Kori Futy Case Study: Bipolar I Mania, Neurotransmitters and Lithium (PMHNP Answers)
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Get it written →Part I: The Case Study
Kori Futy, a 19-year-old Hispanic cis female, is displaying the following symptoms: In the last 3 weeks she presented with a decreased need for sleep, having stayed awake for 4 days straight and maintaining a pattern of only 2 hours of sleep; she is speaking rapidly and with pressured speech. She acknowledges an excessive increase in online shopping, purchasing unnecessary items she cannot afford. Additionally, Kori has engaged in over 10 casual sexual encounters with strangers from dating apps in the past week. This is not her usual dating behavior. She is consistently easily distracted, struggling to maintain focus. Kori’s manager at work has expressed concern over her behavior, prompting her to seek help to prevent job loss.
Questions:
- What diagnosis best describes what may be happening to Kori?
- What neurotransmitters are involved with her current symptoms?
- What classification of medications would best treat her symptoms?
- Choose one medication from the chosen class and provide: FDA approvals; mechanism of action; time frame the patient should see results; common side effects; life-threatening side effects; starting dose and why you picked that dose; common labs and baseline vitals collected, with reasoning.
Awake 4 days; 2 hours a night
Rapid, hard to interrupt
Cannot maintain focus
Spending sprees; impulsive sex
Job at risk; 3 weeks’ duration
Model answers
Original example for study purposes. Dosing and monitoring follow standard references; always check current prescribing information.
1. Most likely diagnosis
Bipolar I disorder, current episode manic (provisional, pending full evaluation). The DSM-5-TR defines a manic episode as a distinct period of abnormally and persistently elevated, expansive or irritable mood and increased activity or energy lasting at least one week (or any duration if hospitalization is needed), with at least three additional symptoms (four if mood is only irritable) that cause marked impairment (American Psychiatric Association [APA], 2022). Kori shows symptoms for three weeks, including decreased need for sleep, pressured speech, distractibility and excessive involvement in risky activities (unaffordable spending and impulsive sexual encounters), and her work functioning is impaired. A single manic episode is sufficient for bipolar I disorder. The clinician should confirm elevated or irritable mood and ask about grandiosity and flight of ideas, and should rule out other causes before confirming the diagnosis, including stimulant, cocaine or other substance use; medical causes such as hyperthyroidism; medications such as corticosteroids or antidepressants; and pregnancy. Bipolar disorder commonly begins in the late teens and early twenties, consistent with Kori’s age.
2. Neurotransmitters involved
- Dopamine: excessive dopaminergic activity in reward pathways is associated with elevated mood, increased goal-directed activity, impulsivity, hypersexuality and risky spending.
- Norepinephrine: increased noradrenergic activity contributes to heightened energy, arousal, decreased need for sleep and rapid speech.
- Glutamate: excess excitatory glutamate signaling is implicated in mania.
- GABA: reduced inhibitory GABA activity may contribute to agitation and poor impulse control.
- Serotonin: dysregulation affects mood stability, impulsivity and sleep.
3. Medication classification
Mood stabilizers (lithium and anticonvulsants such as valproate) and second-generation antipsychotics (such as quetiapine, olanzapine, aripiprazole and risperidone) are first-line treatments for acute mania, alone or in combination (Yatham et al., 2018). For Kori, the mood stabilizer lithium is a strong choice because it treats acute mania, prevents future episodes and has unique evidence for reducing suicide risk. Valproate is generally avoided in women of childbearing potential because of its high risk of birth defects and effects on fertility.
