Patient A is 34 years of age with a history of schizoaffective bipolar disorder, first diagnosed at 18 years of age during his first year at college. His childhood was notable for several episodes of brief counseling for behavioral issues in school and at home, with a brief trial of methylphenidate (Ritalin) at 11 years of age. Patient A graduated from high school with his peers, but once at college, he developed delirious mania, paranoia, and psychosis. Treatment with olanzapine and valproic acid (Depakote) was initiated, but compliance has been an ongoing issue. During the past 16 years, the patient has had numerous episodes requiring hospitalization, one suicide attempt, and three arrests for breach of peace. He is now on probation and has been unable to maintain employment. He is living with his mother, who has communicated that he will have to leave the house if he does not take his medication. Patient A presents for medication management, stating that he does not like the weight gain he has experienced with many of the medications he has used in the past.

The nurse takes and documents a full history. On mental status exam, Patient A is alert and oriented. He scores 27 on a Mini-Mental State Exam (MMSE) and is mildly grandiose. His speech is slightly pressured but interruptible. At the time of presentation, Patient A is not taking any medications, having disagreed with his last provider's prescription of olanzapine, a drug that had been effective in the past.

Patient A is 6 feet 1 inch tall and weighs 235 pounds. His blood pressure is 124/86 mm Hg. Laboratory studies are requested, and all return normal. An EKG reveals a normal QTc and sinus rhythm.

The nurse asks Patient A what he wants to gain in his medication management, and his stated goals are to continue to live with his mother, to avoid future arrest, and to be able to maintain a job. The nurse discusses available typical and atypical oral and decanoate antipsychotics. After a long discussion, Patient A decides to try long-acting injection risperidone (Risperdal Consta). Patient education includes the risks of extrapyramidal reactions (e.g., movement disorders), weight gain, and prolactin elevation, which can lead to gynecomastia, as well as risk mitigation strategies if any of these develop.

A baseline AIMS test is conducted and is negative for any existing issues. The oral trial of risperidone is initiated, as required before using any long-acting injectable to demonstrate tolerance. The patient is titrated up to an oral dosage of 3 mg twice daily, which appears to resolve the patient's paranoia, pressured speech, and hypomania. Patient A reports that he is functioning better, but he reiterates that he does not think he will be able to comply with daily oral medication. The decision is made to progress to long-acting injected risperidone, which requires a three-week overlap with the oral medication.

While there is no exact dosage equivalency, the manufacturer recommends that a 6-mg total oral daily dose of risperidone should be converted to a bimonthly injectable dose of 37.5–50 mg long-acting risperidone. The patient is started at 37.5 mg IM every two weeks. After three weeks, the patient is stable and able to wean off the oral risperidone, decreasing to 4 mg in two divided doses for three days, then 2 mg in divided doses for three days, before total cessation. During this time, the nurse maintains frequent contact with Patient A to verify stability and compliance.

After six weeks, laboratory studies are ordered, including blood glucose level, lipids, and prolactin level, and a repeat EKG is done. All findings are normal. The nurse continues to administer the AIMS test every three months and to check weight and vital signs at every visit. While Patient A continues with this therapy, laboratory values are rechecked every three to six months.

Patient A responds well to treatment and is able to remain living with his mother. After six months, he has gained employment at a fast-food restaurant and has avoided any contact with law enforcement.

Patient B, 46 years of age, presents with a history of mild-to-moderate depression for the past six months. He has been undergoing cognitive-behavioral therapy, and while he has made some gains, he continues to experience depressive symptoms, as documented by a mood map and reports from his therapist. In addition, he is overweight and complains of insomnia.

The nurse does a complete psychiatric history and orders baseline laboratory studies and EKG. The patient reports no history of suicidal ideation and has never been hospitalized. He states that he is functioning well in his job but has been unable to maintain a steady relationship, despite a desire to have a long-term partner.

Patient B's main complaints are depressed mood and insomnia. He does not endorse anxiety or panic attacks and denies any drug or tobacco use. The patient is relatively healthy, has received regular medical care, and does not take any other medications. He has no history of seizure disorder. After a long discussion with the patient, the nurse decides to start a trial of sertraline 50 mg/day and trazodone 25 mg at night.

