Assessing and Treating Clients with With Bipolar Disorder 

Bipolar Therapy
Client of Korean Descent/Ancestry

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. Assessing and Treating Clients with With Bipolar Disorder Essay. 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 Assessing and Treating Clients with With Bipolar Disorder Essay.

Decision Point One
Select what the PMHNP should do:

Begin Lithium 300 mg orally BID

Begin Risperdal 1 mg orally BID

Begin Seroquel XR 100 mg orally at HS

To prepare for this Assignment:
• Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.
The 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
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Assessing and Treating Clients with With Bipolar Disorder Essay.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o 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.

Decision #1

Selected Decision

The first decision is to start Risperdal 1mg orally BID

Reason For Selecting This Decision

Risperdal, originally referred to as risperidone, is a typical antipsychotic that has proven to be highly effective in the management of bipolar disorders.  It does so by trying to influence a rebalance in serotonin and dopamine thus resulting in good conduct. Since the patient was having bipolar confusion, Risperdal happens to be the best alternative also considering that it is readily accessible (Culpepper, 2014).  In the past treatment therapy, the patient happened to default lithium. Therefore, it wouldn’t be a smart option to start lithium 300mg since the chances of the patient not adhering to treatment are high. Similarly, Seroquel XR could be a good alternative. However, its side effects of constipation and weight addition might contribute to non-compliance thus not achieving the therapeutic goals (John & Antai-Otong, 2016).  This leaves Risperdal as the best option in this case. Assessing and Treating Clients with With Bipolar Disorder Essay.

Expected Outcomes

Within four weeks on treatment, the patient is expected to show immense progress. The current manifestations of bipolar disorder that she experiences are also expected to diminish to an extent that the patient has a peaceful state of mind. The patient should be restful and be able to conduct her activities of daily life with little or no difficulty (John & Antai-Otong, 2016) Risperdal is the best choice to influence mental action and improve the patient’s capacity to be of rational sound mind in the way she addresses issues. It is also expected that the patient’s self-destructive practices and tension would diminish and will respond to her environment and social interactions positively (Fang, et al., 2017).

 Difference between Expected Outcomes and Actual Outcomes

After four weeks, the client returned to the clinic accompanied by her mother looking very lethargic and sedated. They, however, agreed that the patient’s self-destructive practices had significantly diminished. The client’s mother explained that the client had been lethargic for about a week after the last visit. Assessing and Treating Clients with With Bipolar Disorder Essay. It should be noted that one of the side effects of Risperdal is sedation (John & Antai-Otong, 2016) Similarly, based on the fact that the client is reportedly positive for CYP2D6*10 allele, it is probable that she might be having a slow rate of clearance of Risperdal from her systems leading to higher levels than normal of Risperdal in blood (Chen et al., 2015). Assessing and Treating Clients with With Bipolar Disorder Essay.

Decision #2

Selected Decision

Based on the client’s presentation and the initial decision, the second best decision, in this case, would be reducing Risperdal to 1mg HS.

Reason for Selecting This Decision

Based on the patient’s progress during the second visit, it was evident that Risperdal was effective in attaining therapeutic goals of treatment. However, the unwanted side effects were the major concerns. It is therefore wise to decrease the dosing to deal with the side effects rather than change to another drug.  Decreasing the dosage to one mg HS would be the best alternative that will help to reduce the significant impact of the side effects (Culpepper, 2014). Assessing and Treating Clients with With Bipolar Disorder Essay. Changing the drug to lithium will possibly result in non-compliance since the client has already developed some demeanor towards it. Besides, the patient may turn out to generally have a negative attitude towards all medicines which may be prescribed by the mental health practitioner. Giving the patient support to adapt to an alternate dosage of the same medication will also improve their dedication, trust, and understanding to collaborate in achieving the treatment goals (John & Antai-Otong, 2016).

Expected Outcomes

As earlier stated, Risperdal has proven to be effective in managing the symptoms of bipolar disorder by influencing a balance in serotonin and dopamine to help address a patient’s self-destructive behaviors. Based on the fact that the client is positive for CYP2D6*10 allele, the initial dosage could have resulted in an accumulation of Risperdal which is slowly being cleared (John & Antai-Otong, 2016). Assessing and Treating Clients with With Bipolar Disorder Essay. Reducing the dosage to one mg HS will definitely reduce the amount of Risperdal accumulated in the body and subsequent side effects of lethargy and sedation. By adjusting this dosage, it is expected that the patient will record some positive progress in terms of reduced self-destructive behaviors, ease in performing activities of daily life and thinking patterns (Fang, et al., 2017). It is also expected that the client will have minimal episodes of lethargy and sedation.

