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Psychopharmalogical Approaches to Treat Psychopathology - Bipolar Disorder 


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.

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?”
She weights 110 lbs. and is 5’ 5”


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.
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

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

 

 

The Decision Tree Assignments are based on interactive case studies that allow you to explore pharmaceutical options and make decisions centered on the client’s needs.  You will be asked to make three decisions concerning the medication to prescribe to a client in the assigned scenarios.  At each decision point, you must evaluate all options before selecting your decision and moving through the rest of the exercise. The rationale for your decisions must be supported with a minimum of five academic resources from the primary and secondary literature. While you may use the course text to support your rationale, it will not count toward the resource requirement.
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.
•    Be aware that the writing template and grading rubric require your introduction to end with one sentence that is your thesis statement.  See the writing template for format and the grading rubric for details on how you are graded on this statement.
Body of your document
The body of your document should contain three sections that are labeled as follows:  decision #1, decision #2, and decision #3.  Each section should address the topics below.  In your writing, you should be concise, clear, and thorough.  Pharmacokinetics, pharmacodynamics, and specific patient factors must be considered in your writing in order to get full credit. 
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. *Ethical considerations must be clearly identified/labeled.  You can identify them within the decision section (“My ethical considerations are…”), or you can identify them separately in a section labeled “Ethical Considerations.”   Either option is acceptable.
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.


note: reference should not be more than 5 years.

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Psychopharmalogical Approaches to Treat Psychopathology - Bipolar Disorder

Bipolar disorder is a mental condition characterized by extreme mood swings and presents in two different phases. One phase is emotional high referred to as mania while the other phase one experiences a low mood called depression. During the euphoria phase, a person has high energy and engages in activities of interest some of which may be dangerous, for example, driving at high speed, irresponsible sexual behavior among others. Like most mental conditions, people with bipolar disorder experience significant impairment in carrying out daily activities, holding jobs, or effective family functioning. The disorder is also difficult to diagnose because of its complexity and other conditions that present with similar symptoms such as schizophrenia. Nevertheless, diagnosis and effective pharmacological and psychotherapy treatment are essential to improve functioning especially to stabilize moods in such patients. The assessment will focus on the case study patient, a 26-year-old Korean woman by exploring a decision-making process leading to an effective treatment plan.

The patient, a 26-year-old Korean woman has come in for the first time. The patient seems unsettled and keeps on shifting and playing with stuff on the desk. She does not believe she has bipolar. The patient reports a good mood, enjoying dancing, singing, and cooking. She sleeps about 5 hours a night but reports that she does not enjoy sleep. Lab results and physical examination show normal results. Additional tests reveal that the patient is positive for the CYP2D6*10 allele. Similarly, the Young Mania Rating Scale (YMRS) gives a score of 22, which confirms the diagnosis of bipolar disorder.

Decision #1

Begin Lithium 300mg orally BID

I started with Lithium. In the assessment, the patient noted that they had been prescribed Lithium but they stopped taking it. Hence, it is plausible to prescribe Lithium since the patient did not report any side effects. The only issue at this point is the lack of adherence to the medication. Lithium is the best choice because it is a first-line treatment for bipolar disorder with proven efficacy and safety with patients. Studies prove the effectiveness of Lithium including its neuroprotective properties and anti-suicidal effects, as well as tolerance in long-term use (Zivanovic, 2017). The other option is Risperdal. However, the patient showed positive for the CYP2D6*10 allele. This means that the patient will not respond well to the medication, people with this genetic makeup tend to have problems metabolizing Risperdal leading to high levels of its accumulation in the patient’s system (Seripa, et al., 2018). Finally, the third option, Seroquel is associated with undesirable side effects, which may persist in a patient to warrant a change in medication. Some of the common side effects of constipation, weight gain, drowsiness, blurred vision, and dry mouth, which can cause dental problems.

With the decision, I expected that the client will gain significant improvement and the medication will help with stabilizing the mood. However, this was not the case, the patient reported back in four weeks with a similar presentation as the first time she visited the clinic. She notes that she has been taking the drug “on and off”, only when she feels like it. Thus, no improvement was achieved because of the patient’s lack of medication adherence.

