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Changes in mood, energy, attention, activity levels, and the capacity to carry out everyday tasks are all symptoms of bipolar illness ("Bipolar Disorder," n.d.). Clients with bipolar disorder will experience times of sadness and anger, as well as intervals of euthymia and happiness, enthused ("Bipolar Disorder," n.d.). 3 Bipolar Disorder is divided into three types: Bipolar One Disorder, Bipolar Two Disorder, and Cyclothymic Disorder.
Clients with Bipolar One Disorder often experience both manic and depressed signs at the same moment, lasting at least seven to two weeks ("Bipolar Disorder," n.d.). The patient will need inpatient therapy at a mental facility due to the severity of the symptoms. Bipolar two customers are less likely to have full-fledged manic episodes. They are hypomanic by nature. Cyclothymic Disorder is characterized by hypomania and depression at the same time, and may persist up to two years ("Bipolar Disorder," n.d.). Unspecified bipolar disorder occurs when individuals have symptoms that do not resemble those listed above. Mixed-feature patients exhibit both manic and depression symptoms at the same time.
Grandiosity, hyperverbal, anticipatory anxiety, flights of ideas, and a desire for less rest are all symptoms of mania. Resting more than normal, losing interest in previously pleasant activities, weight loss, reduced appetite, feelings of worthlessness or despair, and suicidal thoughts are all signs of depression.
Case Study
4 The client is a 26-year-old Korean-American woman who comes in for her follow-up visit following a twenty-one-day intensive hospitalization for psychosis. 1 Bipolar 1 Disorder was identified in the client. The patient is "busy" when she arrives at the office, fiddling with items BIPOLAR DISORDER 3
on her desk and moving from side to side in her chair. “They claim I was Bipolar, but I don't believe it,” the customer says.
Do you believe that? I just like talking, dancing, and singing. Did I mention that I like cooking? ” The customer is 5'5” tall and weights 110 pounds.
The client indicates that she is in a positive mood and that she rests around five hours each night. She then adds, "I detest to rest; it's not enjoyable." Medical records show that the client is in excellent health and that her labs are normal. During her stay in the hospital, the client underwent GeneSight testing, which showed she had the CYP2D6*10 allele. The client claims she has been noncompliant with the Lithium she was given in the hospital for the last two weeks. The client is aware of who he is, where he is, what time it is, and what circumstance he is in. The customer is dressed strangely for her meeting, wearing an evening gown. The speaker speaks quickly, under duress, and in a tangential manner. The mood is euthymic, according to self-report. The client has a large impact. There are no overt signs or symptoms of delusions, and the client denies having hallucinations. Insight and judgment are both intact.
It appears to be harmed. 5 On The Young Mania Rating Scale, the client received a score of 22.
DECISION 1
Lithium For several years, lithium has become the medication of preference for Bipolar Disorder; nevertheless, owing to adverse effects, it is not as commonly used as it used to be. Lithium may induce toxicity and renal adverse effects, thus a change in electrolytes equilibrium or fluid intake might result in toxicity from Lithium buildup in the body. To prevent toxicity, blood Lithium concentrations must be monitored on a regular basis. After ingestion, lithium is quickly absorbed. 3 In approximately 3 hours, peak serum levels are achieved. 6 Eight hours is BIPOLAR DISORDER 4
required for maximum absorption. 3 A constant plasma blood level takes around two weeks to achieve (Stahl, 2018). Because lithium has a limited therapeutic range, it must be monitored on a frequent basis to prevent toxicity. In healthy individuals, lithium has no psychoactive impact. In nerves and, muscle cells lithium affects sodium transfer across cellular membrane (Stahl, 2018) Risperdal
3 Risperdal is an antipsychotic medication, a mood booster and a second-generation antipsychotic (Stahl, 2018). Risperdil was used to treat psychosis in Bipolar Disorder, although it was originally prescribed to treat agitation, aggressiveness, and self-harming behaviors (Atkin, Nunez, & Gobbi, 2017). The typical dose is 2-8mg per day, with drowsiness, irritability, anxiety, sleeplessness, and migraine as adverse effects. 3 Risperdal may make you gain weight. Risperdal may induce convulsions, diabetes, and the neuroleptic malignancy syndrome. 3 Risperdal has a half-life of 20 to 24 hours, while lengthy has a of three to six days (Stahl, 2018). There is no need to use this medicine with meals. 3 The body does not remove long-acting injectable forms for seven to eight weeks following the last shot (Stahl, 2018) Seroquel
In Bipolar Disorder, Sereoquel may be used to treat severe mania and anxiety. 3 Sedation, loss of weight, vertigo, hypotension, dry mouth, constipation, weight gain, stomach discomfort, tardive dyskinesia, and neuromuscular blocking malignancy syndrome are some of the possible side effects. Seroquel is available in doses ranging from 400 to 800 mg per day. Risperdal has been shown to be effective and acceptable in the treatment of Bipolar Mania (Sajatovic, Subramoniam, & Fuller, 2006) Decision 2
Because the customer did not get the desired result, I must choose between the following medications:
1. 3 Stop taking Risperdal and start taking Lithium 300 mg orally BID instead.
2. 3 At HS, reduce Risperdal to 1 mg.
3. 3 At HS, reduce Risperdal to 2 mg.
