Examine Case Study: An Asian American Woman With Bipolar Disorder – NURS 6630

Examine Case Study: An Asian American Woman With Bipolar Disorder – NURS 6630

Examine Case Study: An Asian American Woman With Bipolar Disorder – NURS 6630

The DSM V describes Bipolar disorder as a group of mental disorders that result in extreme fluctuation in an individual’s mood, energy, and functioning. Bipolar disorder presents with intervals of deep, prolonged, and profound depression that alternate with intervals of mania characterized by an excessively elevated or irritable mood (APA, 2013). A manic episode represents a significant change from usual behavior. It manifests with at least three of the following symptoms: Inflated self-esteem or grandiosity, increased talkativeness, decreased need for sleep, racing thoughts, easy distraction, increase in goal-directed activity, and engaging in activities that have negative consequences (APA, 2013). This paper seeks to review a client with Bipolar disorder and outline the client’s treatment plan using a decision tree.

Case Study Overview

The case scenario depicts a 26-year-old woman of Korean descent on her first appointment after a 21-day hospitalization for acute mania. The client has been diagnosed with bipolar I disorder. Her current weight is 110 pounds, and her height is 5’ 5. She describes her mood as fantastic and mentions that she sleeps roughly 5 hours/night, but she hates sleep because it is not fun (Laureate Education, 2016). The client’s patient records show that she is in overall good health and her lab results are within normal limits.

However, genetic testing shows that she is positive for the CYP2D6*10 allele. The client admits that she stopped taking Lithium after being discharged two weeks ago. On MSE, the client is alert and oriented to person, place, time, and event. Her dressing is odd, and her speech is rapid, pressured, and tangential. Her self-reported mood is euthymic, and her affect is broad. She denies visual or auditory hallucinations, and she has no overt delusional or paranoid thought processes readily apparent (Laureate Education, 2016). Her insight is impaired, but she denies suicidal or homicidal ideation. She scores 22 on the Young Mania Rating Scale (YMRS).

Decision Point One

Begin Lithium 300 mg orally BID.

Why I Selected This Decision

Lithium is a mood stabilizer recommended for treating Mania in Bipolar disorder and maintenance therapy of bipolar disorder in persons with a history of mania. I selected Lithium because it targets unstable mood, which is the major symptom of mania (Won & Kim, 2017). Besides, mania is recommended as first-line therapy for long-term prevention of Bipolar disorder, particularly for euphoric mania.

I did not select Seroquel because it has documented side effects of dry mouth, fatigue, constipation, and dizziness, contributing to decreased medication compliance. Seroquel is also associated with increased appetite and weight and elevated triglycerides and total cholesterol levels (Shah et al., 2017). The side effects make it an inappropriate drug since the client is overweight.  I did not select Risperdal since the patient was positive for the CYP2D6*10 allele. According to Puangpetch et al. (2016), the CYP2D6*10 allele slows the drug’s clearance resulting in high levels of Risperdal in the blood, causing sedation.

What I Was Hoping To Achieve By Making This Decision

I hoped that prescribing Lithium would stabilize the patient’s mood and reduce the severity of manic symptoms by at least 50% in the first four weeks of treatment. According to Won and Kim (2017), Lithium exerts mood-stabilizing effects by acting on cellular targets and exerting neuroprotective effects.

How Ethical Considerations May Impact the Treatment Plan and Communication with Patients

Ethical principles of nonmaleficence and beneficence may impact the treatment plan as the PMHNP has a duty to prevent harm and promote better patient outcomes. The PMHNP is obliged to assess a drug for its impact and potential side effects before prescribing it to ensure it will promote better outcomes and have no adverse consequences to the patient (Bipeta, 2019). In this case, the PMHNP assessed each drug’s potential side effects and selected the one associated with better outcomes and fewer adverse effects.

Decision Point Two

Assess rationale for non-compliance to elicit reason for non-compliance and educate the client on drug effects and pharmacology.

Why I Selected This Decision

I selected this decision because the client reported taking the medication “off and on” when she feels that she needs it. The decision aimed at understanding the primary cause for the patient not complying with the medication (Won & Kim, 2017). Besides, educating the patient on the possible side effects and pharmacology of Lithium would enlighten her on the drug’s impact in improving her health outcomes.

I did not increase Lithium to 450 mg because the non-compliance behavior would persist if the reasons for the behavior were not identified and addressed. Besides, it is crucial that the PMHNP assess a patient’s response to Lithium and associated side effects before increasing the dose (Won & Kim, 2017).  I did not switch treatment to Depakote because the patient’s response to Lithium had not been established. According to Shah et al. (2017), the evidence for Depakote efficacy in acute depression is not as robust as that for Lithium.

