Psychopharmacologic Approaches to Treatment of Psychopathology
Tinacherry100$
5_BipolarTherapycasestudy.docxLearning Resources
Required Readings (click to expand/reduce)
Ostacher, M. J., & Hsin, H. (2016). The use of antiepileptic drugs in psychiatry. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 93–98). Elsevier.
Perlis, R. H., & Ostacher, M. J. (2016a). Bipolar disorder. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 48–60). Elsevier.
Perlis, R. H., & Ostacher, M. J. (2016b). Lithium and its role in psychiatry. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 86–92). Elsevier.
Traeger, L., Brennan, M. M., & Herman, J. B. (2016). Treatment adherence. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 20–26). Elsevier.
American Psychiatric Association. (2010b). Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar.pdf
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. https://doi.org/10.1007/s00228-015-1855-6
Hirschfeld, R. M. A. (n.d.). Guideline watch: Practice guideline for the treatment of patients with bipolar disorder (2nd ed.). https://psychiatryonline.org/pb/assets/raw/sitewide/practice_guidelines/guidelines/bipolar-watch.pdf
Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331–333. https://doi.org/10.1007/s40263-013-0060-3
Medication Resources (click to expand/reduce)
IBM Corporation. (2020). IBM Micromedex.
https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537
Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.
Review the following medications:
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· amitriptyline · bupropion · citalopram · clomipramine · desipramine · desvenlafaxine · doxepin · duloxetine · escitalopram · fluoxetine · fluvoxamine |
· imipramine · ketamine · mirtazapine · nortriptyline · paroxetine · selegiline · sertraline · trazodone · venlafaxine · vilazodone · vortioxetine |
Bipolar Therapy Client of Korean Descent/Ancestry
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 confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.
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
Decision Point One
Select what you should do:
Begin Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 100 mg orally at HS
Bipolar Therapy Client of Korean Descent/Ancestry
Decision Point One
Begin Risperdal 1 mg orally BID
RESULTS OF DECISION POINT ONE
Begin Risperdal 1 mg orally BID
· 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”
Decision Point Two
Decrease Risperdal to 1 mg at HS
RESULTS OF DECISION POINT TWO
Decrease Risperdal to 1 mg at HS
· 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 Three
Continue at same dose of Risperdal and reassess in 4 weeks
Guidance to Student At this point, you 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.
