Assessing And Treating Patient With Bipolar Disorder

Case Overview

A 26 years old Korean female presents with a fantastic mood and inability to sleep because it is no longer fun. This is her first appointment 21 days post hospitalization due to bipolar I disorder. on examination, the patient is restless and fidgeting. She has inappropriate dressing for the appointment (wearing an evening gown)Assessing And Treating Patient With Bipolar Disorder. Her speech is rapid, pressured, and tangential with a broad affect and euthymic mood. Her insight is impaired. However, she denies auditory and visual hallucinations. She has no homicidal and suicidal ideation. In addition, she is not delusional or paranoid.

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Bipolar

Bipolar is a severe and persistent mental illness with manic and depressive phases. It has periods of prolonged and profound depression alternating with excessive irritability. Manic episodes consist of profound mood disturbance, irritability, expansiveness, and elation. The classical symptoms are reduced need for sleep, pressured speech or excessive talking, flight of ideas or racing thoughts, excessive pleasurable activities associated with painful consequences, grandiosity, and distractibility (Carvalho, et al, 2020). These symptoms last for over one week. Hypomanic or the depressive phase presents with reduced interest or pleasure, insomnia or hypersomnia, psychomotor retardation, loss of energy, excessive guilt, preoccupation with death or suicide, and feeding disturbance. Bipolar type one presents with symptoms of manic episodes for one week that leads to hospitalization or significant impairment in occupational and social functioning. However, substance abuse or other medical illnesses cannot aggravate manic episodes Assessing And Treating Patient With Bipolar Disorder.

Causes are genetic predisposition, pharmacological, environmental stress, psychodynamic, neurophysiologic, and biochemical factors. Bipolar equally affects both men and women. However, the highest incidence is in females above 21years old. Treatment methods for bipolar disorder are pharmacotherapy and psychotherapy. Psychotherapy improves the quality of life, improves symptoms, and increases functioning. Medication for treating bipolar disorder includes benzodiazepines, anti-manic agents, anticonvulsants, antipsychotics, and dopamine agonists. Drugs improve the patient’s symptoms and increase the function of the patient. Factors affecting the effectiveness of a drug are diet, comorbidities, age, weight, drug interactions, and genetics. Factors such as the patient’s genetics affect drug metabolism and transport, and the target drug increases the risk for adverse effects.

The patient has bipolar because she has diminished interest in sleep, excessive pleasurable activities like playing with things on the desk, shifting from one side of the desk and chair, excessive talking, and singing. She is oddly dressed for the appointment (wearing an evening gown)Assessing And Treating Patient With Bipolar Disorder. Her speech is rapid, pressured, and tangential. Her mood is euthymic and broad affect. The patient’s Young Mania Rating Scale (YMRS) score is 22 showing mild bipolar. She was on lithium and could not comply with treatment. In this paper, I will describe the three decisions for treatment and the impact of ethical consideration. For this patient, the genetic predisposition CYP2D6*10 allele influences the patient prescription.

Decision #1

Which decision did you select?

Begin Seroquel XR 300mg orally at HS

Why did you select this decision?

Seroquel XR is a second-generation antidepressant FDA-approved for treating schizophrenia, acute mania episodes, and adjunct treatment in major depression. It reduces the positive and negative symptoms of bipolar by antagonizing multiple neurotransmitters in the brain. It blocks the dopamine D1 D2 receptors (Abdyrakhmanova, et al, 2021)Assessing And Treating Patient With Bipolar Disorder. The drug has 100% bioavailability with both immediate and extended-release and its metabolism takes place in the liver by the enzyme CYP3A4. It has effects such as weight gain, somnolence, dry mouth, constipation, and weight gain. I chose this drug because it improves the symptoms of acute manic disorder. It does not have adverse effects intolerable to the patient.

Why did you not select the other two options provided in the exercise?

Lithium is a mood-stabilizing medication FDA-approved for bipolar and acute hypomanic disorders. It is effective in reducing the effects of bipolar and schizophrenia. It also reduces the severity and frequency of mania and the risk of suicidal attempts and ideation (Rybakowski, J. K. 2018). However, I did not select lithium because the patient does not comply with it. It has adverse effects such as confusion, loss of memory, tremors, muscle weakness, and headache. In addition, the drug is excreted in the kidneys thus increasing the risk for renal injury. Risperdal 1mg is a second-generation antipsychotic FDA-approved for psychosis, schizophrenia, and bipolar. It has a peak plasma time of six hours and 70% bioavailability. I did select this drug because the patient has a CYP2D6*10 allele in her genetic testing (Wilcox, et al, 2019)Assessing And Treating Patient With Bipolar Disorder. CYP2D6*10 allele blocks the metabolism of risperidone thus increasing its plasma exposure. Increased bioavailability or plasma exposure increases the risk for adverse effects and reduces the drug response.

What were you hoping to achieve by making this decision?

