Finding Balance with Bipolar Disorder

Bipolar therapy: Background Information: Case study analysis of a client, 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 weighs 110 lbs. and is 5’ 5” Finding Balance with Bipolar Disorder

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 Gene Sight testing) as none of the medications that they were treating her with seemed to work.

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Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.

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.

Decision Point one:

Select what you would do?

1-Begin Lithium 300mg orally BID

2-Begin Risperdal 1mg orally BID

3-Begin Seroquel XR 100mg orally at HS.

Note: 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.

QUESTIONS:

-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. Finding Balance with Bipolar Disorder

-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)

• 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. Finding Balance with Bipolar Disorder

Case Study Analysis

Introduction

This assignment focuses on a 26-year-old woman who had a diagnosis of bipolar 1 disorder.  The main symptoms of bipolar disorder include abnormal mood changes and energy changes that impact the ability of an individual to carry out activities of daily living. Specifically, bipolar 1 disorder is characterized by a cyclic pattern of mania and depression episodes. Maniac episodes are characterized by elevated mood and high energy that leads to abnormal behavior that disrupts the activities of daily living. The manic episode stays for around 7 days and a serious manic episode may necessitate immediate hospitalization. The common abnormal behaviors during manic episodes encompass high energy levels, inflated self-image, hyperactivity, lack of sleep, excessive talking, impulse buying, substance abuse, and hypersexuality (Chakrabarti, 2016). The client presented for her first assessment after she was hospitalized for 21 days following an acute mania episode. The client reported that she was having sleep problems as she sleeps for about 5 hours per night and her self-reported mood was fantastic. Generally, she is in good health and the laboratory findings were within the normal limits. The genetic testing indicated that she was positive for the CYP2D6*10 allele. The client reported that she discontinued her lithium treatment. The mental status exam indicated that her speech was rapid, with impaired insight, broad affect, and euthymic mood. This paper will thus analyze and select three treatment decisions for the client and provide a rationale for choosing those decisions. Additionally, ethical considerations that will be affecting the selected decisions will be discussed.

Decision Point One

The chosen decision is for the client to start taking lithium 300 mg. The reason for choosing this decision is because the client had discontinued the medication and hence the efficacy of lithium has not been fully evaluated. Lithium is a first-line medication and the most appropriate mood stabilizer used when treating bipolar, particularly bipolar 1. Lithium improves the metabolism of catecholamines and serotonin, and this assists to improve symptoms of bipolar disorder and stabilizes the mood (Alda, 2015). The reason why Risperdal was not chosen is because as per the genetic testing, the client is positive for the CYP2D6 gene. Therefore, the client has a decreased capability to metabolize risperidone, leading to reduced efficacy, and also the patient may be at a higher risk of experiencing side effects with risperidone since she is positive for the CYP2D6 gene (Puangpetch et al., 2016). Additionally, Seroquel was not considered since she is already taking lithium, the first-line medication for bipolar, and lithium’s efficacy has not been evaluated since the client discontinued the medication.

By selecting lithium, it is hoped that she would start manifesting symptom improvement. This is because lithium has been demonstrated to be effective in improving mania symptoms in people with bipolar type 1 disorder (Alda, 2015). Another expectation is that she would tolerate lithium and not have any side effects.

However, after four weeks, the client did not report any symptom improvement. She was also not complying with the prescribed treatment regimen. Therefore, the lack of symptom improvement is attributable to poor adherence to treatment.

For ethical considerations, the PMHNP needs to take into account that manic episodes can impair the client’s ability to make appropriate treatment decisions. It is therefore important to evaluate the client’s decision-making ability and at the same time respect her autonomy. Informed consent should be sought from her to enable her to make informed decisions. Her confidentiality should be respected where her diagnosis and treatment should not be disclosed to unauthorized parties (Richa et al., 2018).

Decision Point Two

The client was not adhering to the prescribed treatment regimen and hence it is important to assess why the client is not adhering to the prescribed treatment and have her educated regarding the side effects and pharmacology of lithium medication. Poor adherence to the treatment regimen is common among patients diagnosed with bipolar disorder. The decision to have the lithium dose increased to 450 mg was not considered since the client is already showing nonadherence to lithium medication. Therefore, without proper adherence, it is difficult to evaluate the effective lithium dose for the client. On the other hand, Depakote was not chosen since the efficacy of lithium which is the first-line treatment choice for bipolar was not evaluated because the client is not adhering to the prescribed lithium dose (Alda, 2015). Finding Balance with Bipolar Disorder

By choosing this decision, the expectation is that the cause of the client’s poor adherence to lithium medication will be identified. This will enable the client to adhere to the prescribed treatment and eventually achieve symptom improvement.

