Bipolar Disorder

Week 4 Case Study

Walden University

NURS - 6630N Psychopharmacologic Approaches to Treatment of Psychopathology

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Background Information

This case involves a 26-year-old woman of Korean descent who was recently

hospitalized for new onset of mania. She was diagnosed with bipolar I disorder and has presented

for her first appointment. She appears “busy” during the interview and questions her diagnosis of

bipolar disorder. She describes her mood as “fantastic”. She averages about 5 hours of sleep per

night and states “I hate sleep, it’s no fun”. Her medical work up shows she is in good health.

Genetic testing was completed due to a failure to respond to many medications she was being

treated with. She is positive for CYP2D6*10 allele. She has also stopped taking her lithium since

her discharge. Patient is wearing an evening gown. Her speech is rapid, pressured and tangential.

Affect is broad and self-reported mood is euthymic. She is currently denying suicidal or

homicidal ideations, visual or auditory hallucinations. The Young Mania Rating Scale score is

22. The purpose of this paper is to use the case study and decision tree to prescribe treatment for

the patient and provide supporting evidence for my decisions.

Bipolar I Disorder

Bipolar disorder (BPAD) is a serious mental disorder characterized by episodes of

depression, hypomania/mania and mixed episodes, with interepisodic recovery (Shah, Grover, &

Rao, 2017). Manic episodes are characterized by periods of mood elevation. The individual may

experience elevated or irritable mood with increased activity, inflated self-esteem, lack of need

for sleep, increased involvement in reckless activities involving pleasure, racing thoughts, and

increased distractibility. During depressive episodes, the individual experiences quite the

opposite, having low mood, energy, and self-attitude. Bipolar disorder affects men and women

equally; however, women are more likely to rapid cycle. Onset is usually around late teens to

early twenties. It is not uncommon for individuals with bipolar I disorder to also suffer from

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alcohol or substance abuse, generalized anxiety disorder, panic disorders, and personality

disorders.

GeneSight Testing

While in the hospital, the patient underwent genetic testing due to failure to respond to

medications. The Assurex GeneSight Psychotropic test is a pharmacogenomic panel that

provides clinicians with a report to guide medication selection that is unique to each patient

based on their individual genetic profile (Health Quality Ontario, 2017). She was found to have

the CYP2D6*10 allele which is the most common decreased function allele in Asians. This

means she would not properly metabolize risperidone and other similar medications. She would

be at a higher risk for adverse effects and would need dose reductions if being prescribed these

medications.

Decision 1

I chose to start the patient on Lithium 300MG orally BID. The mainstay of

pharmacological treatment of manic episodes is mood stabilizers, with antipsychotic or

benzodiazepines as needed for agitation (Lee & Swartz, 2017). I would hope to see the patients

mood level off and a decrease in her manic behaviors. Lithium is proven to be effective for

treatment of manic and depressive episodes. Lithium has also been found to have anti-suicide

properties. This is especially important since 25-50% or individuals with bipolar disorder attempt

suicide and up to 15% die by suicide (Lee & Schartz, 2017). Lithium actually reduces suicide in

patients with bipolar disorder (Stahl, 2013). At four weeks, the patients reports she is only taking

the medication when she feels like it and her behaviors are similar to the first visit. By this time,

I would have hoped to have seen improvement in her symptoms. Because the patient has not

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been compliant with taking medication as prescribed and only taking it as she feels like it, the

medication has not achieved therapeutic levels.

Decision 2

I decided to assess rationale for noncompliance to elicit reason for noncompliance and

educate the patient on the drug effects and pharmacology. The patient returns to the clinic in four

weeks and states that the medication is making her nauseous and giving her diarrhea. She has

only been taking the medication when the symptoms abate and then restarts until the symptoms

return. About half of the patients diagnosed with bipolar disorder (BD) become non-adherent

during long-term treatment (Post, 2017). Gastrointestinal side effects, like nausea and diarrhea,

are common with the use of lithium, especially early in treatment and can lead to medication

nonadherence. Because of this, educating the patient on the side effects of lithium is an essential

part of clinical practice and managing the side effects is a critical element when treating bipolar

disorder (Gitlin, 2016). By understanding the reason behind the patients noncompliance with

taking medication, I can better address the issue and educate the patient.

