DELIVER WITHIN 6 HRS

Decision Point Two

Discontinue Risperdal and start Lithium sustained release 300 mg orally BID

RESULTS OF DECISION POINT TWO

 Client returns to clinic in four weeks

 Client no longer lethargic after the end of the first week

 Client has a slight decrease in her Young Mania Rating Scale (from 22 to 19)

 Client reports that her sleep is again decreasing, but that overall, she is happy

Decision Point Three

Guidance to Student

Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may be demonstrating slower clearance of Risperdal from her system, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The client responded well to the discontinuation of Risperdal and after about a week of drug cessation, she was no longer lethargic /sedate. However, in the following 3 weeks, she had experienced increased symptoms, although a slight improvement in YMSR score was noted. The PMHNP could make no changes at this time and allow the lithium to remain at its current dose for an additional 4 weeks and reassess. Conversely, the PMHNP can increase the lithium to 450 mg orally BID and then reassess in 4. The additional milligrams may hasten mood stabilization. Risperdal 0.5 mg orally BID may be appropriate if the clients’ symptoms are worsening, however, the PMHNP would need to have the client return to the office sooner than 4 weeks for an interim visit to assess effects of drug and presence of somnolence/lethargy.