Assessing and Treating Clients with Bipolar Disorder

In the opinion of the National Institute of Mental Health (2018), Bipolar disorder is an episodic or chronic mental disorder that occasionally occurs at regular intervals. This disorder often causes extreme fluctuating changes in an individual’s moods, energy, activity, focus, and concentration. Bipolar disorder is also known as manic depressive disorder (Mayo clinic, 2020). Bipolar disorders are characterized by two extreme episodes of mood alterations called mania and depression; these mood alterations are always different from usual mood fluctuations and often require medical attention (American Psychiatric Association, 2020). The high emotional episodes are referred to as mania, while episodes of extreme emotional low are referred to as depression (Bhandari, 2020). The mania episodes are characterized by euphoria, low concentration, and poor judgment, while the depressive episodes are characterized by low energy, loss of interest in activities usually enjoyed. The purpose of this paper is to investigate a case study of a 26-year-old individual who has bipolar and the clinical decisions made for her treatment. The paper will also include ethical consideration and recommendations for treatment Assignment: Assessing and Treating Patients With Bipolar Disorder


Case Study

The client presented is a 26-year-old Korean woman hospitalized 21 days after the episodes of acute mania. She was diagnosed with bipolar I disorder. On the first visit to the office, she appears restless as she busies herself with the things on the desk while fidgeting from side to side on her seat. She soon engages in some conversation, stating that she does not believe her diagnosis of bipolar. She states that she just likes to sing, dance, and talk, and also cook. From her report, she says that her mood is fantastic, and she reports that she does not like to sleep since sleep is no fun. She adds that she sleeps around 5 hours a night. Her weight is about 110 pounds and 5.5″. From the medical records review, her health was in an overall way acceptable, and from the lab results, everything was within the normal limits (Laureate Education, 2016). The patient also had genetic testing done in the hospital. The Gene Sight testing result was positive for the CYP2D6*10 allele (Laureate Education, 2016). She states that she had stopped using lithium, which was prescribed in the hospital after she was discharged two weeks ago.

The decisions towards her treatment are made from the mental exam taken. Her cognitive results indicate that the client is alert, person, place, event, and time oriented. However, she is dressed oddly, as she wears what looked like an evening gown to the appointment. She possesses rapid, pressured, and tangential speech. Euthymic is her self-reported mood. She refutes any form of hallucinations, delusional thoughts, or paranoid thoughts (Laureate Education, 2016). Her judgment is integral, but her insight is impaired. She denies having any form of suicidal or homicidal ideas. From the rating scale, the Young Mania Rating Scale (YMRS), her score is 22, indicating mild mania for the presented client (Dcf. Psychiatry, 2020).

Decision Point One

Aiming towards the client’s treatment, a decision to begin Risperdal 1mg orally BID to treat the bipolar I disorder for this client was made. Risperdal is a prescription medicine used to treat bipolar mania and other bipolar disorders (Stahl, 2014). It is also known as a second-generation antipsychotic (SGA). Risperdal rebalances dopamine and serotonin in improving thinking, behavior, and mood (Delmonte et al., 2016). It works by reducing the number of neurotransmitters available in the brain. Risperdal has been known to stop the reactions of dopamine-2 receptors (D2R), serotonin 2A receptors, and norepinephrine receptors in the brain (Stahl, 2014). These receptors are said to be high in a patient experiencing manic episodes of bipolar one disorder. Hence by blocking the receptors in the brain that are acted upon by dopamine and the effects of decreased dopamine reaction in the brain will help control the manic symptoms in bipolar for this client (Zhang & Stackman Jr, 2015). Risperdal also improves symptoms by coordinating attention, improving sleep, memory, and learning (Bhatia et al., 2020).

In treating manic episodes in bipolar, the first-line drug of administration is lithium (Jauhar & Young, 2019). However, as reported by the client, lithium was prescribed, but she discontinued the use after two weeks of being discharged (Laureate Education, 2016). The client’s symptoms may worsen due to the noncompliance with lithium. The main reason for mania rebounds in bipolar clients is lithium noncompliance (Jauhar & Young 2019). Hence, the decision to use Risperdal as a first line of treatment for the manic episodes in this client is more appropriate.

This treatment decision was aimed at improving the behavioral deficits of the client that suggested manic episodes. For example, she presented with fidgeting, lack of concentration, and tangential speech. The client also dressed in an evening gown while coming for the appointment. According to the American Psychiatric Association (2020), these symptoms showed high dopamine levels, norepinephrine, and serotonin in the brain. The treatment decision to use Risperdal will help regulate dopamine in the Central nervous system; hence improving these symptoms.

