advanced pharmacology

Week 8 Initial Discussion Post Discussion

Decision Making When Treating Psychological Disorders

The psychological disorder selected for this week’s discussion post was Bipolar Disorder in a 26-year-old Korean female. She presented to the clinic after a 21-day hospitalization for onset of acute mania. She arrives to the office dressed in evening attire, and her speech is rapid, pressured, and tangential. She is unable to sit still during the interview as she reports having a “fantastic” mood and decreased need for sleep due to sleep not being “fun”. She admits that she does not believe that she has bipolar because she just likes to “talk, dance, and cook”. She reports being prescribed Lithium while she was hospitalized, but admits that she stopped taking this medication once she was discharged.

These initial assessment behaviors represent those similar to a bipolar, manic or euphoric state. Manic episodes are characterized by heightened or irritable moods that are often associated with hyperactivity, excessive enthusiasm, flight of ideas, and a reduced need for sleep (Rosenthal & Burchum, 2018). Patients with bipolar disorder can often present with varying mood behaviors, and these situations often occur in cycles of unsafe and even risky behavior. Patients can also experience periods of comparably normal moods in-between manic or depressive episodes, which can make adherence to treatment difficult.

Pharmacotherapeutic Impact on Patient Pathophysiology

The first treatment plan decision was to begin Lithium 300 mg orally BID . Research suspects that bipolar disorder may be caused by a neurotransmitter imbalance, or by disruption of neuronal growth and survival. Mood-stabilizing drugs can prevent or reverse neuronal atrophy in patients with bipolar disorder by influencing the signaling pathways that regulate neuronal growth and survival (Rosenthal & Burchum, 2018). Lithium has been effective for approximately 70 percent of the people who take it, as it has helped stabilize or modulate the ups and downs of this illness (Gooding & Wolford, 2019). Starting this patient back on her Lithium was the first choice to address her manic behaviors.

The patient returned to the clinic four weeks later with similar presenting behaviors. She reported taking her medication “off and on” when she “feels like she needs it”. The patient may not feel that her behaviors require medication every day, and she previously reported that she does not feel that her behaviors required a diagnosis or medication. Some people who have taken lithium for bipolar disorder have complained that it robs them of their energy and creativity, and this perceived loss can be a factor in relapse associated with lithium noncompliance (Gooding & Wolford, 2019). The second decision made was to assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology. Thorough patient education is required prior to prescribing all medications. It is equally important to re-assess the patient’s level of understanding at each follow-up encounter to determine if non-compliance is also related to a lack of patient understanding.

She returned to the clinic for another 4 week follow-up and stated that the medication made her feel nauseated and gave her diarrhea. She reported that she would stop take the medication until the symptoms subsided and that she would then only take the medication again until the symptoms returned. Although medication education was provided at the last appointment, the patient was not adhering to her prescribed medications due to the development of these unpleasant symptoms. The third decision involved a medication adjustment of switching her Lithium to a sustained release preparation while keeping the dose and frequency the same. She was reporting that her medication was causing nausea and diarrhea, which are classic side effects of lithium therapy. Switching to an extended release formulation can help prevent unpleasant side effects while it also provides the patient with the same benefit of lithium’s mood stabilizing properties (Laureate Education, 2019). The patient must be clearly informed that these side effect can subside in time, but that she should continue with use to ensure if the medication is working effectively. If the side effects do not subside after completing an adequate trial of this sustained release preparation, it may be necessary to switch her to an alternate medication. Mood-stabilizing anticonvulsant medications, such as divalproex sodium (Depakote), carbamazepine (Tegretol), and lamotrigine (Lamictal), are showing promise in helping some people who were formerly referred to as lithium nonresponders (Gooding & Wolford, 2019).

Treatment Plans Suggestions

To successfully development a treatment plan, the patient and all treatment team members must all work together to develop achievable goals. Patients may resist treatment because they fail to see anything wrong with their thinking or behavior (Rosenthal & Burchum, 2018). Being aware of possible barriers to treatment will help create guidelines for the team to follow. If the patient is resistant to therapy, or if they are afraid of unpleasant side effects, the patient must be provided clear education and steps to move forward successfully. It is important that patients are educated and informed prior to starting any medications, to avoid abrupt discontinuation of treatment along the way. Telling the patient how long symptoms may occur and ways that they can be alleviated could also lead to successful adherence to therapy. Patients may not feel that they need medication due to episodes of mania or instability. It is important to provide support and honest medication education to help reach improved patient outcomes.

Patients should also be informed of the positive ways that medication could impact their life as well. When a patient is recommended medication to treat a disorder or illness, they should be informed of the beneficial factors that this medication can have on their future health and well-being also. A study was conducted to investigate the effect that lithium therapy had on preservation of cognitive functioning. Lithium has emerged as a neuroprotective/neurotrophic drug due to its capacity to activate multiple neurotrophic signaling cascades, upregulate levels of neurotrophic, angiogenic, and anti-apoptotic factors; and to also promote neurogenesis and neuronal process growth (Bersani, Quartini, Zullo, & Iannitelli, 2016). This study was able to demonstrate a potential hippocampus neuroprotective effect of Lithium in patients with borderline disorder. Although continued research will help confirm the extent of protection that Lithium therapy can have on bipolar disorder patients, this information is helpful to add to patient education discussions. Patients should be aware of the possible side effects and positive impacts that their medications can have on their brain activity and future health outcomes.

References

Bersani, G., Quartini, A., Zullo, D., & Iannitelli, A. (2016). Potential neuroprotective effect of lithium in bipolar patients evaluated by neuropsychological assessment: Preliminary results. Human Psychopharmacology: Clinical and Experimental, 31(1), 19–28. https://doi-org.ezp.waldenulibrary.org/10.1002/hup.2510

Gooding, D. C., Wolford, K., & Gooding, D. C. (2019). Bipolar disorder. Salem Press Encyclopedia of Health. Retrieved from https://search-ebscohost-com.ezp.waldenulibrary.org/login.aspx?direct=true&db=ers&AN=93871807&site=eds-live&scope=site

Laureate Education (Producer). (2019d). Bipolar therapy [Interactive media file]. Baltimore, MD: Author.

Rosenthal, L. D., & Burchum, J. R. (2018). Lehne’s pharmacotherapeutics for advanced practice providers. St. Louis, MO: Elsevier.