• Your patient is a 36-year-old woman with bipolar disorder and anxiety. She has been stable on a combination of fluoxetine and olanzapine for two years.  She is morbidly obese at 340 pounds at 5’5” in height, has type II diabetes, hypertension, and hyperlipidemia.  She has concerns about her weight and has tried numerous ‘fad diets’ to no avail.  She explains she has lost, at most, 15 pounds and has been able to keep it off for three months. 
• She has three children, one of which is severely disabled, and a husband who has a terminal diagnosis. She expresses worry that her weight will impact her ability to care for her disabled child when her husband dies.  She reports she eats out frequently due to her children’s busy schedules.  She is a stay-at-home mother but gets little exercise and performs no regular physical activity. 
• She reports feelings of shame that she can no longer orgasm on the rare occasions her husband has the energy and desire to be intimate.

Questions: 

• What would be your approach to managing this patient’s weight concern? (Discuss at least two aspects of your approach). Please support your answer with research-based evidence. 
• What would be our approach to the sexual side effects she is experiencing? 
• If you suggested additional medication, look up your state’s prescribing laws. Are PMHNP’s able to prescribe the medication you recommended?