Difference between Expected Outcomes and Actual Outcomes

After four weeks, the client returned to the clinic accompanied by her mother. She was less sedated, less lethargic and showed a lot of improvement in symptoms. The young mania rating scale had also reduced from 22 to 16, an illustration that there was more than a 25% reduction in symptoms. These outcomes were actually foreseen and were the reason the dosage of Risperdal was reduced to one mg HS (John & Antai-Otong, 2016) Risperdal is a powerful choice for bipolar disorder; its side effects are easily manageable and help in the achievement of therapeutic goals for bipolar patients more easily Assessing and Treating Clients with With Bipolar Disorder Essay.

Decision #3

Selected Decision

My third decision would be to continue at the same dosage of 1 mg HS.

Reason for Selecting This Decision

From the initial visit, it was evident that the client has good progress in terms of reducing self-destructive behaviors and management of the drugs side effects. Maintaining this dosage and reassessing the client after four weeks will contribute to the achievement of the treatment goals for both the client and the attending mental health practitioner. The initial dosage of 1 mg BID had turned out to be detrimental to the patient’s health (Fang, et al., 2017). Therefore, going back to it would prompt similar side effects.  Besides, changing to Latuda is not recommendable in this case since Latuda is FDA approved for bipolar I depression which differs from the patient’s presentation that we are trying to manage. Besides, Latuda is costly and most health insurance companies would decline to pay for it until other drugs have been attempted and proven to fail (John & Antai-Otong, 2016). Assessing and Treating Clients with With Bipolar Disorder Essay.

Expected Outcomes

It is expected that, within four weeks, the patient will record immense progress by reducing self-destructive behaviors. Besides, she will report very minimal or no side effects from Risperdal. She will have a good state of mind, conduct, and good thinking patterns. Risperdal is FDA approved for managing bipolar symptoms and has proven to be highly effective with manageable side effects (John & Antai-Otong, 2016)

Difference between Expected Outcomes and Actual Outcomes

As initially expected, the patient has some significant progress and very minimal side effects of lethargy and sedation. The reassessment proved that Risperdal had adequately helped to achieve the necessary treatment goals in the entire course of treatment. Given the pharmacodynamics and pharmacokinetics of Risperdal, these are certainly the outcomes that ought to be expected. Since the client is for positive for CYP2D6*10 allele, Risperdal could be clearing at a slower rate resulting to higher than normal levels in the blood (Fang, et al., 2017).

However, the effect, in this case, may not be significant as compared to the initial point.

How Ethical Considerations Might Impact the Treatment Plan and Communication With Clients

            The major ethical considerations that ought to be considered in managing clients with bipolar disorder are beneficence, nonmaleficence, and autonomy. Despite the fact that clients need treatment to live near-normal lives, the risks of the choice of medications used should balance with the corresponding benefits. Alternatively, a mental healthcare provider should consider giving the patient some of the best available options for management to maximize the benefits of treatment (Ratheesh et al., 2017).  The impairment or insight and judgment that is always characterized by mania and mood episodes may render a patient as not able to provide informed consent nor incapable of making rational decisions regarding their treatment. Besides, a number of clinical presentations such as delusional thinking and irritability could probably be a threat in damaging the therapeutic alliance that exists between a client and a mental healthcare provider. It should also be noted that, due to the relapsing-remitting nature of bipolar disorder, there are instances where a patient might feel well and question the need to continue with treatment (Ratheesh et al., 2017).  This places the treatment goals laid by the mental healthcare provider in conflict with the patient’s autonomy to make decisions. Assessing and Treating Clients with With Bipolar Disorder Essay.

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.

Culpepper, L. (2014). The diagnosis and treatment of bipolar disorder: decision-making in primary care. The primary care companion for CNS disorders, 16(3).

Fang, F., Wang, Z., Wu, R., Calabrese, J. R., & Gao, K. (2017). Is there a ‘weight neutral’second-generation antipsychotic for bipolar disorder?. Expert review of Neurotherapeutics, 17(4), 407-418.

John, R. L., & Antai-Otong, D. (2016). Contemporary Treatment Approaches to Major Depression and Bipolar Disorders. Nursing Clinics, 51(2), 335-351.

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. Assessing and Treating Clients with With Bipolar Disorder Essay.