Decision 3

I decided to change the patients lithium to an extended release formulation at the same

dose and frequency. I am hoping to reduce the gastrointestinal side effects caused by the lithium

and ultimately improve adherence to the medication. Nausea can be helped by taking the

medication with food or switching to an extended release form of the medication (Aiken, 2017).

Changing the lithium to a different preparation—from capsules to sustained release or vice versa

—is only useful for side effects affected by absorption such as gastrointestinal side effects

(Gitlin, 2016). Overall, choosing lithium for this patients treatment was the best choice. Lithium

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is considered the gold standard in the treatment of bipolar I disorder since it treats manic and

depressive episodes and also decreases suicidality.

Ethical Considerations

Lithium is a drug with a narrow therapeutic index and requires careful therapeutic drug

monitoring to maximize effectiveness and minimize adverse drug effects and toxicity (Nederlof,

et. al., 2018). Providers ordering this medication should be prepared to monitor the patient

carefully to maintain therapeutic dosing. Patients should be educated on possible adverse effects

such as decreased kidney function that may lead to kidney failure, effects to the thyroid leading

to hypothyroidism, possible weight gain, and influence on the blood pressure. Providers have

the responsibility to fully educate patients and adequately monitor patients when prescribing

lithium.

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References

Aiken, Chris. (2017). 7 ways to improve tolerability of lithium. Psychiatric Times. Retrieved

from https://www.psychiatrictimes.com/bipolar-disorder/7-ways-improve-lithiums-

tolerability

Chakrabarti S. (2016). Treatment-adherence in bipolar disorder: A patient-centred

approach. World journal of psychiatry, 6(4), 399-409. doi:10.5498/wjp.v6.i4.399

Dean L. (2017). Risperidone Therapy and CYP2D6 Genotype. Medical Genetics

Summaries. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK425795/

Gitlin M. (2016). Lithium side effects and toxicity: prevalence and management

strategies. International journal of bipolar disorders, 4(1), 27.

Health Quality Ontario (2017). Pharmacogenomic Testing for Psychotropic Medication

Selection: A Systematic Review of the Assurex GeneSight Psychotropic Test. Ontario

health technology assessment series, 17(4), 1-39. Retrieved from

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5433545/

Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder

[Interactive media file]. Baltimore, MD: Author.

Lee, J., & Swartz, K. L. (2017). Bipolar I Disorder. In Johns Hopkins Psychiatry Guide.

Available from

https://www.hopkinsguides.com/hopkins/view/Johns_Hopkins_Psychiatry_Guide/787045

/all/Bipolar_I_Disorder

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Muneer A. (2015). Pharmacotherapy of bipolar disorder with quetiapine: a recent literature

review and an update. Clinical psychopharmacology and neuroscience : the official

scientific journal of the Korean College of Neuropsychopharmacology, 13(1), 25-35.

Nederlof, M., Heerdink, E. R., Egberts, A., Wilting, I., Stoker, L. J., Hoekstra, R., & Kupka, R.

W. (2018). Monitoring of patients treated with lithium for bipolar disorder: an

international survey. International journal of bipolar disorders, 6(1), 12.

doi:10.1186/s40345-018-0120-1

Post R. M. (2017). The New News about Lithium: An Underutilized Treatment in the United

States. Neuropsychopharmacology : official publication of the American College of

Neuropsychopharmacology, 43(5), 1174-1179.

Shah, N., Grover, S., & Rao, G. P. (2017). Clinical Practice Guidelines for Management of

Bipolar Disorder. Indian journal of psychiatry, 59(Suppl 1), S51-S66.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical

applications (4th ed.). New York, NY: Cambridge University Press.

Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. New York, NY: Cambridge

University Press.

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-

0060-3. Retrieved from Walden Library databases.

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