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Psychiatric Mental Health Comprehensive Case Study

Natalie Dunlap

Youngstown State University

NURS 4842L: Mental Health Nursing

Michael Criscione

March 18, 2021

Abstract

The following case study looks at a patient who was admitted to an adult psychiatric unit for

attempted suicide. The patient had many risk factors which are examined and discussed, as well

as cultural and spiritual concerns. The patient’s medical and nursing diagnoses will be

considered, as well as the course of treatment and whether or not it was successful.

Keywords: mental health, suicide, alcoholism, bipolar 2 disorder, depression, risk factors
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Psychiatric Mental Health Comprehensive Case Study

Suicide accounts for hundreds of thousands of deaths per year. The World Health

Organization (WHO) estimates that there is a suicide death every 40 seconds, and for every

death, there are approximately 20 attempts globally (Aquila, 2020). It is difficult to comprehend

a tragedy of this nature. People who commit or attempt suicide are at their breaking point-they

are generally experiencing unbearable amounts of despair, stress, or hopelessness. While it may

not be possible to fully understand the reason someone took their life, there are many stressors,

both internal and external, that contribute to this situation. Mental illness (especially depression),

substance abuse, physical illness, PTSD, recent loss (a family member, job, etc.), and familial

tendencies are just several risk factors for suicide (Videbeck). Current events have also

contributed to risk factors for suicide, specifically the COVID-19 pandemic. The pandemic has

not only claimed lives, but it has also led to extreme isolation, fear, paranoia, economic hardship,

and a risk for drug/alcohol abuse and domestic violence (Aquila, 2020). Without a strong support

system and proper coping skills, these stressors can accumulate and become too much to bear. In

a situation like this, it becomes even more critical to equip people with the resources they need to

cope with their stressors. Talking with individuals one-on-one is an effective way to assess their

strengths, needs, and weaknesses, as seen in the following case study. While interviewing a

psychiatric patient, there were many opportunities for reflection and education which helped

provide a better outcome for the patient.

Objective Data

The psychiatric patient interview took place on Thursday, February 25th. The patient had

been admitted to the emergency department on Monday, February 22nd after an attempted

suicide. Once the patient had been stabilized, he was transferred to the adult psychiatric unit the
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following day, February 23rd. The initial toxicology screen tested positive for cannabinoids and

showed a blood ethanol level of 299 mg/dL. A liver function test was also performed and yielded

the following labs results: ALT-74 units/L (reference range: 7-56 units/L), AST: 46 units/L

(reference range: 5-40 units/L). Elevated liver enzymes generally indicate damage or injury to

the liver. In this case, it was very likely due to chronic alcoholism. The patient was going

through alcohol withdrawal on the day of care as evidenced by several symptoms. He was very

hypertensive, with a systolic blood pressure hovering in the 160s. He was also experiencing fine

tremors in his hands.

An important aspect of the patient interview is conducting a psychosocial assessment.

This can help diagnose issues with cognition, mood, and affect. During the interview, the

patient’s affect was amiable and friendly. His body language showed that he was relaxed and

engaged in the conversation. It was congruent and matched what he was saying. He expressed an

array of emotions with different facial expressions and gestures. He would light up when he

talked about what made him happy and then became more serious when talking about his

struggles. He was very open and real about the issues leading to his hospitalization. His speech

was clear and coherent and showed evidence of a clear thought process. Each topic flowed

logically from one to another.

Summary of Psychiatric Diagnoses and Expected Behaviors

The patient had several mental illnesses which contributed to his hospitalization. One

diagnosis he had been struggling with is mixed bipolar 2 disorder. Bipolar is a mood disorder

characterized by depressive and manic episodes. During a depressive phase, a person may

experience extreme sadness, tearfulness, hopelessness, low self-esteem, insomnia, hypersomnia,

changes in appetite, a lack of interest in activities, fatigue, and diminished concentration

(Videbeck, 2020). Manic episodes are the complete opposite. They are characterized by

euphoria, bursts of energy, and restlessness. A manic patient may not sleep, speak rapidly, have

flights of ideas, show poor judgment, and participate in risky behaviors (Videbeck, 2020).