4. Selected medication: lithium carbonate
| FDA approvals | Monotherapy for bipolar I disorder: treatment of acute manic and mixed episodes and maintenance treatment to reduce the frequency and intensity of episodes, in patients 7 years and older (U.S. Food and Drug Administration [FDA] prescribing information for lithium carbonate). |
| Mechanism of action | Not fully understood. Lithium modulates intracellular signaling by inhibiting inositol monophosphatase (reducing phosphoinositide signaling) and glycogen synthase kinase-3 beta, decreases dopamine and glutamate excitatory activity, enhances GABA activity and has neuroprotective effects (Stahl, 2021). |
| Time frame for results | Antimanic effects usually begin within 1–2 weeks after therapeutic levels are reached, with fuller response over 2–3 weeks. Because of this delay, an antipsychotic or short-term benzodiazepine is often added initially for severe agitation or insomnia. |
| Common side effects | Nausea, diarrhea, fine hand tremor, increased thirst (polydipsia) and urination (polyuria), weight gain, acne, cognitive dulling, hypothyroidism and benign increases in white blood cell count. |
| Life-threatening side effects | Lithium toxicity (boxed warning): narrow therapeutic index; toxicity can occur at levels close to therapeutic levels, causing vomiting, diarrhea, coarse tremor, ataxia, confusion, seizures, arrhythmias, coma and death. Other serious risks: nephrogenic diabetes insipidus and chronic kidney disease, hypercalcemia from hyperparathyroidism, cardiac conduction changes and unmasking of Brugada syndrome, serotonin syndrome with serotonergic drugs, and teratogenicity (Ebstein’s anomaly). Toxicity risk increases with dehydration, low-sodium diets and interacting drugs such as NSAIDs, ACE inhibitors, ARBs and thiazide diuretics. |
| Starting dose and rationale | 300 mg by mouth two to three times daily (600–900 mg/day), titrated every few days based on serum levels and tolerability to a typical acute target of 0.8–1.2 mEq/L. This dose is chosen because Kori is a healthy young adult with (presumed) normal kidney function, so she can tolerate standard dosing, while starting at the lower end allows the prescriber to monitor levels and side effects before increasing. Levels are drawn 12 hours after the last dose, about 5 days after each change. |
| Baseline labs and vitals | Basic metabolic panel (sodium, creatinine, BUN, eGFR) because lithium is cleared by the kidneys and sodium balance affects levels; TSH because lithium can cause hypothyroidism and thyroid disease can mimic mania; calcium for hyperparathyroidism; CBC as a baseline; urinalysis; urine pregnancy test because lithium is teratogenic and Kori is of childbearing age; urine drug screen to rule out substance-induced mania; STI testing given recent unprotected sexual encounters; ECG if cardiac history or risk factors. Vitals: blood pressure, heart rate, temperature, weight and BMI (for weight gain monitoring) and orthostatic vital signs. |
Additional considerations
Kori should receive contraception counseling, education about lithium toxicity signs, the importance of steady fluid and salt intake, avoiding NSAIDs without approval and keeping lab appointments. Psychoeducation, sleep regulation, family involvement if she wishes and psychotherapy support recovery. A safety assessment should address suicide risk, financial harm and sexual health. Culturally responsive care, including attention to family values, language preference and stigma about mental illness in some Hispanic communities, can improve engagement.
References
American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
Stahl, S. M. (2021). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (5th ed.). Cambridge University Press.
U.S. Food and Drug Administration. (n.d.). Lithium carbonate prescribing information. DailyMed. https://dailymed.nlm.nih.gov
Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O’Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., … Berk, M. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97–170. https://doi.org/10.1111/bdi.12609
Frequently asked questions
What is the difference between bipolar I and bipolar II?
Bipolar I requires at least one manic episode. Bipolar II requires at least one hypomanic episode and one major depressive episode, with no history of mania. Hypomania is shorter (at least four days) and does not cause marked impairment or require hospitalization.
What is the therapeutic range for lithium?
Typically 0.8–1.2 mEq/L for acute mania and about 0.6–1.0 mEq/L for maintenance, measured 12 hours after the last dose.
Related reading: mood disorders and neurotransmitter networks, GAD case study with escitalopram and comprehensive psychiatric evaluation example.
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