Psychopharmacology for Bipolar Essay.

Psychopharmacology for Bipolar

Introduction

The focus of this assignment is on a 26-year-old woman diagnosed with bipolar 1 disorder. Bipolar disorder is typified by abnormal mood changes, energy changes, and changes in the ability to perform activities of daily living. Specifically, symptoms of bipolar 1 disorder include maniac episodes that last for about seven days or serious maniac symptoms that require immediate hospitalization (Chakrabarti, 2016).Psychopharmacology for Bipolar Essay.

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The client in this case study presented for her first appointment after 21-day hospital admission due to an episode of acute mania. She also reported sad mood and sleep problems. The MSE findings showed rapid speech, broad affect, impaired insight, and euthymic mood. Genetic testing showed she was positive for the CYP2D6*10 allele. The paper will discuss three decisions about the treatment plan for the client and discuss ethical considerations likely to affect the client’s treatment plan.Psychopharmacology for Bipolar Essay.

Decision-Point One

Begin Risperdal 1mg orally BID

Reason for Choosing the Decision

Risperdal was selected because it can be used as a monotherapy in the treatment of acute mania for people with bipolar. According to Ashok et al (2017), Risperdal works by balancing serotonin and dopamine within the brain and thus improves mood, thinking, and behavior and hence its efficacy in improving bipolar symptoms. Secondly, Risperdal is safe and well-tolerated because of fewer extrapyramidal effects. The option of lithium 300 mg was not chosen due to the severe side effects associated with the medication (Alda, 2015). The client reported that she was not adhering to lithium medication and this could be due to the medication’s side effects. The option of Seroquel was not chosen due to side effects such as dizziness, weight gain, dry mouth, sedation that may lead to nonadherence to treatment (Chiang & Lan, 2018).  Psychopharmacology for Bipolar Essay.

Expected Outcomes

The selection of Risperdal expected that the client would exhibit symptom improvements such as improved mood, behaviors, and balanced energy levels. This is due to the medication’s efficacy in treating mania symptoms in individuals having bipolar type 1 disorder (Ashok et al., 2017). It is also expected that the client would not experience side effects.Psychopharmacology for Bipolar Essay.

Differences between Expected and Actual Outcomes

However, the client did not manifest major symptom improvement, apart from mood improvement. The client also experienced side effects such as fatigue and sedation. Risperdal is associated with sedative effects. The genetic testing indicated that the client was positive for the CYP2D6 gene; this means she has a reduced ability to metabolize Risperdal and may also be at an increased risk of adverse effects such as sedation after taking Risperdal (Puangpetch et al., 2016).

Decision Point Two

The decision made is reducing Risperdal to 1mg HS

Reason for Selecting the Decision

The decision to reduce the Risperdal dose was selected because individuals positive for the CYP2D6 gene have a reduced ability to metabolize Risperdal and may also be at an increased risk of adverse effects (Puangpetch et al., 2016). Therefore, reduce the dose of Risperdal will lower the concentration of the medication within the blood system and thus reduce the side effects associated with the medication. The decision to increase the Risperdal dose to 2 mg orally HS was not selected due to the increased side effects with the medication for people positive for the CYP2D6 gene(Puangpetch et al., 2016). The choice to change to lithium was not chosen because the client has not been adhering to lithium treatment.Psychopharmacology for Bipolar Essay.

Expected Outcomes

The key aim of reducing the Risperdal dose is to lower the side effects the client manifests. With the reduced dose, there will be less concentration of the drug in the body system and thus the client will experience lesser side effects such as reduced sedation or lethargy (Puangpetch et al., 2016). It is also expected that the client will report significant symptom improvement.

Difference between Expected and Actual Outcome

As expected, the client, the side effects reduced as indicated by reduced sedation and reduced lethargy. This is due to improved clearance of the medication from the blood system leading to reduced side effects (Puangpetch et al., 2016). Additionally, the symptoms significantly reduced as per the client’s report as per the mania rating scale, there was a 25% symptom reduction.Psychopharmacology for Bipolar Essay.

