Assessing and Treating Patients with Bipolar Disorder – Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder

Assignment: Assessing and Treating Patients With Bipolar Disorder. 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.

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; 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.

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.

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
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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.

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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.

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.

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.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.

Assessing and Treating Patients with Bipolar Disorder

Introduction to the Case

The case concerns a woman of Korean descent, 26 years old, and having acute mania. She is in for an appointment following a 21-day hospitalization since her diagnosis.  She seems to be distracted, fiddling with the things on her desk and moving from one side of the chair to the other. Patients with acute mania exhibit high energy levels, talkativeness, belligerent, and positive self-esteem (Freudenreich & Goff 2016; Perlis & Ostacher, 2016). She says she was told she is bipolar, but she does not believe the diagnosis. She asks whether the attending practitioner believes she could be bipolar. She tells the practitioner that she likes to talk, dance and sing, and asks whether she had informed the practitioner that she likes to cook. Bodyweight and height measurements reveal she weighs 110 lbs with a high of 5’5”.

The patient reports that she is in a fantastic mood, sleeps approximately 5hrs every night, and mentions that she detest sleeping. The patient has overall good health from her medical workup as tests test results were within standard limits. The patient had shown a positive response to GeneSight testing medication, and the cofounding results reveal she has CYP2D6* ten alleles. The patient further confesses that she had stopped taking the prescribed medication, Lithium, for about two weeks.

Furthermore, the patient’s mental tests show that she is psychologically aware of her surroundings. She is, however, dressed unusually and talks in a quick, pressured, and tangential way. She is in a euthymic state, with no visible or audible symptoms and no obvious psychotic or paranoid thinking patterns. Her judgment seems to be in proper working order, but her insight is hampered. Furthermore, she is reportedly rejecting any suicide feelings. The Young Mania Rating Scale gives a score of 22 for manic symptoms.

Decision One

I chose to select Risperdal 1 mg orally BID. Risperdal is a generic antipsychotic that has proven to be highly effective in managing bipolar disorders. It influences a rebalance in serotonin and dopamine, resulting in good behavior and is readily accessible (Culpepper, 2014). However, the patient will be monitored for oversedation because antipsychotics have a longer half live, thus takes time to sequestrate the parts (Freudenreich & Goff, 2016).

Lithium 300mg was not chosen since the patient had initially stopped medicating herself with it, and there were high chances she would not adhere to a higher dosage of the same medication. On the other hand, Seroquel XR was not chosen since it causes weight gain, constipation, and severe dry mouth, leading to tooth decay, limiting therapeutic goals (John & Antai-Otong, 2016).  Such side effects can cause the patient to stop medication leading to withdrawal lasting several days (Stahl, 2014).

This prescription aims to reduce the symptoms and stabilize the patient’s mental state, limiting self-destructive activities, tension, and response appropriately t0 the environment and with people. Equally, the patient is expected to restful and carry out daily routine with little difficulty. Risperdal influences mental action and improves the patient’s rational capacity (John & Antai-Otong, 2016). However, they returned to the clinic exhibiting high sedation and lethargy and with reduced self-destructive activities.

 The patient’s sedation could be due to Risperdal’s longer half-life or the slow rate of Risperdal’s clearance from the patient’s body system since she is positive for CYP2D6*10 (Chen et al., 2015). Ethically, it is critical to inform the patient of the positive and side effects of medication. The impairment of insight and judgment that is always characterized by mania and mood episodes may render a patient not able to provide informed consent nor incapable of making rational decisions regarding their treatment. Another ethical consideration is to inform the patient and their representative of the available medical intervention to contribute to their care.

Decision Point Two

I chose to reduce Risperdal to 1mg at HS.  Since the patient exhibited high signs of lethargy and sedation, it was crucial to reduce the dosage to allow the patient’s body system to metabolize within the prescription timeline. Freudenreich & Goff (2016) mentions that the CYP2D6 condition causes slow metabolism of paliperidone, which is the active metabolite of Risperdal, leading to sedation. Therefore, reducing the dosage would mitigate lethargy and sedation (Culpepper, 2014).

The option to increase Risperdal to 2mg at HS was not selected since the patient experienced sedation and lethargy with a relatively lower dosage of the same drug. Therefore increasing Risperdal dosage would not produce positive health outcomes. It is better to start at a low dose and increase the dosage as necessary. On the other hand, changing the dosage to Lithium 300mg orally would not suffice since the patient would possibly stop medicating herself due to a negative attitude.

