Nurs 6630: Psychopharmacological approach to treat psychopathology

Week 5: Therapy for Patients With Bipolar Disorders

Marcus, an 18-year-old high school senior, presents with symptoms of difficulty sleeping and feeling sad, which result in an initial diagnosis of depression. His mother later reports, however, that Marcus exhibits symptoms of irritability and risk-taking behaviors. (His little brother reported to his mother that they were driving over 90 miles an hour on the highway.) After further evaluation, Marcus’ psychiatric nurse practitioner diagnoses him with bipolar disorder.

Cases like this are not uncommon with bipolar disorder, as initial assessments rarely provide all the information needed. In your role, as a psychiatric nurse practitioner, you must develop strategies for properly assessing and diagnosing these patients because treatments for bipolar disorder are significantly different than treatments for depression or other mood disorders.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.

BUY A PLAGIARISM-FREE PAPER HERE

Week 5: Therapy for Patients with Bipolar Disorders

Bipolar Disorder

Bipolar disorder is a mental condition characterized by bouts of significant mood swings. A depressed episode lasts only for weeks or even months, while manic episodes last for a few days or months. During a manic episode, a person may have a lot of energy, a bloated feeling of self-confidence, and impulsive or dangerous conduct (Carvalho et al., 2020). A person suffering from a depressive episode may have poor energy, a diminished sense of enjoyment, and feelings of sadness, hopelessness, and worthlessness. Bipolar disorder is caused by a mix of hereditary and environmental causes. It is more frequent in people who have a family member with the ailment, and it starts at a younger age than other mental illnesses. However, there is no one “cause” of bipolar disorder; it is a complicated disease that varies significantly between individuals.

There is no one-size-fits-all treatment method for bipolar illness since the disease may be treated in several ways that are suited to the individual. Medication, therapy, and counseling are common forms of treatment. Drugs such as lithium, mood stabilizers, anticonvulsants, and antipsychotics are essential in treating this illness. Bipolar disorder affects roughly 1% of the population in North America and Europe, and about 3% of the global population (Vieta et al.,2018). Bipolar disorder is most typically diagnosed in adolescence but can occur at any age. Males are more likely than females to suffer from bipolar disorder, and those of African descent are disproportionately affected by it. This paper is based on the case study of Marcus, an 18-year-old high school senior who presented with the principal complaint of trouble sleeping and a sense of sadness. It discusses three therapeutic decisions that will be more applicable for managing his bipolar disorder based on the pharmacokinetic and pharmacodynamic processes. The paper also discusses how ethics influences the patient’s treatment method.

Case study

The study involves Marcus,, an 18-year-old high school patient who presented to the clinic with a complaint of difficulty sleeping and feeling, resulting in an initial diagnosis of depression. His mother noted that he was irritable and engaged in risk-taking behaviors. Upon examination, the patient was diagnosed with bipolar disorder.

Decision 1#

At this decision point, I will choose to start the client on lithium 300mg PO to be taken twice a day. I chose lithium for this selection since it is a first-line and safe option for treating bipolar disorder. Lithium works by altering the balance of chemicals in the brain, which helps avoid the manic and depressed episodes common in bipolar illness. It also modulates the activity of specific neurotransmitters, such as dopamine, restoring equilibrium in the brain and improving bipolar symptoms. Unlike other bipolar medications, its adverse effects are often modest and tolerable.

Risperdal 1mg PO BID is another possible alternative for the patient; however, it was not chosen because it is not FDA authorized for treating the bipolar disorder. Furthermore, it is more likely to elicit extrapyramidal side effects (EPS) than other atypical antipsychotics. Because individuals with bipolar illness are already at heightened risk for EPS, its impact can be harmful and unpleasant. Seroquel XR 100 mg PO HS is an essential medicine in the management of bipolar illness but was not chosen because it intensifies manic symptoms in particular persons with bipolar disorder, making it unsuitable for this decision point.

I am hopeful that by making this decision, the patient would report a considerable reduction in his bipolar disorder depressed and manic episodes. After four weeks of therapy, the patient reported no change in his clinical complaints. This might be due to the severity of the patient’s symptoms, which were not controlled with low-dose lithium.

Decision 2#

In this decision point, I will choose to increase lithium dosage from 300mg to 450mg PO to be taken twice a day. This decision was reached based on the patient’s assertion of no change in his clinical presentation, which I feel was due to insufficient dose and the drug’s devoid of adverse effects, which signifies that the drug is well tolerated. According to Nolen et al. (2019). xxx et al., increasing the lithium dosage is appropriate when there is an insufficient response to treatment but good tolerability. Furthermore, the decision was predicated on the concern of bipolar relapse, which has been tied to lithium discontinuation.