Decision Point Three

Continue the dose of Risperdal and assess after four weeks

Reason for Selecting the Decision

The decision to continue with the same dose was selected because the client was responding to Risperdal’s reduced dose and with minimal side effects. The decision to increase Risperdal to 1 mg orally was not selected due to the likelihood of increased side effects such as lethargy and sedation. The client is positive for the CYP2D6 gene and thus has a reduced ability to metabolize risperidone and at an increased risk of adverse effects after taking Risperdal (Puangpetch et al., 2016). Therefore, increasing the dose of Risperdal for the client is not a good decision. The option to change to Latuda was not selected because Latuda is effective in treating bipolar I depression yet the client manifests manic symptoms.Psychopharmacology for Bipolar Essay.

Expected Outcomes

It is expected that with this treatment choice, the client will manifest significant symptom improvement and eventually attain full symptom remission. Secondly, it is hoped that she would tolerate the dose and not experience any side effects.

Ethical Considerations

People with bipolar disorder tend to have manic episodes that can impair their ability to make treatment decisions. Therefore, the PMHNP should take into consideration the ability of the client to decide about his treatment decisions without interfering with her autonomy(Richa et al., 2018). The PMHNP should also seek informed consent from the client before starting any treatment. The issue of confidentiality is also important during the treatment of this client. When the client experiences acute symptomatic episodes, her health information can be disclosed to a third party due to her inability to make treatment decisions (Richa et al., 2018).

Conclusion

The client was diagnosed with bipolar type 1 disorder, with acute mania episodes. The first treatment decision is for the client to begin Risperdal 1mg orally BID. However, the client experienced side effects such as sedation and lethargy and thus the second decision was to reduce the dose to Risperdal to 1mg HS. The third decision was to continue with the same dose of Risperdal and have the client examined after four weeks. Ethical considerations applicable to this client include the ability to make treatment decisions, confidentiality issues, and autonomy.Psychopharmacology for Bipolar Essay.

Managing Bipolar Disorder

Bipolar disorder is a mood disorder that affects a person’s behaviors, attention, energy level and mood (Diniz et al., 2017). It present with recurring manic and depressive episodes that make it hard for a person to lead a stable, productive life. The depressive phase renders one unable to do anything at all whereas the manic phase makes one irresponsible and hyperactive. It is essential to get an early diagnosis and treatment to avoid the devastating effects of the disease.Psychopharmacology for Bipolar Essay. The procedures can be executed by an experienced mental health professional. To explore more on the management of bipolar disorder a case study will be used. The case is of a woman of Korean descent aged 26 years. She has been hospitalized for acute mania and appear “busy”. She has a rapid and pressured speech and she states that her hobbies are cooking, singing, dancing and talking.  She states that sleep is no fun and her health outlook is perfect. She, however, has a CYP2D6*10 allele and confesses that she stopped taking her lithium (Laureate Media, 2016f). She is dressed oddly and has impaired insight. She, however, denies suicidal or homicidal ideation. The paper will use a decision tree to recommend pharmacological agents for the patient and will outline ethical considerations guiding the treatment plan.Psychopharmacology for Bipolar Essay.

Decision-Point One

Begin Risperdal 1mg orally BID

Why the Decision

Risperdal can be used as a monotherapy in the management of bipolar mania. The drug has demonstrated efficacy and generally good tolerability. It produces positive mood effects through its potent antagonism of the alpha-adrenergic receptors, dopamine D2 and serotonin 5-HT2A (Vasquez & Bobo, 2020). It works by treating mania and reducing mood switch from mania to depression or cycling. It has lower incidences of extrapyramidal systems and significantly delays the time to relapse of any mood episode compared to placebo.Psychopharmacology for Bipolar Essay. Lithium 300mg BID orally is avoided because of its adverse effects. It is linked to cognitive dysfunction which occurs as mental slowness and precipitates nonadherence (Berk et al., 2017). Additionally, the patient has confessed that she stopped taking lithium an indication of poor adherence to the medication. Seroquel is equally rejected due to its probability of inducing side effects via the muscarinic receptors (Berk et al., 2017). The drug causes weight gain, constipation, dizziness, sleepiness, sedation and dry mouth all of which may negatively impact the patient and result in compliance issues.

Expected Outcomes

The patient should improve adequately. She should report improved mood, behaviors, attention and energy levels (Vasquez & Bobo, 2020). She should be able to execute her activities of daily life. The medication should handle her symptoms and she should report no adverse events.