Decision #2

Assess rationale for non-compliance and educate the patient

The major problem at this point is the patient’s lack of medication adherence. The medication is effective and does not present with side effects. Hence, the patient must understand the importance of following a drug routine strictly as prescribed by the PMHNP. Patient education enhances medication adherence because of an enhanced understanding of the role and benefits of the treatment plan (El-Mallakh & Findlay, 2015). If the patient does not understand the need for adherence, increasing the dosage, which is another option at this point will not help the patient. Moreover, it has not been established that the current dose cannot produce the desired therapeutic outcomes as the problem is the patient is taking medication when they feel like it. The third option in decision point two is switching to Depakote. Depakote is a reasonable choice for the treatment of a bipolar disorder, but it is a second-generation medication (Jauhar & Young, 2019). First-generation is more preferred when the patient is responding well to medication. At this point, there is still room to try first-generation medication before deciding to switch to the second generation. If the patient fails to respond to Lithium treatment, then Depakote might be a consideration.

I expected the client to understand the importance of staying strict to medication regimes and the benefits of Lithium medication. As such, I expected that the patient will adhere to the medication regime and achieve significant improvement in symptoms, as well as stabilized mood. The patient returned to the clinic in four weeks citing nausea and diarrhea with the medication. This was unexpected as the patient had not indicated side effects before when using Lithium.

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Decision #3

Change to sustained release at same dose and frequency

Changing from oral to sustained release is beneficial in several ways including the elimination of the symptoms. Moreover, the extended-release option will ensure that medication adherence is achieved by the patient (Tondo et al., 2019). Lithium is still the best choice at this point because of its proven effectiveness over other medications. However, the patient will be closely monitored and if the symptoms fail to abate, a change to another medication may be necessary. Depakote is also a good choice but only recommended when the symptoms fail to go away with the introduction of sustained-release lithium. On the other hand, the option of introducing Oxcarbazpine at this stage is not necessary until the patient has sufficient trial with first-line medication and shown poor response and tolerance. With this option, I was hoping that the patient will experience improvement with a reduction in the Young Mania Rating Scale (YMRS) score.

Ethical Considerations

When providing pharmacological treatment to patients, PMHNP must understand ethical issues that affect their choices of medication, as well as communication with the client. In this case, first, patient autonomy is important to allow the patient to participate in decisions regarding their treatment. The PMHNP provides available treatment options with information regarding risks and benefits to allow the patient to make an informed choice. Similarly, patient education about the treatment plan is a requirement. Patients need to understand the benefits of the treatment plan and the importance of adhering to a medication regime to reap maximum therapeutic benefits. Another ethical issue to be considered in this case is the safety and effectiveness of medication depending on patient factors. For example, the patient tested positive for the CYP2D6*10 allele meaning that certain drugs such as Risperdal would not give maximum benefits (Chen, 2015). Finally, informed consent must be obtained from the patient before initiating treatment, and confidentiality and privacy observed.

Conclusion

The case presented is a 26-year-old female of Korean descent suffering from bipolar disorder. The chosen treatment plan in this case if Lithium, which is effective and safe with the added advantage of preventing suicidal tendencies, which is a common manifestation in patients with mood disorders. Risperdal will not produce the required effect for this patient because of her genetic makeup. Other options are second-generation medications, which are only considered after trial with the first-generation medication has shown poor response and tolerance. Nausea and diarrhea are common side effects of Lithium treatment. However, with extended-release, the symptoms often resolve to allow the patient to experience the benefits of the medication leading to improvement in symptoms including better sleep, mood control among others.

 

References

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

El-Mallakh, P., & Findlay, J. (2015). Strategies to improve medication adherence in patients with schizophrenia: the role of support services. Neuropsychiatr Dis Treat, 11, 1077–1090. doi: 10.2147/NDT.S56107.

Jauhar, S., & Young, A. (2019). Controversies in bipolar disorder; role of second-generation antipsychotic for maintenance therapy. Int J Bipolar Disord, 7(10), https://doi.org/10.1186/s40345-019-0145-0.

Seripa, D., Lozupone, M., Miscio, G., Stella, E., Montagna, M. M., Gravina, C., . . . Mauro, L. (2018). CYP2D6 genotypes in revolving door patients with bipolar disorders. Medicine, 97(37), p e11998. doi: 10.1097/MD.0000000000011998.