However, after four weeks, the client reported that she was experiencing side effects such as nausea and diarrhea and these side effects were compromising her ability to adhere to lithium. Diarrhea and nausea are common side effects of lithium (Chakrabarti et al., 2019).

The ethical principle applicable to this decision is beneficence (Stone, 2018). The decision that was selected took into account the client’s best interests, which was to identify the cause of nonadherence for her and hence facilitate adherence and eventually ensure that the client attains complete symptom remission.

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Decision Point Three

The reason for the client’s non-adherence to treatment was identified as due to the side effects such as diarrhea and nausea. Therefore, the third decision selected for the client was to have the lithium treatment changed to sustained-release preparation. According to Girardi et al (2016) extended-release, lithium formulations are effective mood stabilizers and effective in improving acute mania symptoms. Additionally, extended-release lithium formulation improves adherence due to few side effects. Depakote was not considered since the efficacy of lithium for this client has not been evaluated because she has not been adhering to the treatment regimen. Trileptal was not considered because it is a second-line treatment choice in the treatment of bipolar disorder and therefore the medication cannot be prescribed before examining the efficacy of the first-line treatment choice for bipolar disorder (lithium).

Selection of extended-release lithium formulation expects that the client will adhere to the prescribed treatment regimen and therefore manifest notable symptom improvement. Secondly, it is anticipated that the client would not experience side effects such as nausea and diarrhea. This is due to the efficacy of extended-release lithium formulation in improving symptoms of acute mania bipolar and also due to its few side effects (Girardi et al., 2016).

The ethical principle applicable to this decision is beneficence (Stone, 2018). The decision that was selected took into account the client’s best interests, which was to have the client administered with an extended-release lithium formulation in order to improve her treatment adherence and ensure symptom improvement.

Conclusion

The diagnosis for this client is bipolar type 1 disorder. She presented for assessment after 21-day admission, following an acute mania episode. The client reported that she had discontinued the lithium medication. Therefore, the decision that was selected was for this client to begin lithium 300 mg. Lithium is the first-line treatment option when treating bipolar type 1 disorder, and also lithium has been demonstrated to be effective in the treatment of acute mania episodes. However, after four weeks the symptoms did not improve and the client reported that she was not adhering to lithium treatment. Therefore, the second decision was to evaluate the client and find out the reasons for nonadherence and educate her regarding the side effects associated with lithium as well as the pharmacology of lithium. The client reported that she was having side effects like nausea and diarrhea and these side effects were causing nonadherence. Therefore, the third decision involved changing to lithium sustained-release preparation because this form of lithium has few side effects, and thus this would improve her treatment adherence. With this decision, it was hoped that she would start adhering to the prescribed treatment and as a result, lead to symptom improvement. Before starting treatment, it would be appropriate to obtain informed consent from the client. Moreover, people with bipolar disorder and experiencing manic episodes may have an impaired judgment which may impair their decision-making ability. Therefore, it would be important to evaluate the client and at the same time respect her autonomy. The PMHNP should uphold the ethical principle of beneficence and act as per the client’s best interests. Finding Balance with Bipolar Disorder

References

Alda M. (2015). Lithium in the treatment of bipolar disorder: pharmacology and pharmacogenetics. Molecular psychiatry, 20(6), 661–670. https://doi.org/10.1038/mp.2015.4

Chakrabarti S. (2016). Treatment-adherence in bipolar disorder: A patient-centered approach. World J Psychiatry, 6(4), 399–409.

Girardi, P., Brugnoli, R., Manfredi, G., & Sani, G. (2016). Lithium in Bipolar Disorder: Optimizing Therapy Using Prolonged-Release Formulations. Drugs in R&D, 16(4), 293–302. https://doi.org/10.1007/s40268-016-0139-7.

Puangpetch, A., Vanwong, N., Nuntamool, N., Hongkaew, Y., Chamnanphon, M., & Sukasem, C. (2016). CYP2D6 polymorphisms and their influence on risperidone treatment. Pharmacogenomics and personalized medicine, 9, 131–147. https://doi.org/10.2147/PGPM.S107772.

Richa S, Chammaya A, Dargelb C & Masson M. (2018). Ethical considerations in bipolar disorders. Science Direct, 1(1).

Stone E. G. (2018). Evidence-Based Medicine and Bioethics: Implications for Health Care Organizations, Clinicians, and Patients. The Permanente Journal, 22, 18-030. https://doi.org/10.7812/TPP/18-030 Finding Balance with Bipolar Disorder