The anticipated results of the first decision made included improving manic symptoms that would have been reported and observed at follow up with this patient. However, after four weeks, the client reports back to the office, accompanied by her mother, sedated, and lethargic. From her mother’s explanation, she has been like that since about a week after the last office visit. Although the patient reported improved concentration levels, her appearance indicates possible side effects contrary to the prescribed medication. Although side effects are expected with psychopharmacological agents, this outcome is different from the expected outcomes.

Ethical consideration in caring for this client with bipolar disorder will include informed consent since the client is in a manic state and has poor concentration. The drugs’ side effects always fear committing to a particular treatment plan, resulting in non-effective treatment plans for the patients. It is important for the provider to patiently ensure that the client can understand the course of treatment, possible side effects, and how to recognize and report them. The client is free to ask any questions, accept or decline the treatment (American Medical Association, 2020). If possible, it may be necessary to involve the patient’s medical power of attorney in making treatment decisions.

Decision Point Two

Due to the patient’s response to decision one, Risperdal 1 mg at HS was chosen for the second decision. The client had some signs of improvement four weeks after the drug started but also presented with sedation and lethargy. Although Risperdal may cause drowsiness, genetic testing revealed the presence of CYP2D6*10 alleles in the patient gene, which may have influenced her reaction to the medication, causing her to be sedated and lethargic (Laureate Education, 2016). The decision to change her medication dosage and time was taken to help address the sedation accompanied by a higher dose and help improve symptoms related to bipolar disorder (Jauhar & Young, 2019). Stahl (2014) states that it is often necessary to titrate the Risperdal dose to control mania symptoms.

Reducing the dosage to 1 mg and changing the frequency to once a night was aimed at managing the client’s symptoms without side effects associated with Risperdal toxicity. Also, the Risperdal administered at nighttime will be more appropriate for the client experiencing drowsiness as she could have improved sleep at night and achieve a productive day with daily activities without sedation and lethargy (Jauhar & Young, 2019).

The option to change the medication to lithium would be inappropriate due to the information received on the first visit about the client being non-compliant with lithium, hence, the potential risk of rebound mania (Stahl, 2014). The client also presented with sedation and lethargy while receiving 2mg of Risperdal in divided daily doses; thus, administering 2mg in one dose may worsen the sedation and lethargy, especially for this client, whose genetic testing revealed CYP2D6*10 allele.

The provider’s expected outcomes are a decline in the client’s manic symptoms and recovery from Risperdal’s sedative effects. In the actual result, the client was less sedated and lethargic during the second follow-up visit, suggesting that titrated doses were successful (Laureate Education, 2016). She also had a 25% reduction in mania, with a Young Mania Rating Scale (YMRS) of 16 out of 22 (Dcf. psychiatry, 2020).

The ethical consideration guiding the decision-making for this patient’s treatment plan will be the principle of nonmaleficence. The other scenario options in decision point two are potentially harmful to this patient. Hence providers need to educate the patient and their family about the reason for a change in the treatment plan, emphasizing their potential benefits and disadvantages. Education about the potential risk of Risperdal toxicity in this client cannot be overemphasized. Encourage the family to help with daily medication administration and identification of side effects and how to report them. Instructions should also be given on how to respond in case of overdose/toxicity or unwanted side effects.

Decision Point Three

The second decision yielded immense positive results hence the decision to continue using the Risperdal 1 mg at HS and to reassess in the next four weeks. According to Stahl (2014), maintaining the dosage would ensure close monitoring of the client’s response to the drug. The client also showed improvement on this follow-up visit, implying that the medication was tolerated; hence, the decision to maintain the dose. This treatment option is aimed at improving the symptoms of the patient. Furthermore, the Risperdal dose should be maintained when there are no undesirable side effects until the bipolar symptoms are adequately controlled, this helps prevent manic symptoms from rebounding (Stahl, 2014).

The option of increasing the Risperdal to 1mg orally BID may result in the side effects noted during the first decision. Maintaining the dosage is more suitable since the following assessment indicated that the client had a positive response to this dose. Changing the medication to Latuda would be unnecessary since the current medication and dose have demonstrated a therapeutic effect. Introducing a new drug into the client’s body system at this point increases the potential for unwanted side effects, especially drowsiness, agitation, and lethargy known to be associated with Latuda.

Confidentiality is an important aspect of medical care. Psychiatric illnesses often impact a person’s ability to function in their daily lives, including work, school or relationships. This, in addition to mental illness stigmatization, makes confidentiality for these groups of patients a topmost priority (Healthline, 2020). Patients who can do so should decide who gets information about their treatment and that the decision must be honored. Otherwise, any information about treatment plans should not be shared with anyone except with permission from the patient.