Patient B returns in two weeks and reports that his sleep has improved and the medications are well tolerated. He agrees to return in four more weeks to determine if the medications are helping his mood, which currently has not improved. During that period, he will continue working with his therapist weekly. The nurse and therapist are in good communication, with an understanding that any changes in symptoms or tolerability should be shared immediately.

After four weeks, Patient B comes back to the office. His mood is still described as depressed by both him and his therapist, so the sertraline dosage is increased to 100 mg/day, with a plan for the patient to return in one month.

When Patient B returns in four weeks, he reports that he is feeling better and has been going out and socializing. However, he is experiencing sexual side effects (erectile dysfunction). Several options are discussed, including transitioning from sertraline to a trial of bupropion or adding a trial of sildenafil. The patient decides that he would like to switch to bupropion, because he does not like the idea of having to take another medication.

After decreasing the dose of sertraline to 50 mg for two weeks, the patient is stable and plans are made to discontinue the sertraline and start bupropion (Wellbutrin XR) 150 mg every morning. When Patient B presents in two weeks, he is happy with the new medication, reporting full resolution of the sexual side effects, but reports some residual depressed mood. The dose of bupropion is increased to 300 mg every morning.

In another four weeks, Patient B's depression is in remission and his sleep quality is significantly improved. The medications remain well-tolerated. The patient also notes that he has lost about 5 pounds, which he attributes to decreased appetite. The patient continues to work with his therapist and agrees to return monthly for at least the next three months for continued monitoring.

Patient C, 23 years of age, presents with a history of increasing mood instability, with periods of depression lasting three to four months followed by periods of increasing disorganization, lack of need for sleep, and risky behaviors (e.g., gambling, shoplifting). After her third shoplifting arrest, Patient C agreed to a plea deal that requires her to seek and comply with psychiatric care.

The clinician conducts a full psychiatric history that is significant for school and employment problems. She attempted outpatient treatment at 16 and 21 years of age, both of which were ended by the patient due to her dislike for medications and their side effects and a perceived "loss of energy" when treatment was initiated with olanzapine during a manic episode at 19 years of age.

The workup reveals a healthy woman, normal laboratory studies, normal EKG, and no medical problems. She is gravida 0 para 0 and has a progestin intrauterine device for birth control. She describes her current mood as depressed, rated 3 on a Likert scale. She describes hypersomnia, sleeping about 10 hours per day. She is currently unemployed and living with her parents. She denies any psychotic symptoms and has never attempted suicide. The patient feels her parents are supportive but firm in stating that she must engage in treatment to continue living with them. She is a nonsmoker and has no known drug use, other than occasional cannabis (less than once per week), which she does not view as problematic. She has genetic loading, with an uncle and a sister who have been diagnosed with bipolar disorder.

Patient C is currently not seeing a therapist or receiving psychotherapy. In discussing goals of care, her main goal is compliance with her probation stipulations. She also indicates that she would like to be employed and to eventually move out of her parents' house. Weight gain is identified as an intolerable side effect of pharmacotherapy; the patient states she would like to lose weight. After much discussion, Patient C agrees to see a social worker for cognitive support and to assist with employment goals.

Given the patient's goals and concerns, antipsychotics are determined to be undesirable. The clinician and patient discuss the risks and benefits of valproic acid and lithium. Patient C states that her uncle did well on lithium and that she would like to try it. In preparation for lithium prescription, the patient's thyroid hormone and calcium levels are reviewed along with kidney function; all are normal. Patient C expresses a strong desire to take pills only once per day and does not think she can remember to take a morning dose. The clinician reviews literature, which indicates that once daily dosing of lithium results in similar efficacy, with lower total doses, decreased renal toxicity, and decreased urinary frequency [91]. The patient is started on controlled-release lithium 450 mg taken at night. Eventually, she is titrated to 900 mg daily, with an average serum lithium level of 0.7 mEq/L.

As part of the patient education process, the clinician emphasizes the need for reliable birth control, as lithium crosses the placenta and is associated with serious fetal malformations following exposure in the first trimester [92]. This conversation is documented fully, including a recommendation that the patient use dual birth control (e.g., add condoms). The need to use a different medication during any planned pregnancy is reviewed.