Switching to Depakote ER 500mg PO HS was also a great option. Still, it was not selected at this stage because studies have shown that it increases the likelihood of suicidal thoughts and behaviours in bipolar patients (KATZ et al.,2018). Furthermore, studies have found that patients using this medicine are more prone to relapse. Furthermore, this method will likely enhance side effects such as disorientation, sleepiness, and difficulty concentrating, which would be detrimental to the patient. I expect that by making this decision, the patient will report an improvement in his sleeping pattern, a considerable reduction in irritation, and a lack of sadness.

Decision 3#

In this decision point, I will choose to assess for client’s non-compliance and educate the patient on the drug pharmacotherapeutic. This decision was chosen because bipolar patients have been shown in several studies to be poorly adherent to the medication, and its poor compliance which is the principle reason for the discrepancy between the efficacy and effectiveness of a medication used in bipolar management (Jawad et al., 2018). Non-compliance is a common cause of relapse into depression, an increased risk of suicide, and hospitalization in bipolar patients. Poor understanding, the intensity of the symptoms, and effective medication adverse effects are all common reasons for non-compliance. Assessing the grounds for client compliance and educating the patient on fundamental aspects of his ailment and the risks involved with non-compliance are crucial in bipolar management.

Other options, such as changing the patient to Abilify, were a great option but were not selected at this decision point because of its potential to hurt cognitive function and executive functioning in those who take it (Maini et al., 2021). Additionally, there have been reports of increased levels of anxiety and depression in some patients taking Abilify. Thus, not a preferable option in this case. On the other hand, considering hospitalization was not a realistic option because no suicidal ideation was reported. By making this decision, I hope the patient would be more willing to stick to the treatment plan and consequently report a significant improvement in his symptoms.

BUY A PLAGIARISM-FREE PAPER HERE

Ethical consideration

The ethical concerns involved in treating bipolar disease are vast and diverse. Before beginning any therapy, it is vital to obtain informed consent from the patient. This implies that the patient must be adequately informed about the nature of their illness and the potential dangers and benefits of any given therapy. It is also critical to provide patients with accurate information about their drugs so they may make educated decisions about whether or not to take them. It is also critical that patients are treated safely and effectively. The hazards connected with the disease and its treatment must be carefully addressed and weighed against the inherent benefits to the individual. Many people with bipolar illness feel stigmatized and alienated, which can severely influence their recovery and long-term well-being (Mejia-Lancheros et al., 2021). The therapies for those suffering from the bipolar illness must be supportive and considerate of their requirements.

Conclusion

Bipolar disorder is a psychiatric condition that causes patients to have significant mood swings. The illness can be extremely severe and difficult to control. Several therapy methods are available, and the most successful strategy will most likely differ from person to person. Furthermore, many patients with bipolar disorder are unlikely to stick to medication for various reasons, such as a misunderstanding of the condition; therefore, patient education is frequently necessary. To manage bipolar disorder, some ethics, such as gaining informed permission, are essential. Furthermore, patient autonomy must be honored.

References

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66. https://www.nejm.org/doi/full/10.1056/NEJMra1906193#:~:text=DOI%3A%2010.1056/NEJMra1906193

Jawad, I., Watson, S., Haddad, P. M., Talbot, P. S., & McAllister-Williams, R. H. (2018). Medication nonadherence in bipolar disorder: a narrative review. Therapeutic advances in psychopharmacology, 8(12), 349-363. https://doi.org/10.1177%2F2045125318804364

KATZ, R., & BEECH, R. (2018). Suicide Risk in Bipolar Disorder. 50 Studies Every Psychiatrist Should Know, 30.

Maini, K., Gould, H., Hicks, J., Iqbal, F., Patterson, J., Edinoff, A. N., … & Kaye, A. D. (2021). Aripiprazole Lauroxil, a Novel Injectable Long-Acting Antipsychotic Treatment for Adults with Schizophrenia: A Comprehensive Review. Neurology International, 13(3), 279-296. https://doi.org/10.3390/neurolint13030029

Mejia-Lancheros, C., Lachaud, J., Woodhall-Melnik, J., O’Campo, P., Hwang, S. W., & Stergiopoulos, V. (2021). Longitudinal interrelationships of mental health discrimination and stigma with housing and well-being outcomes in adults with mental illness and recent experience of homelessness. Social Science & Medicine, 268, 113463

