Assignment: Assessing and Treating Patients With Bipolar Disorder
Psychopharmacologic Approaches to Treatment of Psychopathology
In the opinion of the National Institute of Mental Health (2018), Bipolar disorder is an episodic or chronic mental disorder that occasionally occurs at regular intervals. This disorder often causes extreme fluctuating changes in an individual’s moods, energy, activity, focus, and concentration. Bipolar disorder is also known as manic depressive disorder (Mayo clinic, 2020). Bipolar disorders are characterized by two extreme episodes of mood alterations called mania and depression; these mood alterations are always different from usual mood fluctuations and often require medical attention (American Psychiatric Association, 2020). The high emotional episodes are referred to as mania, while episodes of extreme emotional low are referred to as depression (Bhandari, 2020). The mania episodes are characterized by euphoria, low concentration, and poor judgment, while the depressive episodes are characterized by low energy, loss of interest in activities usually enjoyed. The purpose of this paper is to investigate a case study of a 26-year-old individual who has bipolar and the clinical decisions made for her treatment. The paper will also include ethical consideration and recommendations for treatment Assignment: Assessing and Treating Patients With Bipolar Disorder
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The client presented is a 26-year-old Korean woman hospitalized 21 days after the episodes of acute mania. She was diagnosed with bipolar I disorder. On the first visit to the office, she appears restless as she busies herself with the things on the desk while fidgeting from side to side on her seat. She soon engages in some conversation, stating that she does not believe her diagnosis of bipolar. She states that she just likes to sing, dance, and talk, and also cook. From her report, she says that her mood is fantastic, and she reports that she does not like to sleep since sleep is no fun. She adds that she sleeps around 5 hours a night. Her weight is about 110 pounds and 5.5″. From the medical records review, her health was in an overall way acceptable, and from the lab results, everything was within the normal limits (Laureate Education, 2016). The patient also had genetic testing done in the hospital. The Gene Sight testing result was positive for the CYP2D6*10 allele (Laureate Education, 2016). She states that she had stopped using lithium, which was prescribed in the hospital after she was discharged two weeks ago.
The decisions towards her treatment are made from the mental exam taken. Her cognitive results indicate that the client is alert, person, place, event, and time oriented. However, she is dressed oddly, as she wears what looked like an evening gown to the appointment. She possesses rapid, pressured, and tangential speech. Euthymic is her self-reported mood. She refutes any form of hallucinations, delusional thoughts, or paranoid thoughts (Laureate Education, 2016). Her judgment is integral, but her insight is impaired. She denies having any form of suicidal or homicidal ideas. From the rating scale, the Young Mania Rating Scale (YMRS), her score is 22, indicating mild mania for the presented client (Dcf. Psychiatry, 2020).
Decision Point One
Aiming towards the client’s treatment, a decision to begin Risperdal 1mg orally BID to treat the bipolar I disorder for this client was made. Risperdal is a prescription medicine used to treat bipolar mania and other bipolar disorders (Stahl, 2014). It is also known as a second-generation antipsychotic (SGA). Risperdal rebalances dopamine and serotonin in improving thinking, behavior, and mood (Delmonte et al., 2016). It works by reducing the number of neurotransmitters available in the brain. Risperdal has been known to stop the reactions of dopamine-2 receptors (D2R), serotonin 2A receptors, and norepinephrine receptors in the brain (Stahl, 2014). These receptors are said to be high in a patient experiencing manic episodes of bipolar one disorder. Hence by blocking the receptors in the brain that are acted upon by dopamine and the effects of decreased dopamine reaction in the brain will help control the manic symptoms in bipolar for this client (Zhang & Stackman Jr, 2015). Risperdal also improves symptoms by coordinating attention, improving sleep, memory, and learning (Bhatia et al., 2020).
In treating manic episodes in bipolar, the first-line drug of administration is lithium (Jauhar & Young, 2019). However, as reported by the client, lithium was prescribed, but she discontinued the use after two weeks of being discharged (Laureate Education, 2016). The client’s symptoms may worsen due to the noncompliance with lithium. The main reason for mania rebounds in bipolar clients is lithium noncompliance (Jauhar & Young 2019). Hence, the decision to use Risperdal as a first line of treatment for the manic episodes in this client is more appropriate.
This treatment decision was aimed at improving the behavioral deficits of the client that suggested manic episodes. For example, she presented with fidgeting, lack of concentration, and tangential speech. The client also dressed in an evening gown while coming for the appointment. According to the American Psychiatric Association (2020), these symptoms showed high dopamine levels, norepinephrine, and serotonin in the brain. The treatment decision to use Risperdal will help regulate dopamine in the Central nervous system; hence improving these symptoms.
The anticipated results of the first decision made included improving manic symptoms that would have been reported and observed at follow up with this patient. However, after four weeks, the client reports back to the office, accompanied by her mother, sedated, and lethargic. From her mother’s explanation, she has been like that since about a week after the last office visit. Although the patient reported improved concentration levels, her appearance indicates possible side effects contrary to the prescribed medication. Although side effects are expected with psychopharmacological agents, this outcome is different from the expected outcomes.
