Assessing and Treating Patients with Bipolar Disorder Essay Paper

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Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for patients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) patients often present as depressive or manic but may have both; and 2) many symptoms of bipolar disorder are similar to other disorders. Misdiagnosis is common, making it essential for you to have a deep understanding of the disorder’s pathophysiology. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with bipolar disorder.

To prepare for this Assignment:
Review this week’s Learning Resources, including the Medication Resources indicated for this week.
Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring bipolar therapy. Assessing and Treating Patients with Bipolar Disorder Essay Paper

BACKGROUND INFORMATION
The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.
Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”
She weights 110 lbs. and is 5’ 5”

SUBJECTIVE
Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”
You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.
Genetic testing reveals that she is positive for CYP2D6*10 allele.
Patient did well enough on Lithium to be discharged from the hospital but admits she has not been taking it as prescribed. When further questioned on the subject, she provides no additional details.

MENTAL STATUS EXAM
The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.
The Young Mania Rating Scale (YMRS) score is 22

The Assignment: 5 pages
Examine Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

My Assessments Answers:
Decision Point One
Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE
Client returns to clinic in four weeks
Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”
Today’s presentation is similar to the first day you met her

Decision Point Two
Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology
RESULTS OF DECISION POINT TWO
Client returns to clinic in four weeks
Client states that the drug makes her nauseated and gives her diarrhea
Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again

Decision Point Three
Change Lithium to sustained release preparation at same dose and frequency
Guidance to Student
In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.
Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Resources:
Decision Point One

Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”
Today’s presentation is similar to the first day you met her
Decision Point Two

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Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology
RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client states that the drug makes her nauseated and gives her diarrhea
Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again
Decision Point Three

Change Lithium to sustained release preparation at same dose and frequency
Guidance to Student
In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.

Decision Point One

Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE

Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology
RESULTS OF DECISION POINT TWO

Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE

Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology
RESULTS OF DECISION POINT TWO

Resources:

Ostacher, M. J., & Hsin, H. (2016). The use of antiepileptic drugs in psychiatry. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 93–98). Elsevier.

Perlis, R. H., & Ostacher, M. J. (2016a). Bipolar disorder. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 48–60). Elsevier.

Perlis, R. H., & Ostacher, M. J. (2016b). Lithium and its role in psychiatry. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 86–92). Elsevier.

Traeger, L., Brennan, M. M., & Herman, J. B. (2016). Treatment adherence. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 20–26). Elsevier.

American Psychiatric Association. (2010b). Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf

Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: Comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835–841. https://doi.org/10.1007/s00228-015-1855-6

Hirschfeld, R. M. A. (n.d.). Guideline watch: Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar-watch.pdf

Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331–333. https://doi.org/10.1007/s40263-013-0060-3 Assessing and Treating Patients with Bipolar Disorder Essay Paper

Assignment: Assessing and Treating Patients with Bipolar Disorder

Mental illnesses occur in different forms where they also differ according to the intensity of their symptoms. Bipolar is one of the mental illnesses that is associated with impacting cognitive impairment, shifts in mood swings and self-esteem as well as the sleeping patterns of an individual (Bartoli et al., 2017). There are numerous causes of bipolar disorder where the US records 2.8% of bipolar cases in the whole population. However, despite the percentage being significantly small, about 83% of these patients are diagnosed with severe cases of bipolar. Bipolar is also categorized as a chronic disorder due to its recurring nature. The presented case study concerns a 26years old Korean woman who visits the clinic after being hospitalized for 21 consecutive days with acute mania. The patient’s sight is damaged but is still alert. Any thoughts of committing suicide are not admitted by the patient. Her judgement and mood are intact and happy respectively. She also has a speedy speech and appears energetic and hyperactive. One of the major test that was done to the patient revealed a CYP2D6*10 allele. The woman’s CYP2D6 allele result will be essential if recommended with medications such as beta blockers and opioids, antidepressants, antiarrhythmic, antipsychotics and tricyclic drugs. According to Traeger et al (2016), A tremendous variation in the functionality of CYP2D6 enzymes is impacted by the genetic polymorphism in CYP2D6. The aim of this paper is to detail the three possible decisions that I might consider as a healthcare provider to initiate the treatment of the patient in the case study.

Decision #1

My initial choice was for the patient to begin taking Lithium 300 mg orally BID after realizing that it was among the prescribed medication during the 21days that she had been hospitalized. Furthermore, the patient had well-responded to the medication to a point of being discharged but under some dose of maintenance. Lithium is a medication that restores balance to certain neurotransmitters in the brain thereby impacting treatment to some maniac bipolar symptoms such as mood swings as well as extreme behavior reduction (Madhusoodanan, Reddy & Mohan, 2017). The medication is also essential considering that the patient was found to have CYP2D6*10 Allele which is more prone to her Asian population. The test is a clear indicator of reduced functionality of alleles which correlates to clearance of antipsychotic drug clearance such as the risperidone, hence Seroquel would be ruled out. Some of the common side effects that were as a result of influence of CYP2D6 Genetic polymorphisms that plays essential role in 9-hydroxyrisperidone, concentration of iron plasma variability and risperidone required risperidone to be used in an adjustable dosage.