What I Was Hoping To Achieve By Making This Decision

I was hoping that assessing and eliciting reason for non-compliance would help in identifying a practical solution to increasing compliance and eventually improve the manic symptoms. I was hoping that educating the patient on Lithium’s drug effects and pharmacology would enable her to understand the importance of adhering to treatment and increase her medication compliance.

How Ethical Considerations May Impact the Treatment Plan and Communication with Patients

The ethical principle of autonomy, which means that patients have a right to make decisions about their lives without interference from others, may impact the treatment plan. The PMHNP must respect the patient’s decision regarding her care which may impact the treatment interventions (Bipeta, 2019). In this case, the PMHNP had to elicit the rationale for the patient not complying with treatment, which determined the next intervention.

Examine Case Study: An Asian American Woman With Bipolar Disorder – NURS 6630

Bipolar disorder refers to a mental illness that makes one experience a dramatic shift in mood, energy, and ability to think clearly. The disease causes a high and low mood referred to as mania and depression. The average age onset of bipolar is 25 years and it affects about 2.8% of adults in the United States (Grunze, 2015). The disease worsens without treatment but with proper management, one can execute daily tasks with ease. To explain more on bipolar management, this paper will review a 26-year-old Korean woman diagnosed with bipolar I disorder. The patient was hospitalized for acute mania.

The patient appears to be busy and states she likes to talk, dance, sing and cook. Her mood is fantastic and she asserts that she hates sleep. Medications are not working on her and she is positive for the CYP2D6*10 allele (Laureate media, 2020). She reports that she stopped taking her lithium. She has a rapid, pressured and tangential speech with a broad affect. She denies delusions, hallucinations or suicidal ideation. She has a score of 22 on the Young Mania Rating Scale (YMRS). The paper will use a decision tree to prescribe psychopharmacological agents for the patient. The paper will also outline ethical considerations guiding the treatment protocol.

Decision -1

Begin Seroquel XR 100 mg orally at HS

Reason for Selection.

Seroquel XR 100 is selected because of its efficacy in the management of the bipolar disorder. As an atypical antipsychotic, it works by interacting with serotonin 5-HT2 receptors and dopamine D2 receptors. The main mechanism behind Seroquel’s antipsychotic efficacy is the blockade of the dopamine D2 receptor in the mesolimbic pathway (Muneer, 2015). The drug can modify the systems of dopaminergic, serotonergic and noradrenergic neurotransmission. The drug has a liner kinetic and an elimination half-life of approximately 7 hours. Seroquel XR has a peak plasma of 5 hours and sustains higher plasma levels for long allowing for once-daily dosing. Minimal metabolism occurs through CYP2D6 thus the patient’s positive allele will not affect the drug. The drug has minimal side effect profile, it’s well-tolerated and requires no therapeutic plasma monitoring.

Risperdal 1mg orally BID is avoided because the patient is positive for the CYP2D6*10 allele. The allele makes her a “poor metabolizer” with a decreased capacity to metabolize risperidone. She is therefore at a higher risk of adverse effects caused by increased exposure to plasma risperidone (Puangpetch et al., 2016). Equally lithium 300 mg orally BD is avoided because research indicates that it has limited clinical efficacy in severe manic and mixed episodes. It also has a narrow therapeutic index which calls for frequent plasma determination to avoid toxicity and adverse effects (Muneer, 2015).

Expected Results

The clinician expects that the patient will report improvement in symptoms. Seroquel efficiently improves mood, thinking, and behaviors and thus it will stabilize the patient increased energy, enhance her sleep, reduce nervousness and enhance her social life (Muneer, 2015). Her tolerance for the medication should also be better. The YMRS score should also decrease.

Difference between Expected and Actual Results

After four weeks, the patient stated that she slept more at bedtime, had a good mood and her YMRS score reduced from 22 to 18 (Laureate media, 2020). All these were in line with the clinician’s expectations. However, she indicated that she had gain 2-3 pounds, was constipated and had a dry mouth. The presentation is in line with frequent adverse events seen when using Seroquel which are dry mouth, sedation, constipation, increased appetite, dizziness and somnolence (Muneer, 2015). The client requested for a change of medication.

Decision 2

Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal

Reason for Selection

The need to maintain a strong therapeutic relationship prompted the change of the drug. The patient experienced adverse events from Seroquel. Geodon is backed up by research on reducing weight and generating better lipid profiles. A third of Geodon is cleared via CYP-3A4, 1A2 alleles while the rest is cleared via aldehyde oxidase and thus will not cause the adverse effects like Seroquel (Bahar, Setiawan, Hak & Wilffert, 2017).