Nolen, W. A., Licht, R. W., Young, A. H., Malhi, G. S., Tohen, M., Vieta, E., … & ISBD/IGSLI Task Force on the treatment with lithium. (2019). What is the optimal serum level for lithium in the maintenance treatment of bipolar disorder? A systematic review and recommendations from the ISBD/IGSLI Task Force on treatment with lithium. Bipolar disorders, 21(5), 394-409. https://doi.org/10.1111/bdi.12805

Vieta, E., Berk, M., Schulze, T. G., Carvalho, A. F., Suppes, T., Calabrese, J. R., … & Grande, I. (2018). Bipolar disorders. Nature reviews Disease primers, 4(1), 1-16. https://www.nature.com/articles/nrdp20188

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.
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)

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.
Decision #2 (1 page)

BUY A PLAGIARISM-FREE PAPER HERE

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)Learning Resources
Required Readings (click to expand/reduce)

Ostacher, M. J., & Hsin, H. (2016). The use of antiepileptic drugs in psychiatry. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 93–98). Elsevier.

Perlis, R. H., & Ostacher, M. J. (2016a). Bipolar disorder. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 48–60). Elsevier.

Perlis, R. H., & Ostacher, M. J. (2016b). Lithium and its role in psychiatry. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 86–92). Elsevier.

Traeger, L., Brennan, M. M., & Herman, J. B. (2016). Treatment adherence. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 20–26). Elsevier.

American Psychiatric Association. (2010b). Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf

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

Hirschfeld, R. M. A. (n.d.). Guideline watch: Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar-watch.pdf

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

Medication Resources (click to expand/reduce)

Required Media (click to expand/reduce)

Optional Resources (click to expand/reduce)

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: 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.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references. The Sample Paper provided at the Walden Writing Center provides an example of those required elements (available at

https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

By Day 7
Submit your Assignment. : To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

Review the following medications:

Optional Resources (click to expand/reduce)

BUY A PLAGIARISM-FREE PAPER HERE

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.

Introduction to the case (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.Note: To access the following medications, use the Drugs@FDA resource. Type the name of each medication in the keyword search bar. Select the hyperlink related to the medication name you searched. Review the supplements provided and select the package label resource file associated with the medication you searched. If a label is not available, you may need to conduct a general search outside of this resource provided. Be sure to review the label information for each medication as this information will be helpful for your review in preparation for your Assignments.

Review the following medications:

Optional Resources (click to expand/reduce)

BUY A PLAGIARISM-FREE PAPER HERE

Introduction to the case (1 page)

Review the following medications:

BUY A PLAGIARISM-FREE PAPER HERE

amitriptyline
bupropion
citalopram
clomipramine
desipramine
desvenlafaxine
doxepin
duloxetine
escitalopram
fluoxetine
fluvoxamine
imipramine
ketamine
mirtazapine
nortriptyline
paroxetine
selegiline
sertraline
trazodone
venlafaxine
vilazodone
vortioxetine
Required Media (click to expand/reduce)
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)

https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.

By Day 7

Submission and Grading InformationBipolar 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?”

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 did well enough on Lithium to be discharged from the hospital but admits she has not been taking it as prescribed. When further questioned on the subject, she provides no additional details.

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 the PMHNP should do:

Begin Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 300 mg orally at HSRubric Detail

Select Grid View or List View to change the rubric’s layout.

Name: NURS_6630_Week5_Assignment_Rubric
Grid View
List View
Excellent

Point range: 90–100 Good

Point range: 80–89 Fair

Point range: 70–79 Poor

Point range: 0–69
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.
9 (9%) – 10 (10%)
The response accurately, clearly, and fully summarizes in detail the case for the Assignment.

The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient.
8 (8%) – 8 (8%)
The response accurately summarizes the case for the Assignment.

The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient.
7 (7%) – 7 (7%)
The response inaccurately or vaguely summarizes the case for the Assignment.

The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.
0 (0%) – 6 (6%)
The response inaccurately and vaguely summarizes the case for the Assignment, or is missing.

The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient.
Decision #1 (1–2 pages)

• 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.
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.

BUY A PLAGIARISM-FREE PAPER HERE

The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected.

The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response.

The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients.

Examples provided fully support the decisions and responses provided.
16 (16%) – 17 (17%)
The response accurately explains the decision selected.

The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected.

The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response.

The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response.

The response accurately explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided support the decisions and responses provided.
14 (14%) – 15 (15%)
The response inaccurately or vaguely explains the decision selected.

The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected.

The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response.

The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients.

Examples provided may support the decisions and responses provided.
0 (0%) – 13 (13%)
The response inaccurately and vaguely explains the decision selected.

The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing.

The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing.

The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing.

Examples provided do not support the decisions and responses provided, or is missing.
Decision #2 (1–2 pages)