognitive behavioural therapy can

be used well to make her feel better, especially with her disturbed sleep patterns (Emery, Wilson,

& Kowal, 2014). In cognitive therapy, I would work on Daphne’s thoughts about suicide to see

to it that she doesn’t contemplate suicide any longer.

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