Differences between Expected and Actual Outcomes

The patient appears to be experiencing some adverse events towards the medication. The mother supports her into the clinic and she appears sedated and lethargic (Laureate Media, 2016f). The mother reports that her condition has persisted in the last three weeks although her mood has improved. Sedation is a common side effect of Risperdal however the patient has a CYP2D6*10 allele which could be delaying the clearance of the medicine in her system (Jukic et al., 2019).Psychopharmacology for Bipolar Essay.

Decision Point Two

The decision made is reducing Risperdal to 1mg HS

Why the Decision

Research indicates that patients who are positive for *10 alleles have decreased metabolism and clearance of risperidone(Jukic et al., 2019). Generally, risperidone is cleared through CYP 2D6 alleles and CYP3A4 although to a lesser extent. Poor metabolizers have low CYP2D6 activity which results in less metabolic conversion. To optimize conversion and reduce the concentration of the drug in the blood system, there is a need to lower the dosage. With increased clearance, the adverse events experienced by the patient will reduce. Increasing the dosage to 2mg orally HS is avoided because of the poor conversion and metabolism. Increased dosage translates into increased accumulation of the drug resulting in increased lethargy and sedation. Changing the drug to lithium is also avoided because the patient has compliance issues. Risperdal is also normally tapered off rather than being stopped abruptly to avoid intense withdrawal symptoms (Vasquez & Bobo, 2020).Psychopharmacology for Bipolar Essay.

Expected Outcomes

The main aim of the second decision is to reduce the adverse symptoms experienced while handling the disease symptoms. The reduced dosage of Risperdal should optimize conversion and reduce accumulation in the body resulting in lesser episodes of sedation and lethargy (Jukic et al., 2019). The patient should report a better score on the YMRS scale with a reduction in symptoms of above 25%.Psychopharmacology for Bipolar Essay.

Difference between Expected and Actual Outcome

The client met the set expectations. The reduced dosage resulted in better clearance and helped in reducing sedation and lethargy. The patient also had a positive therapeutic response since her symptoms improved as indicated by the YMRS score of 16 (Laureate Media, 2016f). The score indicated that the disease symptoms reduced by more than 25%.Psychopharmacology for Bipolar Essay.

Decision Point Three

Continue the dose of Risperdal and assess after four weeks

Why the Decision

The patient has positively responded to a reduced dosage of Risperdal. The presence of the CYP2D6*10 allele led to poor metabolism of Risperdal and increased its accumulation in the blood (Jukic et al., 2019). The overall effects were sedation and lethargy. Reverting the current dosage to the initial 1mg orally BID will induce sedation and lethargy which have already been managed. Maintaining the dosage is the best decision because it will help the client and clinician achieve the treatment goals which are reducing disease symptoms and managing drug side effects. Lastly, the introduction of Latuda is avoided because the patient has manic symptoms yet Latuda is approved for bipolar I depression (Burt & Nasrallah, 2016).  The drug is equally expensive and insurance companies reserve it as the last resort when other medications have failed.Psychopharmacology for Bipolar Essay.

Expected Outcomes

The disease symptoms should improve further. Additionally, the side effects experienced earlier should be gone. The patient should report better mood and behavior as well as enhanced daily functioning. Her YMRS score should reduce further.Psychopharmacology for Bipolar Essay.

Differences between Expected and Actual Outcomes

The patient presented as expected. The low dosage of Risperdal managed to reduce the plasma concentration of the drug in the blood and helped in arresting the bipolar symptoms. She scored 10 on the YMRS scale indicating that her symptoms had reduced beyond 50%.Psychopharmacology for Bipolar Essay.

Ethical Considerations

Autonomy, non-maleficence, and beneficence are the ethical considerations that govern the management of bipolar disorder (Salagre, Vieta & Grande, 2020). Medications are essential for bipolar patients to lead a stable, productive life. However, any medication selected should balance the risks with benefits. Informed consent should guide the choices to ensure that the patient understands available treatment options and their risk and benefits. Due to the cyclic nature of bipolar, patients have poor insight which reduces their ability to consent and make rational decisions (Salagre, Vieta & Grande, 2020). Additionally, disease symptoms like irritability and delusion can affect the therapeutic relationship and patients may feel relieved indicating a need to stop the treatment. All these factors create conflict between the treatment goals and patient autonomy and should be handled well. Psychopharmacology for Bipolar Essay.