After 12 months of therapy, Patient C has not experienced any episodes of mania. However, she describes her mood as depressed and complains of amotivation, sadness, hypersomnia, and a 10-pound weight gain. Her lithium level is stable and within the therapeutic range, and the clinician is concerned that raising the lithium dose could increase the risk of toxicity.

To address these issues, bupropion (Wellbutrin XL) 150 mg/day is added to the patient's regimen. Augmentation with low-dose bupropion appears to have the lowest risk of inducing mania among available antidepressants [93]. In six weeks, Patient C reports a gradual improvement in mood, a slight weight loss (2 to 3 pounds), and no signs or symptoms of mania. She continues to meet with her social worker and has attained employment as a front desk clerk at a hotel. She is pursuing her goal of living independently and has had no further contact with law enforcement.

Patient D, 33 years of age, presents with a chief complaint of anxiety. He describes increasing anxiety symptoms for the last eight months, including persistent worrying that he finds challenging to control, overthinking plans, inability to let go of a worry, difficulty concentrating, fatigue, difficulty falling asleep, irritability, and nervousness. He is employed as a corrections officer with two young children. A medical workup is normal. He has engaged with a therapist for the past three months, and while he has made some gains with cognitive-behavioral therapy, his therapist has suggested a medication consultation to help with his ongoing symptoms.

Upon review of symptoms and consultation with the patient's therapist, a diagnosis of generalized anxiety disorder is confirmed. The clinician discusses goals of care with the patient; he states that he wants to avoid the medication side effects of daytime sedation or impaired concentration due to his job. Available medications are reviewed, and the decision is made to start escitalopram to address the continued symptoms of generalized anxiety. Treatment is initiated at a daily dose of 10 mg. Patient D asks about alprazolam (Xanax), as a friend told him that this medication worked for him. The clinician spends time on patient education explaining that alprazolam has a known risk of addiction and a potential for sedation. The patient agrees to the trial of escitalopram.

When Patient D returns for follow-up in four weeks, he reports improvement in his anxiety symptoms and is continuing his cognitive-behavioral therapy. After three months, the patient indicates that his symptoms are manageable and he has not experienced any adverse effects of the pharmacotherapy.

Patient E, 54 years of age, presents with active opioid use disorder. He began using prescription opioids for back pain after having served in the infantry. His usage eventually resulted in his leaving military service prior to retirement, and he currently works in construction. The patient reports having relied on prescription opioids until three years ago, when he started using heroin. He buys 10 bundles per day of what is described as heroin but is most likely synthetic fentanyl. He has accidentally overdosed on two occasions, and emergency medical services used naloxone nasal spray to revive him. He is seeking care at an intensive outpatient program for treatment.

After reviewing goals of care with the patient, the clinician identifies that he has residual chronic back pain in addition to cravings for opioids when not using. The patient is diagnosed with opioid use disorder.

Patient E states that he recently sought care for his back pain and was referred to physical therapy and advised to take nonsteroidal anti-inflammatory drugs (NSAIDs) as needed for pain management. The possibility of methadone maintenance is discussed, but the patient does not want to have to go daily for dosing and is afraid that it will impair his ability to work around heavy machinery. Safety issues are also reviewed, and nasal naloxone is prescribed for emergency use. The patient's partner receives education on use as well.

The patient states he does not wish to take a medication, but he starts attending daily 12-step meetings and working with a drug counselor. Within five days, Patient E is able to successfully complete detoxification. However, after about six weeks he experiences a relapse. His partner administers nasal naloxone after finding him unconscious.

When Patient E returns for follow-up, various options for medication-assisted therapy are discussed, and he decides to enroll in buprenorphine/naloxone therapy, with a goal of eventually being maintained on monthly buprenorphine injection. The clinician emphasizes the need for continued counseling and the need to understand that, like all chronic diseases, patients with opioid use disorder are subject to relapse. The patient is advised of the importance of seeking help early in the event of a relapse. The biologic basis of substance use disorder is stressed; there is no judgement or shame.

Patient E does well on buprenorphine/naloxone therapy and is attending physical therapy for his back pain. He has continued with regular 12-step meetings and individual psychotherapy. At each follow-up appointment, the need to keep naloxone nasal spray available for emergency use is emphasized.