Conclusion

Bipolar disorders are very common mood disorders that affect an individuals ability to function daily. Several factors should be considered in the diagnosis and treatment of patients with bipolar disorders. Pharmacokinetics and pharmacodynamics factors for each individual patient should be considered before choosing psychopharmacological agents, their dosage, route, frequency, and administration time. It is also noted that abruptly noncompliance with medications when treating bipolar disorders can bring unwanted side effects that can be potentially dangerous. Hence Risperdal was chosen over lithium which is a first line of treatment for manic bipolar

Recommendations for the treatment options are to include laboratory diag ostics to help determine a patient’s ability to process a drug, for example, patients with decreased renal and hepatic functions may be prone to toxicity, hence testing before and during the course of treatment is recommended. Although genetic testing had been done on this patient, it was not duly considered in the initial decision making for the treatment of this client. It is important to always consider genetic composition and how they may influence a persons reaction to medications and hence medication choices when planning care. For example, patients who possess the CYP2D allele may have a decreased clearance when taking psychopharmacological agents. Hence the need to consider a smaller dosage or alternatives (Chen et al, 2015). Assignment: Assessing and Treating Patients With Bipolar Disorder

References

American Medical Association. (2020). Informed consent. Retrieved from https://www.ama-assn.org/delivering-care/ethics/informed-consent

American Psychiatric Association. (2020). What Are bipolar disorders? Retrieved from https://www.psychiatry.org/patients-families/bipolar-disorders/what-are-bipolar-disorders

Bhandari, S. (2020). Bipolar I disorder symptoms, treatments, causes, and more. Retrieved from https://www.webmd.com/bipolar-disorder/guide/bipolar-1-disorder#1

Bhatia, A., Lenchner, J. R., & Saadabadi, A. (2020). Biochemistry, dopamine receptors. Treasure Island, FL: StatPearls Publishing.

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. doi:10.1007/s00228-015-1855-6

Dcf.psychiatry.ufl.edu. (2020) Young Mania rating scale. Retrieved from https://dcf.psychiatry.ufl.edu/files/2011/05/Young-Mania-Rating-Scale-Measure-with-background.pdf

Delmonte, D., De Santis, C., Brioschi, S., Barbini, B., & Colombo, C. (2016). Haloperidol,

risperidone and quetiapine in the treatment of acute severe manic episode in bipolar

disorder: The experience at the mood disorder unit in Milan. European

Psychiatry, 33, S125-S126. Assignment: Assessing and Treating Patients With Bipolar Disorder

Jauhar, S., & Young, A. H. (2019). Controversies in bipolar disorder; the role of second-generation antipsychotics for maintenance therapy. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6435763/

Laureate Education. (2016). Case Study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author.

Mayo Clinic (2020). Bipolar disorder – Symptoms and causes. Retrieved from https://www.mayoclinic.org/diseases-conditions/bipolar-disorder/symptoms-causes/syc-20355955

National Alliance on Mental Illness. (2020). Risperidone (Risperdal). Retrieved from https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Risperidone-(Risperdal)

National Institute of Mental Health. (2020). Bipolar Disorder. Retrieved from https://www.nimh.nih.gov/health/topics/bipolar-disorder/index.shtml

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

Zhang, G., & Stackman, Jr., R. W. (2015). The role of serotonin 5-HT2A receptors in memory and cognition. Frontiers in Pharmacology. https://doi.org/10.3389/fphar.2015.00225

Assignment: Assessing and Treating Patients With Bipolar Disorder

// Bipolar Therapy
Bipolar Therapy
Client of Korean Descent/Ancestry
Asian girl

BACKGROUND INFORMATION

The client is 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?” Assignment: Assessing and Treating Patients With Bipolar Disorder

She weights 110 lbs. and is 5’ 5” Assignment: Assessing and Treating Patients 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 GeneSight testing) as none of the medications that they were treating her with seemed to work.

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. Assignment: Assessing and Treating Patients With Bipolar Disorder

The Young Mania Rating Scale (YMRS) score is 22

RESOURCES

§ 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. doi:10.1007/s00228-015-1855-6 v

Decision Point One

Select what you should do:
Begin Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 100 mg orally at HS
Assignment: Assessing and Treating Patients With Bipolar Disorder
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; and 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. Assignment: Assessing and Treating Patients 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. Assignment: Assessing and Treating Patients With Bipolar Disorder
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). Assignment: Assessing and Treating Patients With Bipolar Disorder
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). Assignment: Assessing and Treating Patients With Bipolar Disorder
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). Assignment: Assessing and Treating Patients With Bipolar Disorder
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. Assignment: Assessing and Treating Patients With Bipolar Disorder
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. Assignment: Assessing and Treating Patients With Bipolar Disorder

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