Patient Demographics:
Patient Initials: JM Age: 14 Sex: Female Marital Status: Single
Language: English Race: Caucasian Ethnicity: non-Hispanic
Sexual Orientation: Heterosexual Education: Currently in 9th grade
Occupation: Full time student
Allergies: NKDA
Current Medications
Trileptal 150 mg PO daily
Melatonin 10 mg PO PRN for insomnia
Sprintec PO daily for birth control
Chief Complaint: “I’ve been on this medication for years and it’s not even helping.”
History of Presenting Illness
JM is a 14-year-old Caucasion female with history of PTSD, ODD, and cannabis use disorder that presents today for intake visit. Patient was admitted to residential facility about 2 weeks ago due to emotional dysregulation and running away from home. Patient reports her problems started around 11 years od when she started having flashbacks of her abuse when she was younger. She is unable to recall when the abuse occurred. She states when she was 11 years old, she stared using marijuana and methamphetamine. Her last methamphetamine use was about 2 years ago. She states she stopped using this because she went to jail. She reports continued use of marijuana that she gets from friends. She reports a history of overdose a few years ago by taking “whatever medication I was on at that time.”
Context:
Psycho-Social, Medical, Family History
Relationship Status: Single. Identifies as a bisexual female. Reports that she is not in a current relationship.
Support System: Reports that she has a good relationship with her grandmother. Reports that she has “some friends”. Otherwise, she denies any other support systems.
Housing: Prior to coming to facility, she lived with her maternal grandmother. She reports being adopted by her around 2 years of age.
Education: Currently in 9th grade at a public school
Developmental Milestones: Denies any delays in developmental milestones.
Legal: Previous history of running away and drug abuse.
Abuse/Trauma: Reports alleged history of sexual abuse by a “male family member.” Reports being physically abused by her biological mother.
Military Service: Denies
Cultural Concerns: None identified. Patient denies any need for religious, cultural, or spiritual help. Patient denies any religious background.
Family History: Denies any known mental health or medical conditions.
Social History: Reports a history of cannabis methamphetamine use that began around 11 years old.
Psych History: Reports psychiatric hospitalization at 11 years old for self-harm due to cutting her arms and overdosing on “meds that I was on at that time.” She cannot recall what previous medications these were.
Medical History: Denies any medical problems or physical disabilities
Mental Status Exam
Appearance: 14-year-old Caucasian female. Appears stated age. Well-groomed and appropriately dressed. Overweight. No visible scars, tattoos, or jewelry noted
Psychomotor Activity: Sitting in chair with slouched posture, swaying chair back and forth
Speech: Clear rhythm, rate, and quality. Logical and comprehendible.
Affect: Irritable, labile
Mood: Anxious
Thought Processes: Linear, logical, and goal oriented
Thought content: appropriate, relevant, clear and concise. No hallucinations or delusions
Suicidal ideation: Denies current SI.
Homicidal ideation: Denies current HI.
Orientation: Alert and oriented to person, place, time and situation
Memory: Immediate, recent, and remote intact. The patient can recall some events from childhood. The patient can recall names of her treatment team and what she ate for breakfast that morning. The patient can recall events that occurred at school or in her home over the past several months.
Insight: Poor – Reports that “I don’t need the meds I’m on” and that “there is no point in taking meds.”
Judgement: Poor – Continues to engage in arguments with peers and authority figures. Continues to use cannabis despite knowing its potential consequences on the brain.
Stream of Thought: engaged, goal-directed, coherent
Fund of Knowledge: Below average intelligence
Cognitive Function Abilities:
Attention span– Good. She is able to hold appropriate conversation without getting distracted
Concentration– Intact and well maintained
Abstract thinking– Intact. She makes the comment that “I know I need meds to help me.” She also states that she needs them to help process and “deal with” her past trauma.
Concrete thinking– Intact. She reports eating more unhealthy foods and states “that is why I have gained weight.”