The major pathway of metabolizing Geodon is 3A4 while 2D6 acts as a minor pathway for metabolism. The meal is added to assure adequate absorption of the drug. Increasing Seroquel to 300mg is avoided because it will exacerbate the adverse events resulting in compliance issues. Additionally maintaining the current drug and counseling on constipation will not help because the major concern of the patient is weight loss.

Expected Results

The patient is expected to report improved disease symptoms. Her bipolar symptoms should be better and weight gain should not be a problem anymore. An improvement in symptoms will be indicated by a better YMRS score.

Difference between expected and actual results

After four weeks, the patient had improved remarkably. Her YMRS score was 11, an indication that her disease symptoms reduced by 50% (Laureate Media, 2020). She tolerated the medication well and reported that weight gain was no longer an issue.

Decision Three

Increase Geodon to 60 mg orally BID with a 500 calorie meal

Reason for Selection

The patient responded positively to Geodon. Her disease symptoms improved and her weight gain problem resolved. Geodon can be adjusted depending on tolerability and efficacy within the range of 40-80mg twice daily (Wecker, Currier & Catalano, 2018).  The increased dosage will offer significant symptomatic improvement. Nevertheless, there is a risk of adverse events. Maintaining the patient on the current dosage and assessing after four weeks is also an option.  However bipolar patients require rapid relief of symptoms to prevent and minimize mood cycling (Murray et al., 2017). Augmenting the current medication with lithium is avoided because it is only an option when the plan is to stop the antipsychotic therapy and initiate a lithium monotherapy. The patient also indicated that she stopped taking Lithium initially before visiting the clinic meaning that she will have compliance issues unless educated about its side effects.

Expected Results

The increased dosage is expected to result in rapid relief of symptoms and significant symptomatic improvement. The patient should YMRS score should reduce by 75% and she should report a balanced mood, better concertation, clear thoughts, normal sleep, and positive behaviors.

Differences between Expected and Actual Results

As per the clinician’s expectation, the patient went to remission. She tolerated the medication well and she scored 7 on her YMRS. She executed her daily activities normally and her social life improved.

Ethical Considerations

When managing bipolar patients, it is the duty of the clinician to ensure rapid relief of symptoms because it is a cyclic disorder. One should strive to have a positive therapeutic relationship with the patient. Additionally, informed consent should be followed to ensure that the patient understands the risk and benefits of medication used as well as alternative psychopharmacological therapies that can be used (Ratheesh et al., 2017). Evidence-based research should guide the therapies used. For the current patient, she was started on a drug that has a research backup on its efficacy on the management of bipolar.

However, due to adverse events, she requested a change of drug.  As a way of creating a therapeutic alliance and resolving the patient’s concerns, the clinician offered a different drug. The patient was taken through the risks and benefits of the new drug and consented on the use of the drug. Additionally, since the patient had a therapeutic response without any adverse events, the new drug dosage was increased to get a rapid relief of symptoms. The patient improved and went to remission.

References

Bahar, M. A., Setiawan, D., Hak, E., & Wilffert, B. (2017). Pharmacogenetics of drug-drug interaction and drug–drug-gene interaction: a systematic review on CYP2C9, CYP2C19, and CYP2D6. Pharmacogenomics, 18(7), 701-739.

Grunze, H. (2015). Bipolar disorder. In Neurobiology of brain disorders (pp. 655-673). Academic Press.

Laureate Media. (2020). Psychopharmacologic Approaches to Treatment of Psychopathology. Retrieved 20^th March 2020, from https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/04/mm/bipolar_therapy/2.html

Muneer A. (2015). Pharmacotherapy of bipolar disorder with quetiapine: a recent literature review and an update. Clinical psychopharmacology and neuroscience: the official scientific journal of the Korean College of Neuropsychopharmacology, 13(1), 25–35.

Murray, G., Leitan, N. D., Thomas, N., Michalak, E. E., Johnson, S. L., Jones, S., … & Berk, M. (2017). Towards recovery-oriented psychosocial interventions for bipolar disorder: quality of life outcomes, stage-sensitive treatments, and mindfulness mechanisms. Clinical psychology review, 52, 148-163.

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.

Ratheesh, A., Cotton, S. M., Davey, C. G., Adams, S., Bechdolf, A., Macneil, C., … & McGorry, P. D. (2017). Ethical considerations in preventive interventions for bipolar disorder. Early intervention in psychiatry, 11(2), 104-112.

Wecker, L., Currier, G. W., & Catalano, G. (2018). Drug Therapy for Psychoses and Bipolar Disorder. Brody’s Human Pharmacology E-Book, 134.

Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients 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 client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with bipolar disorder.

Required Readings

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 6, “Mood Disorders”

Chapter 8, “Mood Stabilizers”

Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. New York, NY: Cambridge University Press.