Tondo, L., Alda, M., & Bauer, M. (2019). Clinical use of lithium salts: guide for users and prescribers. Int J Bipolar Disord, 7(16). https://doi.org/10.1186/s40345-019-0151-2.

Zivanovic, O. (2017). Lithium: A classic drug—Frequently discussed, but, sadly, seldom prescribed! Australian and New Zealand Journal of Psychiatry, 51(9), 886-896. https://doi.org/10.1177/0004867417695889.

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Sample#2

Assessing and Treating Patients with Bipolar Disorder

Introduction to the Case Study

            Bipolar disorder, sometimes referred to as manic depression, is a typical mental illness associated with extreme mood changes, both low and high in sleep, energy, thinking, and behavior (Ramirez, 2018). As a result, those who have bipolar disorder have episodes in which they feel overly happy and energetic, while the mood can change almost instantly. They exhibit very low feelings associated with sadness and hopelessness.

            The case study presented is that of a 26-year old Asian-American Korean woman who has been hospitalized for 21 days following the onset of acute mania. She was diagnosed with bipolar 1 disorder. The case study gives an encounter with the patient in which her behavior of getting “busy” by talking and swinging on the chair is highlighted, indicative of her mental condition. The patient is 5’5” and weighs 110 pounds.  The patient also reports a "fantastic" mood and sleeps for five hours in which she remarks that "I hate to sleep; it's no fun." Similarly, the patient is medically overworked as the initial intervention treatments have failed to work as intended. After conducting genetic testing, she tested positive for the CYP2D6*10 allele. The patient also ceased taking her Lithium two weeks ago after she was discharged from the hospital. The mental status examination reveals that the patient is highly alert and has recognition for people around her, time, and events. She denies suicidal thoughts and has grossly intact judgment even though her insight is impaired.  In deciding to administer treatment, there is a need to consider factors that might impact the patient's pharmacokinetics and pharmacodynamics processes. These include medication history, age, gender, education and understanding level, and actions of the patient.

 

Decision 1

            Upon assessing the condition of the patient with respect to her previous medical history, I took the decision to administer Lithium 300 mg two times a day orally. Mood stabilizers are critical in the pharmacological treatment of manic episodes. In light of this, I would administer mood stabilizers using an antipsychotic needle for the purpose of agitation. In doing so, I would hope to see the patient’s mood attain equilibrium and suppress the exhibition of maniac behaviors.  Clinical tests have confirmed that it is effective in treating bipolar disorder as it suppresses manic episodes.

Manic patients may have episodes marked with low moods, depression, and suicidal thoughts. Studies indicate that between 25% to 50% of individuals having bipolar disorder contemplate committing suicide, while 15% of them actually die of committing suicide (Sanacora, 2016). Since Lithium has anti-suicidal characteristics, it would be effective in preventing suicidal thoughts inpatient. After four weeks of dosage administration, the patient reports back to the hospital and remarks that she is only taking the medication when she feels it’s convenient, while there is no indication that her behavior has improved. I would have hoped that she would have shown some behavioral improvement after properly taking her prescribed medication. The failure of the patient to take medication at prescribed intervals implies that therapeutic levels have not been achieved. In psychiatric care, the most rampant problem that affects the treatment process is the failure of patients to comply with the prescription. Antipsychotics and mood stabilizers should be taken as prescribed for maximum achievement in improving the patient’s health. In cases where the prescription is not followed, or when the drugs are entirely not taken, there is a relapse of symptoms, re-hospitalizations, homelessness, jail incarceration, victimization, and episodes of violence.

Decision 2

            The first step in my second decision was to assess why the patient failed to comply with the prescription. Given that all factors are constant, one of the contributing factors contributing to the failure of patients to take drugs with prescription is the level of education. This case, however, had other contributing factors, like the mental state of the patient. I, therefore, took the initiative of educating the patient on the effects of drugs and pharmacology. This was an exceptional case because even though the patient had impaired insight, she had a good recognition of the immediate surrounding, above-average judgment, and sense of time.