I was hoping to reduce the patient’s symptoms (diminished interest in sleep, excessive pleasurable activities, euthymic mood, and pressured speech). Improve the young mania rating scale. Seroquel is an antipsychotic that works on the positive and negative symptoms in a patient with mood disorders.

Explain how ethical considerations may impact your treatment plan and communication with patients.

Ethical principles are the values influencing nursing practice. These principles are beneficence, non-maleficence, consent, respect for autonomy, justice and fairness, and integrity (McCradden, et al, 2020). The patient’s symptoms have not improved since discharge. In addition, she does not comply with the medication given at the time of discharge. As the PNP, I will practice beneficence by prescribing a safer drug with no side effects. For example, I did not prescribe Risperdal 1mg because it is not effective for the patient since she has the CYP2D6*10 allele. Assessing And Treating Patient With Bipolar Disorder

Decision #2

Which decision did you select?

Discontinue Seroquel and start Geodon 40mg orally BID. Administer with a calorie meal.

Why did you select this decision?

Geodon or ziprasidone is an antipsychotic drug FDA approved for bipolar, schizophrenia, and acute agitation. It is an H1-receptor antagonist with somnolence effects to improve the patient’s mood and improves insomnia, behavior, ideation, and energy (Yeh, et al, 2018)Assessing And Treating Patient With Bipolar Disorder. Geodon is 100% bioavailable with a peak plasma time of 8 hours. it is 99% protein bounds and its metabolism is in the liver by the CYP3A4 enzymes. It is taken together with a calorie meal greater than 500 to ensure it has optimum absorption and has a reproducible bioavailability. The drug is effective and has no documented effects.

Why did you not select the other two options provided in the exercise?

Seroquel improved the patient’s symptoms at bet time, decreased the young mania rating scale from 22 to 18, and improved the patient’s mood. However, she complained of gaining weight by about 2 to 3 pounds which she is not comfortable with. In addition, she has had constipation and dry mouth that she did not like. Therefore, I did not increase Seroquel XR to 400mg because it will worsen the patient’s symptoms (weight gain, constipation, and dry mouth)Assessing And Treating Patient With Bipolar Disorder. Continuing with the same drug and counseling the patient regarding ways of preventing constipation is not a good option because the patient will complain of weight gain and dry mouth. In addition, the drug rate of effectiveness is slow, compared to that of Geodon. Geodon improves the patient’s symptoms b 50% and does not have side effects on the patient.

What were you hoping to achieve by making this decision?

I was hoping to reduce the patient’s symptoms (diminished interest in sleep, excessive pleasurable activities, euthymic mood, and pressured speech). Improve the young mania rating scale. In addition, I was hoping to stop weight gain, constipation, and dry mouth.

Explain how ethical considerations may impact your treatment plan and communication with patients.

The principle influencing the decisions in treating a patient with bipolar is non-maleficence. For example, I changed from Seroquel to Geodon because the patient complained of undesirable effects such as weight gain, dryness of the mouth, and constipation. Non-maleficence is avoiding harm to all patients. Chronic constipation is uncomfortable and may lead to hemorrhoids, anal fissures, and colorectal carcinoma. Changing the drug to stop constipation protects the patient from chronic diseases Assessing And Treating Patient With Bipolar Disorder.

Decision #3

Which decision did you select?

Continue with the same dose and reassess after four weeks

Why did you select this decision?

Geodon is an antipsychotic with an established efficiency and effectiveness in bipolar. It improves insomnia, mood, excessive energy, and overall behavior or ideation. In addition, the drug improved the patient’s symptoms by 50% and reduced the young mania rating scale from 22 to 11. The patient did not have additional weight gain, constipation, and dry mouth.

Why did you not select the other two options provided in the exercise?

I did not increase the 60mg BID because it would increase the risk of granulocytosis, leukopenia, and suicidal ideation. There is no need for hastening symptom recovery because it exposes the patient to undesirable side effects. Augmenting with lithium sustained release of 300mg is not the best option for the patient because of adverse side effects like confusion, loss of memory, tremors, muscle weakness, and headache Assessing And Treating Patient With Bipolar Disorder

What were you hoping to achieve by making this decision?

Improve the patient’s symptoms gradually with no side effects.

Explain how ethical considerations may impact your treatment plan and communication with patients.

The ethical principle I would apply in this section is respect for autonomy. Autonomy is allowing the patients to make an informed decision regarding their treatment. The patient’s symptoms have improved and I will educate them about the illness, symptoms, complications, side effects, and treatment methods. I would advise on the importance of compliance with medicine and the need for psychotherapy.

