Other / General Medicine
Caroline Jones, BA
Medical Student
University of Miami
Miami, Florida, United States
Simran Prakash, BA
Medical Student
University of Miami Miller School of Medicine
Miami, Florida, United States
Shemar Crawford, MD
Resident Physician
UMiami
Miami, Florida, United States
Jose Vives-Alvarado, MD
Attending Physician
University of Miami
Miami, Florida, United States
Caroline Jones, BA
University of Miami
Miami, Florida, United States
 The patient underwent T7-pelvis laminectomy and fusion for intractable back pain and was admitted for acute inpatient rehabilitation. On day 3, she developed insomnia, disorganized speech, and perseveration. Psychiatry evaluation diagnosed acute decompensation of her pre-existing mood disorder with hypomanic features. She remained on the rehabilitation floor, as inpatient psychiatric admission was not feasible.
She was started on lithium 300 mg BID and olanzapine 15 mg QHS, initially worsening and later developing signs concerning for lithium toxicity. Her regimen was transitioned to valproate 500 mg BID and olanzapine 5 mg AM/20 mg QHS, leading to improvement but persistent distractibility and disorganized thoughts.
Initially unable to participate meaningfully in therapy, her engagement improved with mood stabilization, optimized pain management, and behavioral strategies including frequent verbal and tactile cues, activity choice, and seating near the nursing station to reduce agitation and enhance adherence to spinal precautions.
Discussions:
By optimizing psychiatric and pain medications and implementing behavioral strategies in therapy sessions, this patient was able to participate in inpatient rehabilitation despite acute decompensation of her chronic mood disorder. Functionally at the time of discharge, she improved from maximum to minimal assist for sit-to-stand, increased her standing tolerance to 10 minutes with the use of a rolling walker and improved from total assist for TLSO management to requiring only moderate assistance. She improved from total assist to moderate assist for lower body dressing and was able to perform grooming and oral hygiene with supervision.
Conclusions:
Adequate medical management of psychiatric conditions improves patients’ inpatient rehab experience by reducing psychiatric symptoms and withdrawal, improving stability and facilitating engagement in therapy and other treatments. A combination of medication, therapy, and other lifestyle changes can be more effective than medication or therapy alone.