To access the following chapters, click on the Illustrated Guides tab and then the Mood Stabilizers tab.

Chapter 4, “Lithium and Various Anticonvulsants as Mood Stabilizers for Bipolar Disorder”

Chapter 5, “Atypical Antipsychotics as Mood Stabilizers for Bipolar Disorder”

Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331-333. doi:10.1007/s40263-013-0060-3

Note: Retrieved from Walden Library databases.

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

Note: Retrieved from Walden Library databases.

Case Study: An Asian American Woman With Bipolar Disorder Required Media

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

Note: This case study will serve as the foundation for this week’s Assignment.

Case Study: An Asian American Woman With Bipolar Disorder Optional Resources

Mostafavi, A., Solhi, M., Mohammadi, M., Hamedi, M., Keshavarzi, M., & Akhondzadeh, S. (2014). Melatonin decreases olanzapine induced metabolic side-effects in adolescents with bipolar disorder: a randomized double-blind placebo-controlled trial. Acta Medica Iranica, 52(10), 734-739.NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment

Retrieved from http://acta.tums.ac.ir/index.php/acta

Analyze ethical and legal implications related to prescribing bipolar therapy to clients across the lifespan ..

Learning Objectives

Students will:

• Assess client factors and history to develop personalized plans of bipolar therapy for clients
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring bipolar therapy
• Evaluate efficacy of treatment plans

To prepare for this Assignment:

Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.

The Case Study: An Asian American Woman With Bipolar Disorder Assignment

Examine Case Study: An Asian American Woman With Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.

At each decision point stop to complete the following:

Decision #1

• Which decision did you select?
• Why did you select this decision? Support your response with evidence and references to the Learning Resources.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
• Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?

Decision #2

• Why did you select this decision? Support your response with evidence and references to the Learning Resources.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
• Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

Decision #3

NURS 6630 – Psychopharmacologic Approaches to Treatment of Psychopathology Essay Assignment

• Why did you select this decision? Support your response with evidence and references to the Learning Resources.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
• Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?

Also include how ethical considerations might impact your treatment plan and communication with clients.

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Assessing and Treatment for Bipolar Disorder Patient

Introduction

Bipolar disorder is not an uncommon illness. It is a very chronic and severe mental disorder, affecting approximately 1-2% of the adult population. The signs and symptoms of bipolar disorder are different depending on the type of episode (i.e., manic or depressive).

Each episode is marked by an abrupt shift in the patient’s general attitude, the patient’s thoughts, and the patient’s actions. 1 As a result, the changes will be noticeable to those around them (Robert et al., 2017). This deadly mood disease, which affects millions of individuals in all walks of life, can be found in all walks of life, from the poor to the wealthy (Robert et al., 2017). There is some evidence of bipolar disorder in the teenage years, although it is not completely absent. It is estimated that 2.6 percent of the population has been diagnosed with bipolar disorder. 3 National Alliance on Mental Illness, 2017.

This condition can be deadly if left untreated; early detection of symptoms with an appropriate treatment plan may include medication, counseling, a healthy lifestyle and regular scheduling will keep the patient healthy (National Alliance on Mental Illness) (2017). 1 To effectively care for this patient, the nurse practitioner (NP) must have a thorough knowledge of this illness and how it impacts one’s overall health (National Alliance on Mental Illness) (2017). 1 In this paper, I’ll examine a case study of an Asian American woman who has been diagnosed with bipolar disorder, including her symptoms, diagnosis, and therapy. The treatment and care alternatives that are the safest and most appropriate will be examined in this study.

Selecting a Course of Action She is a 39-year-old Asian American woman with four children and three ground children, all of whom live with her. The husband notes that she sings and dances in a way that doesn’t always match the song she’s singing. In the future, she will be bored and unable to think of anything to do, and she will stay in bed for hours without ever going to work at the company she has worked so hard to develop and love. The patient’s demeanor is stoic and reticent. 4 She has been diagnosed with bipolar disorder, according to her doctor.

1st Decision: The Primary Motive for Making It Risperdal 2 mg twice a day is the best course of action for this disease. Bipolar disorder is best treated with Risperdal. The findings of Lee et al. (2011). Antipsychotic benzisoxazole compounds include risperidone, the generic name for Risperdal. It is an effective treatment for bipolar disorder when used as prescribed (Lee et al., 2011). To treat schizophrenia, Risperdal’s risperidone works with the brain, stabilizing the nervous system (Lee et al., 2011). Dopamine and serotonin are rebalanced by Risperidone, which has a positive effect on mental health. An atypical antipsychotic, Risperidone is approved by the Food and Drug Administration (FDA) Bipolar disorder and irritability can also be treated with the medication (NAMI, 2017).

Results to Be Achieved