The University of Texas System

PeriPAN Case of the Month – November 2023

Each month, OBs and PCPs call PeriPAN with a wide variety of mental health questions. Find out how PeriPAN helped an OB during this consultation.

Patient: 36-year-old woman G1P0, 36-week GA with a history of s/p temporal lobectomy for partial complex seizures, bipolar II d/o, ADHD, and OCD

Reason for PeriPAN Consultation: The patient’s primary psychiatrist and the L&D OBGYN who was
treating the patient referred the patient for perinatal depression and anxiety with acute mental health decline. She was recently admitted to L&D unit following medical ER presentation with SI, depression, and anxiety. For 2-4 weeks patient requested hospitalization for remainder of her
pregnancy. Potential marital tension, some control themes, and no clear IPV. Has had various ER visits for psychiatric symptoms, would leave AMA before completion of treatment and/or assessment. Sunday
presented to BS&W for L&D at 9 pm for SI, indicating having bottles of medications she intended to ingest, was admitted overnight, and assessed by Psychiatric APP. UDS: + for amphetamines and
cannabinoids, then on repeat was negative. Concern for low distress tolerance, leaving room with husband while on SI monitoring, staff requesting support with patient q1hour, and patient no longer with
SI. Patient’s outpatient psychiatrist was notified and offered recommendations. At that point patient indicated the following medication regimen: mirtazapine 15 mg QD and 30 mg QHS (written 45 mg QHS), luvox 300 mg QD (reduced to 100 mg QD, then increased to 200 mg QD, most recently on 250 mg QD), trazodone 75 mg QHS + PRN anxiety, quetiapine 100 mg QHS, changed to Latuda 20 mg QD, unclear if taken with food, recommended to increase to 25 mg QD and give dose of quetiapine 25 mg x1.

Explanation of the Case and Outcome of the Call: Patient was seen for a same day consultation and during the visit patient reported depression since July having low mood, low PMA, anhedonia. States had SI for a few days “maybe I do want to kill myself.” Denies having SI today and wants help with depression and anxiety. States 1 month of anxiety, hasn’t slept in 2 days, first time occurring. States withdrawal from suboxone and no longer on Remeron, “I have off the chart anxiety for the past month and a half.” Feels Seroquel and Remeron were helping her sleep, taking Seroquel during the day due to high anxiety. Started Adderall on her own, felt she was able to manage her symptoms and thoughts with this, and symptoms were becoming more manageable. States started suboxone for a kidney stone related pain, was given 3 mg suboxone from her husband for 1 month, stopped 2 days ago. Anxiety is characterized as shaking, “my eyes are bulging out of my head,” “I had to leave a restaurant” from parents, hard to relax, heat in palms of hands and feet, and “felt a bomb would go off.” Reports knots in stomach, upset stomach, muscles will feel sore. “My depression is really disabling.” No SI/HI/AVH. When attempting to clarify bipolar diagnosis, started “more so OCD and ADHD,” “looks like depression, I’m up then down.”