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Conclusion

Bipolar is a common severe and persistent mental illness with manic and depressive phases. It has periods of prolonged and profound depression alternating with excessive irritability. Bipolar type one presents with symptoms of manic episodes for one week that leads to hospitalization or significant impairment in occupational and social functioning. However, substance abuse or other medical illnesses cannot aggravate manic episodes. Medication for treating bipolar disorder includes benzodiazepines, anti-manic agents, anticonvulsants, antipsychotics, and dopamine agonists. However, there are factors affecting drug efficiencies such as drug metabolism, transport, and the target drug increases the risk for adverse effects. The appropriate drug for the patient is Geodon because it achieves the therapeutic goals with no side effects. Lithium is a mood-stabilizing medication with adverse effects such as confusion, loss of memory, tremors, muscle weakness, and headache. Seroquel is an effective antipsychotic with undesirable effects like weight gain, constipation, and dry mouth. Psychotherapy like cognitive-based therapy helps to improve the quality of life, improve symptoms, and increase functioning. Assessing And Treating Patient With Bipolar Disorder

References

Abdyrakhmanova, A. K., Shnayder, N. A., Neznanov, N. G., & Nasyrova, R. F. (2021). Pharmacogenetics of quetiapine. Personalized Psychiatry and Neurology, 1(1), 73-83. https://doi.org/10.52667/2712-9179-2021-1-1-73-83

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66. https://www.nejm.org/doi/full/10.1056/NEJMra1906193

McCradden, M. D., Joshi, S., Anderson, J. A., Mazwi, M., Goldenberg, A., & Zlotnik Shaul, R. (2020). Patient safety and quality improvement: Ethical principles for a regulatory approach to bias in healthcare machine learning. Journal of the American Medical Informatics Association, 27(12), 2024-2027. https://doi.org/10.1093/jamia/ocaa085

Rybakowski, J. K. (2018). Challenging the negative perception of lithium and optimizing its long-term administration. Frontiers in molecular neuroscience, 11, 349. https://doi.org/10.3389/fnmol.2018.00349

Wilcox, M.A., Coppola, D., Bailey, N. et al. Risperdal^® CONSTA^® Needle Detachment. Incidence Rates Before and After Kit Redesign: A Retrospective Study using Electronic Health Records and Natural Language Processing in the Department of Veterans Affairs. Neurol Ther 8, 95–108 (2019). https://doi.org/10.1007/s40120-019-0130-7

Yeh, Y. C., Yu, X., Zhang, C., Hao, W., Du, F., Liu, D., & Gao, X. (2018). Literature review and economic evaluation of oral and intramuscular ziprasidone treatment among patients with schizophrenia in China. General Psychiatry, 31(3). https://doi.org/10.1136%2Fgpsych-2018-100016

CASE SCENARIO: The client is a 26-year-old woman of Korean descent who present to her first appointment following a 21- day hospitalization for the onset of acute mania. She was diagnosed with bipolar 1 disorder. Upon arrival in the office, she is quite ” busy”, playing with things on your desk and shifting from side to side in her chair. She informed you that ” they said I was bipolar, I don’t believe that, do you? I just like to talk, dance, and sing. Did I tell you that I like to cook?” She weighs 110lbs. and is 5ft 5inches. Patient reports ” fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, its 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 out 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 the CYP2D6*10 allele. The 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. The young Mania Rating Scale (YMRS) score is 22. The patient is alert and oriented to person, place, time, and events. She dressed quite oddly-wearing what appears to be an evening gown to her apartment. Speech is rapid, pressured, and tangential. The self-reported mood is euthymic. Affect broad. The patient denies visual or auditory hallucination, no overt delusional thought process is readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation. Assessing And Treating Patient With Bipolar Disorder
DECISION POINT ONE:
Select what the PMHNP should do:
1. Begin Lithium 300mg orally BID
2. Begin Risperdal 1mg orally BID
3.BeginSeroquel XR 300mg orally at HS.
To Prepare for this Assignment:
Review the learning resources, including the medication resources indicated for this week.
Reflect on the psychopharmacology treatments you might recommend for the assessment and treatment of patients requiring bipolar therapy. Be sure to consider factors that may impact the patient’s pharmacokinetic and pharmacodynamic process.
You are required to make three decisions concerning the medication to prescribe to this patient. SEE above medications. At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Make sure you have researched each option before you make your decision. 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 for this patient.
* Decision #1 (1 page)
1. Which decision did you select?
2. Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
3* 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.
4* 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)
5* Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
DECISION #2 (1 Page):Assessing And Treating Patient With Bipolar Disorder
1* Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
2* 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.
3* 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).
4* Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
DECISION #3 ( 1 Page ):
(A)* Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
(B) 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.
(C) What were you hoping to achieve by making this decision? Support your response with references to the learning resources ( including the primary literature).

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(D) Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
CONCLUSION (1 Page):Assessing And Treating Patient With Bipolar Disorder
1. Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendation and support your response with clinically and patient-specific resources including the primary literature. Support your rationale with a minimum of five academic resources. You should be utilizing the primary and secondary literature. Reminder: The college requires all papers submitted to include a title page, introduction, summary, and references. Please answer all parts of the assignment questions with no spelling or grammar errors using APA writing rules and style. Assessing And Treating Patient With Bipolar Disorder