            The patient returns to the clinic one month later and states that the prescribed medicine gives her nausea and running stomach. Upon questioning her, she reveals that she only took the drugs when her symptoms worsened, but as soon as they were under control, she stopped taking the drugs. This is consistent with the observation made among other bipolar patients. They tend to take medications at their convenience and often do not adhere to scheduled care plans for long-term treatments. However, the basis for her non-adherence is valid, as she stated that she experienced nausea and diarrhea. In early treatment interventions using lithium-based drugs, the patient is likely to register gastrointestinal side effects that include diarrhea and nausea, making them avoid the drug and only take them as symptoms become noticeable. Educating patients on the side effects of drugs and the need to adhere to prescriptions strictly is a critical nursing practice element. When dealing with bipolar disorder patients, it is crucial to enlighten them on Lithium's various side effects and suggest ways to manage such effects (Goodwin, 2020). As such, a clear understanding of the patient's non-compliance in taking medicine is essential in informing the subsequent decision to be taken by the doctor.

 

Decision 3

            Being mindful of the reasons behind the failed treatment intervention, I decided to change the medication of the patient to an extended-release formulation. However, the dosage and frequency of administration remained the same. The decision taken at this point onwards had to address the medication's side effects to prevent instances of patient non-adherence to the treatment plan. In doing so, I was hoping to minimize the gastrointestinal side effects caused by Lithium significantly. The medication can be taken along with food or shifting to entirely a different extended release of the medication to reduce nausea.

            Arguably, changing the lithium "form," say from capsules to sustained release, and vice versa, can only help the side effects that result in the drug's absorption mechanism. The side effect associated with the absorption of Lithium is gastrointestinal side effects that manifest in diarrhea and nausea (Gessler, 2017). In a keen assessment of the patient's treatment history and considering other factors, choosing Lithium was the best choice under the given circumstances. In administering long-term medication for bipolar type 1 disorder, Lithium is the best alternative. This is because it efficiently treats the maniac disorder, acts as an antidepressant to stabilize the moods, and also decreases suicidal thoughts. I, therefore, hoped that by administering a lithium drug and educating the patient on the side effects and the need to take the drug according to the prescription would increase the chances of recovery and stabilize the behavior of the patient.

Ethical considerations during treatment

            Ethics is required of healthcare professions, especially when dealing with patients with mental illness. During drug administration, the doctor must be well-aware of the side effects and take precautions to minimize them. Lithium has been proven to have a narrow therapeutic index, and it requires careful therapeutic drug monitoring. This is essential in increasing the effectiveness of the medication while significantly reducing any associated adverse side effects and toxicity. Healthcare providers who order Lithium to use it to treat patients with bipolar disorder must be on high alert to monitor its effects and reach out to these patients frequently during the care plan. This is important in maintaining therapeutic dozing and also avoiding instances of patient non-compliance to the prescription.  Similarly, it is ethical to educate patients on the various side effects of the medication, such as the decreased functioning of kidneys that could potentially lead to kidney failure with continued lithium administration. Other side effects that patients and their families need to be educated on include possible hypothyroidism, rapid increase in weight, and effects on the blood pressure, increasing or decreasing it. As such, there is a need to be ethical when prescribing Lithium to bipolar patients by educating them on the side effects and making follow-up activities.

Conclusion

            The case study presents a 26-year old Korean woman who has bipolar disorder. Given that the first prescription has failed to work, three decisions had to be made, with each one being an improvement of the previous decision. Initially, a decision was made to put the patient on lithium drugs. However, she reported back four weeks later, showing no signs of improvement. This is because she did not adhere to the prescribed medicine and often missed taking the drugs on many occasions.

Similarly, she complained of nausea and diarrhea as side effects. The second decision to change the form of the drug but maintaining dose and frequency was reached to eliminate the side effects. Similarly, the text reiterates the need to apply ethical considerations in delivering long-term care for bipolar patients. The three decisions made in the treatment process are aimed at improving the efficiency of lithium administration to bipolar patients.

References

Gessler, D. (2017). The use of Lithium for the treatment of bipolar disorder: Recommendations from clinical practice guidelines. Journal of Affective Disorders, 217(1), 266-280.

Goodwin, G. (2020). Lithium - A continuing story in the treatment of bipolar disorder. Acta Psychiatrica Scandinavica. Supplementum, 111(426), 7-12.

Ramirez, L. F. (2018). Bipolar medications, mechanisms of action. Depression and Anxiety, 15(3), 1-17.

Sanacora, G. (2016). Reviewing medications for bipolar disorder: understanding the mechanisms of action. The Journal of Clinical Psychiatry, 70(1), 13-15.

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