Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder .

PLEASE I WILL PREFER WRITER 1747 TO COMPLETE THIS ASSIGNMENT. PLEASE FOCUS ON THE RUBRIC. COPY AND PASTE THE LINK BELOW FOR THE CASE STUDY https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/index.html 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. RUBRICS 1)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. 2)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. 3)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. 4)Decision #3 (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. 5)Conclusion (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. Optional Learning Resources Required Readings (click to expand/reduce) 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. Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

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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.).Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder 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

Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

Bipolar I disorder is a neuropsychiatric condition that belongs to the diagnostic category known as ‘Bipolar and Related Disorders’. This is found in the fifth and latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The other disorders in this diagnostic category include cyclothymic disorder and bipolar II disorder (Sadock et al., 2015; APA, 2013). The symptomatology of bipolar I disorder falls between that of depressive disorders and schizophrenia spectrum disorders and other psychotic disorders. As per the American Nurses Association or ANA standards of practice, bipolar I disorder is a condition that can be managed by the psychiatric-mental health nurse practitioner or PMHNP through assessment, prescription, therapy, and follow up (ANA, 2014). This paper is about the decision on psychopharmacologic management of a 26 year-old woman of Korean descent with a diagnosis of bipolar I disorder and a problem of non-compliance to treatment.Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

Background

This 26 year-old woman is of Korean ancestry and just presented herself for her first follow-up visit after 21 days of hospitalization. She had been diagnosed with bipolar I disorder after presenting with acute mania. Objective observation in the office by the PMHNP revealed that she was hyperactive, talkative, and elated. Subjectively, she reported feeling ‘fantastic’ and admitted to insomnia. Laboratory tests and physical evaluation indicated that she was in good health with no underlying physical/ medical condition that could explain her symptoms. Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I DisorderGene testing had revealed that the client was positive for the CYP2D6*10 allele. This is the gene responsible for the translation of the cytochrome P450 isoenzyme 2D6 that metabolizes risperidone. In Asians, there is a pair of the gene that shows decreased function. For this reason, Asians (such as the client who has Korean ancestry) are susceptible to having higher plasma levels of risperidone even after therapeutic dose administration. This means that they are at risk of developing serious adverse effects of the drug such as sustained sedation (Dean, 2017).Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

On discharge from the hospital, the client had been put on lithium. However, she was showing early signs of non-compliance to treatment as she claimed during this first follow-up visit that she had stopped taking the medication. It was now two weeks since she decided to stop taking the lithium. Her mental status examination is reflective of bipolar I disorder, with euthymic mood, rapid and tangential speech, inappropriate grooming, intact judgement and impaired insight. She denied homicidal or suicidal ideation during this visit. Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I DisorderThe PMHNP assessed the level of severity of her mania using the Young Mania Rating Scale or YMRS. She scored a baseline of 22 points which meant that she was having mild mania (Mohammadi et al., 2018; Clinicaltrials.gov, 2012). On this scale, scores range from 0 to 60. The higher the score, the more severe the mania and the lower it is the higher the likelihood of remission. Actual remission is shown by scores less of than 12, mild mania is 20-25 points, moderate mania 26-37 points, and severe mania 38-60 points (Mohammadi et al., 2018; Clinicaltrials.gov, 2012). The subsequent YMRS scores would be compared to the baseline score of 22 points to determine remission or otherwise. A decrease from this baseline would indicate an improvement in the symptoms of mania in the client.Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

Decision Point 1: The Choice of Psychopharmacologic Agent

When it came to deciding on the best drug that would be prescribed for the client to reduce her manic symptoms, the decision was made to begin her post discharge on lithium (Eskalith) 300 mg orally twice daily. The reason why this decision was selected was that lithium is FDA-approved for the treatment of mania (Stahl, 2017). Available evidence-based practice (EBP) indicators also show that lithium has a higher chance of controlling the mania and also reduces the risk of suicidality substantially (Stahl, 2017; Stahl, 2013). The reasons as to why the other two options were not selected are also informed by evidence-based practice.Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

