Treatment-Resistant Bipolar Disorder

Assessing and Treating Clients with Bipolar Disorder

Introduction

Bipolar disorder is a mental disorder that is mainly characterized by manic/hypomanic and depressive symptoms. Bipolar disorder is associated with a high risk of cognitive disabilities and high suicidal risk (Jauhar & Young, 2019).  The manic episodes have symptoms such as high energy levels, euphoria, racing mind, lack of sleep, engaging in risky behaviors, and poor concentration. Depressive symptoms are typified by symptoms like poor concentrating, sadness, fatigue, forgetfulness, social withdrawal, sleep problems, among other depressive symptoms.

The patient in this case study is a 26-year-old female who had been admitted to the hospital for acute mania. She presented for her first appointment after discharge and reported that she was feeling fantastic and she was sleepless. According to the medical documentation, her physical health was okay, while the lab findings were normal. According to genetic testing, she was positive for the CYP2D6*10 allele. The client also reported she did not comply with the lithium treatment while the MSE indicated that her mood was euthymic, having a broad affect, while her speech was rapid. Her insight appeared impaired, but her judgment was intact. She scored 22 for the YMRS. The purpose of this paper is to review the case study and select the treatment decisions for the client. The ethics relevant to the chosen treatment decisions will be discussed.Treatment-Resistant Bipolar Disorder

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Decision Point One

The client should start Lithium 300 mg orally BID. This is because lithium is an effective mood stabilizer and it is approved by the FDA as the first-line treatment choice to treat manic-depressive symptoms. Risperdal was not selected even if it is approved by the FDA to treat manic-depressive symptoms due to its many metabolic effects and poor tolerance (Jauhar & Young, 2019). Seroquel was not chosen since the client has started lithium treatment but had not been adherence and hence the efficacy of lithium should be evaluated before changing the medication.

The treatment goal was for the client to attain symptom remission, through gradual symptom improvement. This is due to lithium’s efficacy as a mood stabilizer, thus improves bipolar symptoms (Volkmann et al., 2020). It was also expected the client would adhere to lithium medication and tolerate the medication, as well.

However, when the client presented for review after four weeks, there was no symptom improvement. She reported that she did not adhere to lithium medication as this is the reason why the was no symptom improvement.

Ethical principles relevant to this decision encompass informed consent and patient autonomy. The PMHNP should obtain informed consent before administering any treatment and respect her autonomy because her mental impairment is not very severe (Richaa et al., 2017).

Decision Point Two

The appropriate decision is to have the client’s reason for non-adherence assessed to identify the reason for non-adherence and have her educated regarding lithium. Jawad et al (2018) explain that non-adherence among people with bipolar is common and because sudden discontinuation of lithium medication results in symptom relapse, it is vital to assess her reasons for nonadherence (Baldessarini & Tondo, 2019). The decision to increase the lithium dose to 450 mg was not selected because the efficacy of the lithium start dose has not been examined. Depakote was not chosen since it is important to first determine the efficacy of lithium before changing the medication (Stahl, 2019).

The treatment goal included identifying the reason for her nonadherence to help improve adherence in order to facilitate symptom improvement.

When she returned after four weeks, she reported that side effects like diarrhea and nausea were attributable to the nonadherence. These are common side effects of lithium medication (Chakrabarti, 2018).

The ethical principle relevant to this decision is beneficence. When selecting this decision, the PMHNP aimed to address the client’s best interests by exploring the reason for her nonadherence to facilitate adherence to treatment (Richaa et al., 2017).

Decision Point Three

The client should be administered with a sustained-release preparation. Sustained-release preparation has few side effects and therefore this will improve her adherence and therefore result in symptom improvement. Depakote was not chosen since the client is not adhering to treatment therefore the efficacy of lithium should be evaluated before changing medication. Similarly, Trileptal was not chosen as it is a second-line treatment choice in bipolar and thus the efficacy of lithium should be examined before changing treatment (McCormick et al., 2015).Treatment-Resistant Bipolar Disorder

The treatment goal for this decision is to ensure the client attains symptom remission, with minimal side effects since the side effects were the main reason for nonadherence. Sustained-release preparation is associated with few side effects.

Informed consent is the ethical principle relevant to this treatment decision. Before changing to a sustained-release preparation, the PMHNP should explain to the client about this lithium preparation to ensure that she makes an informed treatment choice (Richaa et al., 2017).

 Conclusion

The first decision was administering the client with lithium 300 mg since the medication is a first-line treatment choice for bipolar 1 disorder. The client was not adhering to the treatment and thus the second decision involved exploring the reasons for her nonadherence and educating her about lithium medication. The side effects were causing the nonadherence and hence the third decision was to change to a sustained-release lithium preparation because it has few side effects and thus will lead to treatment adherence. Ethical principles relevant to the treatment decisions include informed consent, patient autonomy, and beneficence.

References

Baldessarini, R. J., & Tondo, L. (2019). Effects of treatment discontinuation in clinical psychopharmacology. Psychotherapy and psychosomatics, 88(2), 65-70.

Chakrabarti S. (2018). Treatment alliance and adherence in bipolar disorder. World J Psychiatry, 8(5), 114–124.

Jauhar S & Young A. (2019). Controversies in bipolar disorder; the role of second-generation antipsychotic for maintenance therapy. Int J Bipolar Disorder, 7(10).

Jawad I, Watson S, Peter H, Peter T & William H. (2018). Medication nonadherence in bipolar disorder: a narrative review. Ther Adv Psychopharmacology, 8(12), 349–363.

McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 27(9), 530–542. https://doi.org/10.1002/2327-6924.12275

Richaa S, Chammaya A, Dargel C & Masson H. (2017). Ethical considerations in bipolar disorders. Encéphale. xxx–xxx.

Volkmann, C., Bschor, T., & Köhler, S. (2020). Lithium Treatment Over the Lifespan in Bipolar Disorders. Frontiers in psychiatry, 11, 377. https://doi.org/10.3389/fpsyt.2020.00377 Treatment-Resistant Bipolar Disorder