The goal of lowering Risperdal to 1 mg was to effectively manage the symptoms of bipolar disorder by influencing a balance in serotonin and dopamine to help address a patient’s self-destructive behaviors (Fang et al., 2017).  Besides, the dosage was reduced to limit side effects of lethargy and sedation. This was to enable the body to clear Risperdal from the blood effectively. As expected, the patient’s symptoms reduced by 25%, and she showed no sign of lethargy and sedation. This is because the dosage was optimal enough to reduce maniac symptoms and low enough to be effectively cleared from the bloodstream. Equally, the optimal dosage of Risperdal has been shown to effectively treat bipolar disorder with manageable side effects (John & Antai-Otong, 2016).

Ethically, the practitioner must support the patient to encourage their adaptation to the same medication’s alternative dosage. This would improve their compliance, trust, and understanding of the mechanism with which medication work (John & Antai-Otong, 2016). As such, they will be able to achieve their treatment goals.

Decision Point Three

I chose to continue the dosage and reassess after four weeks. My choice was founded by the patient’s positive response to medication and limited side effects. With the patient responding well to the dosage, it is expected that her condition will continue to improve. Therefore, maintaining this dosage and reassessing the client after four weeks will help achieve the treatment goals for both the client and the attending mental health practitioner.

Increasing the dosage to 1mg orally, BID was not chosen because it would have cause lethargy and sedation due to the slow metabolism of paliperidone and associated side effects. Latuda 40mg daily was not chosen because it is costly. Besides, Lauda is approved for managing bipolar I depression, which is different from the patient’s clinical expression. Moreover, Latuda is costly, and most health insurance companies would decline to pay for it until other drugs have been attempted and proven to fail (John & Antai-Otong, 2016).

The expectation was that the patient would continue to respond to the medication to eliminate at least 50 percent of the symptoms before the next appointment. Besides, it was expected that the patient would show no side effects of the medication, have a good state of mind, conduct and thoughts. The actual outcome signified the patient’s expectations as the patient showed positive progress with minimal side effects, proving that the medication and dosage choice were optimal for managing her condition.

The medication was ethically justified considering the patient responded well without any significant side effects and symptoms. A mental healthcare provider should consider giving the patient some of the best available management options to maximize treatment benefits (Ratheesh et al., 2017). However, the patient’s ethnic origin, Asia, could have influenced medication choice since the culture tends to shy away from people diagnosed with mental illnesses (Wang, 2015; Ryu et al., 2017).  Wang further argues that family problems are dealt with secretly rather than seeking counseling from professionals. It is critical for the practitioner to educate the patient and the mother of the origin and effects of mental illnesses and the importance of psychotherapy in mitigating cultural dynamics that affect those diagnosed with mental disorders.

Patients diagnosed with CYP2D6 tend to respond differently to medication compared to those who test negative to CYP2D6. CYP2D6 limits the elimination of Risperdal from the blood, whose high concentration is toxic (Salloum et al., 2014). As such, it is crucial to include close monitoring as part of the treatment plan. Studies have also shown that people of Asian descent tend to test positive for CYP2D6. Thus they should be treated and monitored to prevent adverse effects such as seen in this case study.

References

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

Culpepper, L. (2014). The diagnosis and treatment of bipolar disorder: decision-making in primary care. The primary care companion for CNS disorders, 16(3).

Fang, F., Wang, Z., Wu, R., Calabrese, J. R., & Gao, K. (2017). Is there a ‘weight neutral second-generation antipsychotics for bipolar disorder? Expert review of Neurotherapeutics, 17(4), 407-418. https://doi.org/10.1080/14737175.2016.1276284

Freudenreich, O., & Goff, D.C. (2016). Psychotic Patients. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital Psychopharmacology and neurotherapeutics (pp. 119-129). Elsevier. https://www.ncbi.nlm.nih.gov/books/NBK425795/ 

John, R. L., & Antai-Otong, D. (2016). Contemporary Treatment Approaches to Major Depression and Bipolar Disorders. Nursing Clinics, 51(2), 335-351.

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.

Ratheesh, A., Cotton, S. M., Davey, C. G., Adams, S., Bechdolf, A., Macneil, C., & McGorry, P. D. (2017). Ethical considerations in preventive interventions for bipolar disorder. Early intervention in psychiatry, 11(2), 104-112. Assessing and Treating Clients with With Bipolar Disorder Essay. https://doi.10.1111/eip.12340

Ryu, S., Park, S., Lee, J. H., Kim, Y. R., Na, H. S., Lim, H. S., … & Choi, S. E. (2017). A study on CYP2C19 and CYP2D6 polymorphic effects on pharmacokinetics and pharmacodynamics of amitriptyline in healthy Koreans. Clinical and translational science, 10(2), 93-101. https://doi.10.1111/cts.12451

Salloum, N. C., McCarthy, M. J., Leckband, S. G., & Kelsoe, J. R. (2014). Towards the clinical implementation of pharmacogenetics in bipolar disorder. BMC medicine, 12, 90. https://doi.10.1186/1741-7015-12-90

Stahl, S. M. (2014). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.

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