While making the initial decision of administering the lithium medication to the patient, my aim was to make the patient regain the status she had acquired during the time of her initial discharge. The major aim of treatment by use of lithium medication is to reduce the effects of mania through treatment of individual symptoms, where the treatment should continue until when improvements are stable and consistent to avoid recurring cases of the disease (Traeger et al., 2016). On returning to the clinic after 4weeks, there was totally no change that was recorded from her initial visit. The patient admits to be taking the medication only whenever she feels like. The patient’s non-compliance to take the medication as per instructed was the major reason for her condition not improving.

Decision #2

After observing the level of ignorance of the patient towards taking her medication, my second decision would be to address the reasons of her non-compliance to medications. Furthermore, I would educate her on the importance of acting in accordance to the prescribed medication. At first I would explain to the patient that lithium medication had gained a higher level of efficacy in her body since she had used it before and hence resulted to her feeling euthymic. I would also educate the patient on the dangers of discontinuing the medication abruptly after a continued use. Lithium is a very sensitive medication that if one suddenly ceases from taking after a continued use, it results to recurrence of the mania symptoms (Ostacher & Hsin, 2016). I would also inform her that it was the main reason why she had initially visited me in the clinic after being discharged from the hospital. I would also inform her that her bipolar condition was so stable and that stopping the medication abruptly would result to higher chance of recurrence of the bipolar disease.

My aim of taking this decision was to help the patient gain the compliance of her medication for more improvements to be observed. However, on returning to the clinic, she complained of diarrhea and nausea as the two major side effects. She was however not consistently taking her medications as was instructed. There was also no significant symptom improvement recorded.

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Decision #3

The third decision would be to change her medication from lithium to Depakote ER 500 mg at HS. While making this decision of changing the medication to Depakote, I thought that the patient would be more compliant to another medication as compared to lithium. It is an improved plan that would hopefully help her gain tolerance and medication compliance to the drug. From the provided student guidance, changing the formulation would help to prevent recurrence of nausea and diarrhea which are the major symptoms that the patient is experiencing (Chen et al., 2015). I agree that considering the bipolar disorder, I would have concentrated on treating individual symptoms. However, my main focus in this particular case study was to make the patient gain relief from the primary disorder that she was experiencing as had indicated earlier when starting on the lithium. I had also been informed by one of my mentors that if any medication has been proven to work, simply don’t stop its use but it would be ok to add or reduce the dosage so long as I have the control. Assessing and Treating Patients with Bipolar Disorder Essay Paper

Ethical considerations

There are various ethical considerations that should be considered in patients suffering from illnesses and disorders where multiple possible treatment options exist. Some of these ethical considerations should include nonmaleficence, beneficence and autonomy. The choice of treatment medication involves occurrence of a risk and benefit at the same time. However, the risk and benefit when making such a decision should always balance. Alternative method is for the healthcare provider to always provide the best available treatment option to help maximize the benefit while at the same time minimizing the risk (Traeger et al., 2016). The judgement impairment characterized by mood and mania disorders may make the patient not to make proper decision making concerning their preferred treatment options. Moreover, other factors such as irritability and delusional thinking could also be a hindrance that destruct the mutual alliance between the client and the healthcare provider (Jawad et al., 2018). There are also instances where the patient may require to know whether to progress with their medications due to the re-lapsing limiting nature of their bipolar disorder and hence such questions should be well acknowledged.

In a recap, bipolar is a very critical disorder that affect a significantly small part of US population but in a severe manner. Patients suffer from the disorder in its lows and highs especially if they fail to comply with the medication prescription from their physician. Many of these patients strive to overcome the stigma associated with bipolar disorder, especially those practicing at professional levels. During the process of determining the best therapeutic approach of treating the 26year old woman in this case study, it was clear that epigenetics can also play a part in impacting some determinants of bipolar. It was through my thorough research on CYP2D6*10 allele in this particular case study that I got to realize the effects of genotypes on pharmacokinetics. It is however also important to always consider the ethical considerations concerning the available treatment options since such patients are not in a situation to make proper decisions of their own.

References

Bartoli, F., Crocamo, C., Clerici, M., & Carra, G. (2017). Allopurinol as add-on treatment for

mania symptoms in bipolar disorder: systematic review and meta-analysis of randomised

controlled trials. The British Journal of Psychiatry, 210(1), 10-15.

https://doi.org/10.1192/bjp.bp.115.180281

Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects

the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects:

Comparison of traditional phenotype and activity score systems. European Journal of

Clinical Pharmacology, 71(7), 835–841. https://doi.org/10.1007/s00228-015-1855-6

Jawad, I., Watson, S., Haddad, P. M., Talbot, P. S., & McAllister-Williams, R. H. (2018).

Medication nonadherence in bipolar disorder: a narrative review. Therapeutic advances

in psychopharmacology, 8(12), 349-363. https://doi.org/10.1177/2045125318804364

Madhusoodanan, S., Reddy, V., & Mohan, S. (2017). Intermittent Transient Motor Aphasia

Associated with Acute Lithium Toxicity: A Case Report and Brief Review. Current Drug

Safety, 12(3), 201-204. https://doi.org/10.2174/1574886312666170601092949

Ostacher, M. J., & Hsin, H. (2016). The use of antiepileptic drugs in psychiatry. In T. A. Stern,

Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital

psychopharmacology and neurotherapeutics (pp. 93–98). Elsevier.

Traeger, L., Brennan, M. M., & Herman, J. B. (2016). Treatment adherence. In T. A. Stern, M.

Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital

psychopharmacology and neurotherapeutics (pp. 20–26). Elsevier.

Assessing and Treating Patients with Bipolar Disorder Essay Paper