Bipolar 2 disorder is a slight variation of the symptoms. The JNOUL Journal of Nursing

describes type 2 as being “…characterized by mild elevation of mood, described by hypomania,

which requires one or more major depressive episodes and at least one hypomanic episode

during the course of life” (de Sousa Moura, 2019). Videbeck also explains a relevant link

between bipolar disorder and suicide: “Young men early in the course of the illness are at the

highest risk for suicide, especially those with a history of suicide attempts or alcohol abuse as

well as those recently discharged from the hospital” (2020). The patient certainly fit the profile

of an high-risk individual.

The patient also had a history of major depressive disorder. During a depressive episode,

patients can experience any array of debilitating symptoms. Similar to the depressive phase of

bipolar disorder, people may experience hopelessness, despair, low motivation, emptiness,

fatigue, little interest in activities, poor hygiene, diminished cognitive ability/concentration, and

disturbances in sleep and eating habits (Videbeck, 2020). The symptoms and duration of a

depressive episode vary from person to person. While most episodes of depression last around 6

months, they can also last weeks or years without treatment (Videbeck, 2020).

Finally, the patient struggled with alcohol dependence, drinking around 12 drinks plus

vodka daily. Alcohol is a mood-altering substance that causes depression of the central nervous

system (Videbeck, 2020). The signs of alcohol intoxication are a result of this depressive effect.

At first people will feel relaxed, which leads to a loss of inhibitions and poor judgement. They

may become emotional, aggressive, uncoordinated, unsteady, slur their words, and have impaired
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memory (Videbeck, 2020). It is important to be aware of the association between alcohol

consumption and suicide. In 2016, General Hospital Psychiatry published a study on the

relationship between alcohol consumption and suicide among 119 U.S. Army Soldiers. The

study concluded that,

Alcohol use during the 24 h prior to a suicide attempt was associated with significantly

faster transition from suicidal impulse to action. Among suicide attempts in the past year,

lethality significantly increased as the length of time since the last alcoholic drink

increased (para 3).

It is clear that a pattern of alcohol abuse and dependence is a serious risk factor for suicide. Due

to the mood and judgment-altering properties of alcohol, this habit ought to be carefully

monitored and regulated, especially in people with other suicide risk factors.

Stressors and Behaviors Leading to Hospitalization

The patient was facing many stressors at the time of the attempted suicide. His mental

illness certainly contributed to the situation, as were several environmental and relational

stressors. The patient stated that he was living with his girlfriend and grandmother, both of

whom were alcoholics. He explained that there had been ongoing tension between him and his

girlfriend. This was partially due to the fact that the patient was “never at home”, he stated. He

went on to explain that he owns an auto repair shop and had many responsibilities related to that.

He felt the need to be there to support his business which had possibly been affected by the

COVID-19 pandemic. The conflict between himself and his girlfriend resulted in her leaving him

6 days before the attempted suicide. The girlfriend also took their dog and threatened to never let

the patient see it again. As these stressors accumulated, combined with the history of mental

illness and alcohol use, the breakup seemed to have pushed the patient to his absolute limit. The
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patient went on to explain that, “One morning I got up, got dressed for work, and went to the

basement and hung myself with a rope.” He was found unconscious by a family member and was

taken to the emergency department for immediate treatment.

Patient and Family History of Mental Illness

The patient stated that his family has a history of alcohol abuse. Many of his family

members struggled with alcoholism, including his mother, father, and grandmother. The familial

link in alcoholism can be attributed to both environmental and genetic factors (Videbeck, 2020).

So, if a child has parents who are both alcoholics, there is an increased risk they too will become

an alcoholic as opposed to a child whose parents are not alcoholics (Videbeck, 2020).