I decided to reduce Risperdal to 1 mg at HS for this choice. I would have chosen this option initially if it had been offered for choice one. My decision was based on the fact that the customer has the CYP2D6*10 allele, which means that larger doses will result in higher plasma levels (Puangpetch, et al.,2016). To avoid toxicity, this customer need a lower dosage. Risperdal 0.5 mg daily would have been the optimum dose in real life, with the drug titrated up as required. I decided against increasing Risperdal to 2 mg at HS since it would raise plasma levels and may produce greater drowsiness and adverse effects (Puangpetch, et al.,2016). 3 Since this client was already non-compliant on Lithium, I did not opt to switch Risperdal to Lithium. My objective is to observe a decrease in drowsiness and lethargy, as well as an increase in Bipolar symptoms.
In four weeks, the patient presented for a follow-up visit. As per the Young Mania Rating Scale, the client looks less sluggish and sedate, and his Bipolar symptoms have decreased by 25%.
Decision 3
3 I was given the following options for my final decision:
1. Maintain the same Risperdal dosage and reevaluate after four weeks.
2. Reintroduce Risperdal to a daily dose of 1 mg.
3. 3 Switch from Risperdal to Latuda and take 40 mg orally every day.
I decided to maintain the client on his current Risperdal dose and reevaluate in four weeks. I didn't want to raise Risperdal to 1 mg BID since the customer was sedated and sluggish at that dose. Because the patient is of Korean ancestry and has tested positive for CYP2D6*10, Risperdal may take time to clear her system. As a result, the client's plasma level rose, leading her to become sedated. It would raise plasma levels once again, resulting in adverse effects and toxicity (Puangpetch, et al., 2016). I chose not to switch to Latuda since the client's Bipolar symptoms have already improved, and there are no adverse effects at this moment. To evaluate Risperdal's effectiveness, it's best to wait four to six weeks (Stahl, 2018). 8 Latuda is a second-generation antipsychotic that is used to treat schizophrenia and bipolar disorder (Stahl, 2018). This customer suffers from mania rather than sadness. Latuda is also a costly medicine, and most insurance companies may refuse to pay for it.
Impact of Ethical Consideration on Treatment Plan
When deciding on therapy, we must take into account a client's race and values. 3 This client is of Korean ancestry, and there is still a stigma associated with mental health in Korea. Koreans think they are unlucky and that mental illness lowers their quality of life (Min & Wong, 2017) The PMHNP must be informed of the customer's CYP2D6*10 positivity. When prescribing medicines for this patient, the PMHNP should use extreme caution. We must take a step back and consider that with certain medicines, less is more. When the patient is outpatient, we should start with a lower dosage and gradually increase it. If the client was an inpatient, he or she BIPOLAR DISORDER 7
would be monitored 24 hours a day to check for adverse effects.
9 References Atkin, T., Nunez, N., & Gobbi, G. (2017). Practitioner Review: 9 The effects of atypical antipsychotics and mood stabilizers in the treatment of depressive symptoms in pediatric bipolar disorder. Journal of Child Psychology and Psychiatry, 58 (8), 865-879. http://dx.doi.org/10.1111/jcpp.12735
Bipolar Disorder. (n.d.). 4 Retrieved from https://www.nimh.nih.gov/health/topics/bipolardisorder/index.shtml Fountoulakis, K. N. (2015). Bipolar Disorder: 3 An Evidence-Based Guide to Manic Depression. http://dx.doi.org/10.1007/978-3-642-37216-2 Gao, K., Ganocy, S. 2 J., Conroy, C., Brownrigg, B., Serrano, M. B., & Calabrese, J. R. (2017, May 17). 2 A placebo-controlled study of quetiapine-XR in bipolar depression accompanied by generalized anxiety with and without a recent history of alcohol and cannabis use. Psychopharmacology, 234, 2233-2244. 10 http://dx.doi.org/10.1007/s00213-017-4642-5 Ketter, T. 11 A., Miller, S., Dell'Osso, B., & Wang, P. W. (2016). 12 Treatment of bipolar disorder: 11 Review of evidence regarding quetiapine and lithium. Elsevier, 191, 256-273. 7 http://dx.doi.org/10.1016/j.jad.2015.11.002 Min, S., & Wong, Y. I. (2017, Feb. 23). 9 Association Between Community Contextual Factors and Stigma of Mental Illness in South Korea: a Multilevel Analysis. Psychiatric BIPOLAR DISORDER 8
3 Quarterly, 88, 853-864. http://dx.doi.org/10.1007/s11126-017-9503-1 Okanovic, M., Zivanovic, O., Bosnjak, M. 9 C., Knezevic, V., Siladi, D., & Bjelan, S. (2020). 9 LITHIUM IN THE TREATMENT OF BIPOLAR DISORDER – MONITORING OF THE ADVERSE EFFECTS. Med Pregl, 49-53. http://dx.doi.org/10.2298/MPNS2002049O BIPOLAR THERAPY 10
3 Puangpetch, A., Nuntamool, N., Hongkaew, Y., Chamnanphon, M., & Sukasem, C. (2016, Sept. 15). 9 CYP2D6 Polymorphisms and Their Influence on Risperidone Treatment. Pharmacogenomics and Personalized Medicine , 9, 131-147. 13 http://dx.doi.org/10.2147/PGPM.S107772 Sajatovic, M., Subramoniam, M., & Fuller, M. A. (2006). 13 Risperidone in the treatment of bipolar mania. Neuropsychiatric Disease and Treatment, 2(2), 127-138. 14 http://dx.doi.org/10.2147/nedt.2006.2.2.127 Stahl, S. M. (2018). 15 Stahl’s Essential Psychopharmacology: 9 Prescriber’s Guide (6th ed.). 16 New York, NY: 9 University Printing House.