Ethical consideration in caring for this client with bipolar disorder will include informed consent since the client is in a manic state and has poor concentration. The drugs’ side effects always fear committing to a particular treatment plan, resulting in ineffective treatment plans for the patients. It is important for the provider to patiently ensure that the client can understand the course of treatment, possible side effects, and how to recognize and report them. The client is free to ask any questions and accept or decline the treatment (American Medical Association, 2020). It may be necessary to involve the patient’s medical power of attorney in making treatment decisions if possible.
Decision Point Two
Due to the patient’s response to decision one, Risperdal 1 mg at HS was chosen for the second decision. The client had some signs of improvement four weeks after the drug started but also presented with sedation and lethargy. Although Risperdal may cause drowsiness, genetic testing revealed the presence of CYP2D6*10 alleles in the patient’s gene, which may have influenced her reaction to the medication, causing her to be sedated and lethargic (Laureate Education, 2016). The decision to change her medication dosage and time was taken to help address the sedation accompanied by a higher dose and help improve symptoms related to bipolar disorder (Jauhar & Young, 2019). Stahl (2014) states that it is often necessary to titrate the Risperdal dose to control mania symptoms.
Reducing the dosage to 1 mg and changing the frequency to once a night was aimed at managing the client’s symptoms without side effects associated with Risperdal toxicity. Also, the Risperdal administered at nighttime will be more appropriate for the client experiencing drowsiness as she could have improved sleep at night and achieve a productive day with daily activities without sedation and lethargy (Jauhar & Young, 2019).
The option to change the medication to lithium would be inappropriate due to the information received on the first visit about the client being non-compliant with lithium, hence, the potential risk of rebound mania (Stahl, 2014). The client also presented with sedation and lethargy while receiving 2mg of Risperdal in divided daily doses; thus, administering 2mg in one dose may worsen the sedation and lethargy, especially for this client, whose genetic testing revealed the CYP2D6*10 allele.
The provider’s expected outcomes are a decline in the client’s manic symptoms and recovery from Risperdal’s sedative effects. In the actual result, the client was less sedated and lethargic during the second follow-up visit, suggesting that titrated doses were successful (Laureate Education, 2016). She also had a 25% reduction in mania, with a Young Mania Rating Scale (YMRS) of 16 out of 22 (Dcf. psychiatry, 2020).
The ethical consideration guiding the decision-making for this patient’s treatment plan will be the principle of nonmaleficence. The other scenario options in decision point two potentially harm this patient. Hence providers need to educate the patient and their family about the reason for a change in the treatment plan, emphasizing their potential benefits and disadvantages. Education about the potential risk of Risperdal toxicity in this client cannot be overemphasized. Encourage the family to help with daily medication administration and identification of side effects and how to report them. Instructions should also be given on how to respond in case of overdose/toxicity or unwanted side effects.
Decision Point Three
The second decision yielded immense positive results, hence the decision to continue using the Risperdal 1 mg at HS and to reassess in the next four weeks. According to Stahl (2014), maintaining the dosage would ensure close monitoring of the client’s response to the drug. The client also showed improvement on this follow-up visit, implying that the medication was tolerated; hence, the decision to maintain the dose. This treatment option is aimed at improving the symptoms of the patient. Furthermore, the Risperdal dose should be maintained when there are no undesirable side effects until the bipolar symptoms are adequately controlled; this helps prevent manic symptoms from rebounding (Stahl, 2014).
The option of increasing the Risperdal to 1mg orally BID may result in the side effects noted during the first decision. Maintaining the dosage is more suitable since the following assessment indicated that the client responded positively to this dose. Changing the medication to Latuda would be unnecessary since the current medication and dose have demonstrated a therapeutic effect. Introducing a new drug into the client’s body system at this point increases the potential for unwanted side effects, especially drowsiness, agitation, and lethargy known to be associated with Latuda.
Confidentiality is an important aspect of medical care. Psychiatric illnesses often impact a person’s ability to function in their daily lives, including work, school, or relationships. This, in addition to mental illness stigmatization, makes confidentiality for these groups of patients a topmost priority (Healthline, 2020). Patients who can do so should decide who gets information about their treatment and that the decision must be honored. Otherwise, any information about treatment plans should not be shared with anyone except with permission from the patient.
Bipolar disorders are very common mood disorders that affect an individual’s ability to function daily. Several factors should be considered in the diagnosis and treatment of patients with bipolar disorders. Pharmacokinetics and pharmacodynamics factors for each patient should be considered before choosing psychopharmacological agents, their dosage, route, frequency, and administration time. It is also noted that abrupt noncompliance with medications when treating bipolar disorders can bring unwanted side effects that can be potentially dangerous. Hence, Risperdal was chosen over lithium, which is the first line of treatment for manic bipolar.
Recommendations for the treatment options include laboratory diagnostics to help determine a patient’s ability to process a drug; for example, patients with decreased renal and hepatic functions may be prone to toxicity; hence, testing before and during treatment is recommended. Although genetic testing had been done on this patient, it was not duly considered in the initial decision-making for the treatment of this client. It is important to consider genetic composition and how it may influence a person’s reaction to medications and, hence, medication choices when planning care. For example, patients with the CYP2D allele may have a decreased clearance when taking psychopharmacological agents. Hence, there is a need to consider a smaller dosage or alternatives (Chen et al., 2015). Assignment: Assessing and Treating Patients With Bipolar Disorder
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Assignment: Assessing and Treating Patients With Bipolar Disorder