Considering the environment the patient grew up in, it is not surprising that he also struggled

with alcoholism.

Ethnic, Spiritual, and Cultural Influences

The patient stated that he had both Irish and German heritage. He felt that his heritage

partially contributed to his alcoholic tendencies, explaining, “It’s in my blood.” However, the

patient expressed that he was ready to get help. He was able to see how his alcoholism had

become a self-destructive pattern and he wanted help breaking the cycle. He had already made

arrangements to start going to Alcoholics Anonymous (AA) meetings after discharge.

Concerning spiritual influences, the patient’s belief in a higher power was important to

him. He recognized that he could not fix his problems on his own and needed to rely on

something bigger than himself. In fact, his beliefs seemed to align with the values of AA. A

study published by the National Institutes of Health explain, “AA itself believes it is indeed

spirituality that is the answer, explicitly stating that recovery is achieved through a “spiritual

awakening” from working through its 12-step program” (Kelly, 2017, para. 7). It will be very
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beneficial for the patient to attend a group therapy where his beliefs are supported. The evidence

all points toward the patient having a good outcome.

Prioritized Nursing Diagnoses

There were several priority nursing diagnoses used to guide the patient’s care during his

hospitalization. The primary nursing diagnosis was ineffective coping related to the inability to

cope during stressful circumstances, as evidenced by alcohol abuse and attempted suicide. A top

priority for this patient was to teach healthy coping techniques so he could learn how to

effectively handle stressful circumstances in the future. Another critical nursing diagnosis was

hopelessness, related to severe stressful events, also evidenced by alcohol abuse and attempted

suicide. Addressing these feelings of hopelessness and despair is an important step in helping the

patient. From there, the therapist or HCP can determine the appropriate course of treatment.

Potential Nursing Diagnoses

When planning care for the patient, there were several potential nursing diagnoses to take

into consideration. Since the patient was withdrawing from alcohol during his hospitalization, he

was at risk for confusion, altered sensory/perception, and violence, all related to symptoms of

alcohol withdrawal. It would be important for the staff on the unit to keep safety a priority since

the patient could be a danger to himself (fall risk) or others (violent behavior). Another potential

diagnosis related to chronic alcoholism would be imbalanced nutrition, possibly evidenced by

vitamin/mineral deficiencies or anemia. It would be necessary to assess the patient’s nutritional

status and treat any deficiencies that were present. Finally, there are several other concerns

related to the patient’s diagnosis of depression and bipolar 2 disorder that should be considered.

The patient would potentially be at risk for ineffective health maintenance and fatigue related to

depression, so it would be important to ensure the patient was able to perform basic hygiene and
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was eating. If these things were being neglected, a nurse would need to help with these activities.

The patient’s diagnosis of depression could put him at risk for chronic low esteem, impaired

social interactions, and loneliness, related to stress and conflict. Psychosocial health is just as

important as physical needs, so nurses on the unit must make sure to look out for potential

problems in this area.

Psychiatric Evidence Based Nursing Care Provided

Nursing care for this patient was very safety oriented. He was on suicide/self-harm

precautions which consisted of a safe environment, removal of any objects that could be used to

cause self-harm (cords, drawstrings, sharp utensils, etc.), and continual staff supervision. During

the patient’s hospitalization on the psychiatric unit, he participated in group therapy sessions and

was seen by specialists. He was also following a specific medication regimen to treat his various

mental illnesses. He was taking haloperidol (Haldol), a 1st generation antipsychotic used to

manage psychotic manifestations and agitation. He was also taking olanzapine (Zyprexa), an

atypical antipsychotic used to treat bipolar disorder. Chlordiazepoxide (Librium), a

benzodiazepine, was ordered for alcohol withdrawal and anxiety. Additionally, he was getting

started on acamprosate (Campral) which was prescribed to treat his alcohol addiction by

decreasing his cravings.

