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.
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)
· 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.
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.
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: Support your rationale with a minimum of six 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.
Bipolar 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
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 HS
Decision Point One
Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”
· Today’s presentation is similar to the first day you met her
Decision Point Two
Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Client states that the drug makes her nauseated and gives her diarrhea
· Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again
Decision Point Three
Change to Depakote ER 500 mg at HS
Guidance to Student In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.
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Assessing and Treating Patients with Bipolar Disorder is an assignment.
Bipolar disorder is a rare disorder that causes mood and energy swings in people, resulting in sadness and mania. Diagnosing this condition correctly can be difficult for two reasons: 1) Patients with bipolar disorder are frequently depressed or manic, but they can be both; and 2) many of the symptoms of bipolar disease are similar to those of other conditions. Misdiagnosis is widespread, so you’ll need to know everything there is to know about the disorder’s pathogenesis. Consider how you may assess and treat patients who present with bipolar disorder as you look over the patient case study in this week’s Learning Resources for this Assignment.
To get ready for this assignment, do the following:
Review the Learning Resources for this week, including the Medication Resources for this week.
Consider the psychopharmacologic treatments you might suggest for the evaluation and treatment of people who require bipolar therapy.
The Project: 5 pages
Consider the following case study: An Asian American Woman. Bipolar Disorder is the diagnosis. You’ll have to make three selections about the medication you should give this patient. Take into account any potential influences on the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should weigh all of your possibilities before making your choice and continuing with the exercise. Make sure you’ve done your homework on each choice and that you’ve considered all of your options before making a selection. Make careful to conduct primary research on each option.
The case’s introduction (1 page)
Explain and summarize the case for this assignment in a few sentences. When prescription medication for this patient, be sure to consider the individual patient factors that may influence your decision.
1st decision (1 page)
Which option did you choose?
Why did you come to this conclusion? Make your response particular, and back it up with therapeutically relevant and patient-specific resources, such as primary literature.
Why didn’t you choose one of the other two possibilities in the exercise? Make your response particular, and back it up with therapeutically relevant and patient-specific resources, such as primary literature.
What were your intentions when you made this decision? Evidence and references to the Learning Resources should be used to back up your response (including the primary literature).
Describe how ethical issues may affect your treatment approach and patient communication. Give instances and be specific.
Second choice (1 page)
Why did you come to this conclusion? Make your response particular, and back it up with therapeutically relevant and patient-specific resources, such as primary literature.
Why didn’t you choose one of the other two possibilities in the exercise? Make your response particular, and back it up with therapeutically relevant and patient-specific resources, such as primary literature.
What were your intentions when you made this decision? Evidence and references to the Learning Resources should be used to back up your response (including the primary literature).
Describe how ethical issues may affect your treatment approach and patient communication. Give instances and be specific.
3rd Choice (1 page)
Why did you come to this conclusion? Make your response particular, and back it up with therapeutically relevant and patient-specific resources, such as primary literature.
Why didn’t you choose one of the other two possibilities in the exercise? Make your response particular, and back it up with therapeutically relevant and patient-specific resources, such as primary literature.
What were your intentions when you made this decision? Evidence and references to the Learning Resources should be used to back up your response (including the primary literature).
Describe how ethical issues may affect your treatment approach and patient communication. Give instances and be specific.
final thoughts (1 page)
Summarize your therapeutic recommendations for this patient’s treatment alternatives. Make careful you defend your suggestions and back them up with clinically relevant and patient-specific materials, such as primary research.
Note: Include at least six academic resources to back up your argument. The course text may be used to support your reasoning, but it does not count toward the resource requirement. You should make use of both primary and secondary sources.
Client of Korean Descent/Ancestry in Bipolar Therapy
Asian woman
INFORMATION ON THE BACKGROUND
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
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 HS
Decision Point One
Begin Lithium 300 mg orally BID
RESULTS OF DECISION POINT ONE
· Client returns to clinic in four weeks
· Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”
· Today’s presentation is similar to the first day you met her
Decision Point Two
Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology
RESULTS OF DECISION POINT TWO
· Client returns to clinic in four weeks
· Client states that the drug makes her nauseated and gives her diarrhea
· Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again
Decision Point Three
Change to Depakote ER 500 mg at HS
Guidance to Student In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents.