It has been stated in the introduction that the client is Asian with Korean ancestry. This means that she carries two inactive copies of the gene CYP2D6*10 making her unable to properly metabolize risperidone (Risperdal). For this reason, the choice of starting her on risperidone 1 mg orally twice daily was not considered.Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder If given this medication, she would have developed symptoms of overdose such as sustained sedation due to high plasma levels of the active metabolite. On the other hand, the other option of starting her on quetiapine (Seroquel XR) 100 mg orally at bedtime was also rejected due to the risk of severe side effects. The drug has got debilitating side effects such as dry mouth and constipation that would have made the already non-compliant client even more non-compliant. What was hoped by taking this decision was that in four weeks the lithium would have started helping to reduce the manic symptoms as shown by a reduction in the YMRS scores from the baseline. Ethically, the treatment chosen is based on the goal of giving the client the most benefit (beneficence) and avoiding giving them what will cause problems (nonmaleficence) such as the Seroquel XR.Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

Decision Point 2: Next Decision Following 4 Weeks of Treatment with Lithium

This was the second follow-up visit for the client after discharge from the hospital. She had been taking the lithium for four weeks now and an assessment needed to be made on the progress of the treatment. Unfortunately, the client again reported erratic compliance with the medication. This made it difficult to correctly assess the effectiveness and efficiency of the lithium in reducing her manic symptoms. Her symptoms on this day were still the same as they were on the first visit four weeks ago. The decision taken at this point was to assess the client for the reasons as to why she was not complying with treatment. Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I DisorderThe objective was to educate her on the dangers of noncompliance, the expected side effects of drugs and what to do when they occur, and the actions of the drugs. This decision was selected because it was the right one. It could not be said that the lithium was ineffective because the patient had not been taking it as required. Also, changing the medication to another one would not have meant that the client would now comply. It was therefore necessary to find out the cause for noncompliance first before proceeding. This also involved counseling and psychoeducation (Corey, 2017). The other two options were not taken because the patient would still have not complied anyway. What was hoped to be achieved by this decision was to get the client to comply with treatment and get the full benefits of the lithium. Ethically, the patient needed not to feel that they were being forced to take treatment. She still needed to feel that she was part of the decision on her fate with regard to her treatment. Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I DisorderThat is what the bioethical principle of autonomy is all about.

Decision Point 3: Assessing for Response to Treatment after Patient Education and Counseling

            After another four weeks the client returned for evaluation again. This time there was better compliance and the lithium had started showing some of its usual side effects in the form of nausea and diarrhea. Unfortunately, because of these symptoms the client had been forced to stop for a while until the symptoms subsided. Overall, however; the client seemed to be responding to the treatment with lithium. Because of the side effects showing in the client, the decision taken at this point was to change the lithium to a sustained release preparation. The dose and frequency was however left as before. Evidence-based practice informs that a change of lithium to the extended release formulation usually has the effect of preventing the side effects and stabilizing the mood better (Stahl, 2017). This is the reason why this decision was taken.Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

The other two options were not selected for specific clinical practice reasons. The choice of Depakote (sodium valproate) is usually made only when the sustained release preparation of the lithium fails to control the side effects. That was not yet the case. As for Trileptal (oxcarbazepine), it could not be considered at this juncture because it is a second line drug. First line medications had not yet been exhausted. What was hoped to be achieved was a full response by the client to the sustained release lithium with freedom from side effects. The expectation was that in the next four weeks, she would have a YMRS score of at least 13-19 points below the baseline at the next visit in 4 weeks. The ethics of this was that the patient would be given the maximum benefit they can derive from the therapy (beneficence). They would also remain part and parcel of their treatment decision as dictated by autonomy.Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder

Conclusion

Bipolar I disorder is characterized by mania or manic episodes during which the patient is hyperactive, talkative, and elated. Treatment is informed by the pharmacodynamic and pharmacokinetic profiles of medications as well as evidence-based practice. The characteristics of the patient also play a role in the treatment decision. For instance, the fact that the client in this case study was Asian with Korean ancestry determined that she had a gene that made it difficult to break down risperidone. For this reason, it would have been unethical to prescribe this drug for her knowing this information. The most beneficial and well-informed decision taken in this case was to give the patient lithium. The initial non-response was most likely due to her non-compliance.    Psychopharmaclogic Treatment of a 26 Year-Old Woman of Korean Descent Diagnosed with Bipolar I Disorder