Metaphors– She is able to explain simple metaphors such as, “Better to be safe than sorry.”
Screening Tools
CRAFFT = positive for marijuana use
Child and Adolescent Trauma Screen (CATS) = 26
Diagnosis
(APA, 2022)
(APA, 2022)
(APA, 2022)
Intervention and Plan
Patient continues to have impulsivity and anger despite being on Trileptal. She reports that she has been on Trileptal for “a few years and its never really helped me.” Due to her behaviors and ineffectiveness of medication, the Trileptal will be decreased to 75 mg daily for 3 days, then it will be discontinued. While Trileptal is being titrated off, the patient will be started on Wellbutrin 75 mg daily for her impulsivity and mood. The patient will also be started on Seroquel 50 mg daily at nighttime to help with her mood and sleep. She will continue with group and individual counseling with therapist to help with coping skills. Her admission lab work showed elevated cholesterol, triglycerides, and LDL. The patient was educated on making healthier choices and weight loss due to her elevated lipid levels. The patient will be seen again in approximately 4 weeks to re-assess her behaviors and medication effectiveness.
Outcome of Case Presentation
JM is a 14-year-old Caucasian who identifies as bisexual female. She has a history of PTSD, ODD, and cannabis use disorder. She completed a 45-minute intake visit with psychiatrist and PMHNP student for her residential treatment stay. She was admitted to the facility due to running away, impulsivity, self-harm, and concerns from grandmother for “emotional dysregulation.”
At the initial intake visit, her Trileptal was titrated off due to being ineffective, as well as its use not being supported in the adolescent population. She was then put on Wellbutrin and Seroquel to help with her impulsivity, mood, and sleep. Her next follow-up occurred roughly 4.5 weeks after these changes were made. At this follow-up, the staff denied any concerning behaviors or incident reports. The patient reported improved mood, less anger, and improved sleep. The patient was maintained on these medications due to her overall improvement. She was encouraged to continue with group and individual therapy to continue to learn coping skills and address her past trauma.
Patient Selection
I selected this patient based on her psychiatric history and current medication list. Additionally, the psychiatrist changed some of her medication based on what is FDA approved for certain symptoms and conditions. The psychiatrist also made her treatment decisions based on reports of research lacking evidence of Trileptal’s use in adolescents. Due to what the psychiatrist discussed with the patient, this prompted me to do my own investigation to see if her claims were accurate based on current evidence-based research.
Trileptal is considered an anticonvulsant medication. It works by blocking L-type calcium channels (Grunze et al., 2021). Trileptal is FDA-approved for seizures in both adults and children (FDA, 2017). However, it is also used off label in the psychiatry realm as a type of mood stabilizer Grunze et al., 2021). One articles states, “the American Association of Child and Adolescent Psychiatry practice parameters do not include oxcarbazepine as a treatment for autism, ODD, or depressive disorders” (Morrow et al, 2020). In fact, it is listed as a fifth-line treatment option for bipolar disorder in children and adolescents. This is likely because of the lack of evidence to support its treatment of mania in this specific population. It has been shown to be efficacious in “reducing irritability and agitation in ASD.” Overall, it appears that Trileptal is an option to keep “in our back pocket”, especially if the patient has a wide range of psychiatric symptoms and already on a high dose of antipsychotics.
Questions Regarding Clinical Decision Making
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
FDA. (2017). Trileptal prescribing information. Retrieved February 8, 2023, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021014s036lbl.pdf
Grunze, A., Amann, B. L., & Grunz, H. (2021) Efficacy of Carbamazepine and its derivatives in the treatment of bipolar disorder. Medicina, 57, 1-17.
Morrow, K., Young, K. A., Spencer, S., Medina, E. S., Marziale, M. A., Sanchez, A., & Bourgeois, J. A. (2020). Utility of oxcarbazepine in the treatment of childhood and adolescent psychiatric symptoms. Baylor University Medical Center Proceedings, 34(1), 34-38.
