Nurs 6630 Psychopharmacology Client of Korean Descent/Ancestry/ Assessing and Treating Clients with With Bipolar Disorder
CASE STUDY: Week 4: Bipolar TherapyJay, an 18-year-old high school senior, presents with symptoms of difficulty sleeping and feeling sad, which results in an initial diagnosis of depression. His mother later reports, however, that Jay 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, Jay’s psychiatric mental health nurse practitioner diagnosed him with bipolar disorder.Cases like this are not uncommon with bipolar disorder, as initial assessments rarely provides all the information needed. In your role, as a psychiatric mental health nurse practitioner, you must develop strategies for properly assessing and diagnosing these clients because treatments for bipolar disorder are significantly different than treatments for depression or other mood disorders.This week, as you examine bipolar therapies, you explore the assessment and treatment of clients with bipolar disorder. You also consider ethical and legal implications of these therapies.Photo Credit: [Vanessa Galeote]/[Hemera / Getty Images Plus]/Getty ImagesAssignment: Assessing and Treating Clients with With Bipolar DisorderBipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients 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 client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with bipolar disorder.Learning ObjectivesStudents will:Assess client factors and history to develop personalized plans of bipolar therapy for clientsAnalyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring bipolar therapyEvaluate efficacy of treatment plansAnalyze ethical and legal implications related to prescribing bipolar therapy to clients across the lifespanLearning ResourcesNote: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus.Required ReadingsNote: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.
Chapter 6, “Mood Disorders”Chapter 8, “Mood Stabilizers”Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. New York, NY: Cambridge University Press.To access the following chapters, click on the Illustrated Guides tab and then the Mood Stabilizers tab.
Chapter 4, “Lithium and Various Anticonvulsants as Mood Stabilizers for Bipolar Disorder”Chapter 5, “Atypical Antipsychotics as Mood Stabilizers for Bipolar Disorder”Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331-333. doi:10.1007/s40263-013-0060-3Note: Retrieved from Walden Library databases.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/s00228-015-1855-6Note: Retrieved from Walden Library databases.Required MediaLaureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: AuthorNote: This case study will serve as the foundation for this week’s Assignment.Optional ResourcesMostafavi, A., Solhi, M., Mohammadi, M., Hamedi, M., Keshavarzi, M., & Akhondzadeh, S. (2014). Melatonin decreases olanzapine induced metabolic side-effects in adolescents with bipolar disorder: a randomized double-blind placebo-controlled trial. Acta Medica Iranica, 52(10), 734-739.Retrieved from http://acta.tums.ac.ir/index.php/actaTo prepare for this Assignment:Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.The AssignmentExamine 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 #1Which decision did you select?Why did you select this decision? Support your response with evidence and references to the Learning Resources.What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?Decision #2Why did you select this decision? Support your response with evidence and references to the Learning Resources.What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?Decision #3Why did you select this decision? Support your response with evidence and references to the Learning Resources.What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.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.Note: Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.Submission and Grading Information CASE STUDYClient of Korean Descent/AncestryBACKGROUND INFORMATIONThe 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”
SUBJECTIVEPatient 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 EXAMThe 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
1. Decision Point OneSelect what the PMHNP should do:Begin Lithium 300 mg orally BIDBegin Risperdal 1 mg orally BIDBegin Seroquel XR 100 mg orally at HSSELECTED ANSWER: Begin Risperdal 1 mg orally BIDDecision 2Bipolar TherapyClient of Korean Descent/Ancestry2. Decision Point TwoRESULTS OF DECISION POINT ONE Client returns to clinic in four weeks Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic Client's mother explains that “she has been like this since about a week after the last office visit”Select what the PMHNP should do next:Discontinue Risperdal and start Lithium sustained release 300 mg orally BIDDecrease Risperdal to 1 mg at HSChange Risperdal to 2 mg at HSAnswer selected: Decrease Risperdal to 1 mg at HSDecision Point THREERESULTS OF DECISION POINT TWO Client returns to clinic in four weeks Client is less sedate, less lethargic and shows symptom improvement Young Mania Rating Scale has decreased from 22 to 16 (a bit more than a 25% decrease in symptoms)Decision Point ThreeSelect what the PMHNP should do next:Continue at same dose of Risperdal and reassess in 4 weeksIncrease Risperdal back to 1 mg orally BIDChange to Latuda 40 mg orally dailySelected answer: Continue at same dose of Risperdal and reassess in 4 weeksRESULTS FOR DECISION THREE AND SUMMARYGuidance to StudentAt this point, the PMHNP may be wise to allow the client to remain at the same dose and reassess in 4 weeks. Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may have slower clearance of Risperdal from her system, which may have resulted in higher than normal levels of Risperdal in the blood, which in turn resulted in sedation. Therefore, if we were to increase back to 1 mg orally BID, she may have the same side effects. Latuda is FDA approved for bipolar I depression, which is not the presentation we are attempting to treat. Additionally, it is quite expensive and many insurance companies will not pay for it until other agents have been attempted and failed.