Discharge Plans

The patient had several arrangements made in preparation for discharge. As mentioned,

he agreed to begin attending AA meetings to aid in the recovery of his alcohol addiction. He also

organized a new living situation for himself post discharge. He explained how it had been

challenging to live with two other alcoholics and how he needed to get out of that situation. He

has plans to move into an apartment by himself where he would not be tempted to start
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consuming alcohol again. When asked what healthy coping mechanisms the patient could use

going forward, he listed several options. He enjoys meditation and had used that technique in the

past to manage stress. He also stated that his siblings were a huge support system for him. They

all have a close relationship, and the patient knew he could count on them if he were to need

anything. The patient had many goals that he was looking forward to. One of his main goals was

to regain custody of his two children. That was a big motivator for him. He was also looking

forward to riding his motorcycle again as well as going to the gym.

Evaluation of Patient Outcomes Related to Care

Overall, the patient seemed to be responding well to his treatments and interventions. He

was at a place where he was open to receiving help, and he even shared his story with other

patients in order to try and help them. He mentioned several times how he wanted to share his

experiences to help others. He had many goals and aspirations which he talked about during the

patient interview, indicating that he had hope for the future. He was looking forward to moving

into a healthier living situation and attending the AA meetings to become free of his alcohol

addiction. He was serious about recovery and during the interview stated, “I have no desire for

alcohol.” The patient was very eager in general and it was apparent he was in a much better place

mentally and emotionally. He was looking forward to being discharged so he could work

towards building a better life, staying healthy, and doing the things he enjoyed.

Concluding Remarks

While mental illness and suicide can have devastating consequences, there are an

overwhelming amount of resources and help available for anyone who is struggling. One-on-one

therapeutic communication is a great place to start. By establishing a trusting relationship with a

patient, it opens the door for healing and recovery to take place. It can be used as an opportunity
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to connect the patient with more resources, like counselors, churches, and support groups. The

patient in this case study is a good example of someone who was at rock bottom but began to

flourish after receiving the right help. Oftentimes, people have to hit rock bottom before they

realize there is a Rock at the bottom. As this patient continues his journey to recovery, his story

will no doubt be a source of hope to any who are struggling.

References

Aquila, I., Sacco, M. A., Ricci, C., Gratteri, S., Montebianco Abenavoli, L., Oliva, A., & Ricci,

P. (2020). The Role of the COVID-19 Pandemic as a Risk Factor for Suicide: What Is Its

Impact on the Public Mental Health State Today? Psychological Trauma: Theory,

Research, Practice & Policy, 12, S120–S122. https://doi-

org.eps.cc.ysu.edu/10.1037/tra0000616

Bryan, C. J., Garland, E. L., & Rudd, M. D. (2016). From impulse to action among military

personnel hospitalized for suicide risk: alcohol consumption and the reported transition

from suicidal thought to behavior. General Hospital Psychiatry, 41, 13–19. https://doi-

org.eps.cc.ysu.edu/10.1016/j.genhosppsych.2016.05.001

de Sousa Moura, H. D., Caetano Lira, J. A., Martins Ferraz, M. M., Soares Lima, C. L., & Cruz

Rocha, Â. R. (2019). Bipolar Affective Disorder: Feelings, Stigmas and Limitations.

Journal of Nursing UFPE / Revista de Enfermagem UFPE, 13, 1008–1013. https://doi-

org.eps.cc.ysu.edu/10.5205/1981-8963.2019.241665

Kelly, John F. (2017). Is Alcoholics Anonymous religious, spiritual, neither? Findings from 25

years of mechanisms of behavior change research. NCBI.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5385165/#:~:text=AA%20itself

%20believes%20it%20is,experiences%20which%20have%20revolutionized%20our

Videbeck, S. Lippincott CoursePoint Enhanced for Videbeck's Psychiatric-Mental Health

Nursing. [CoursePoint]. (2020). Retrieved from

https://coursepoint.vitalsource.com/#/books/9781975133887/