Bipolar Decision Tree

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11 Student paperStudent paper 22 Student paperStudent paper 33 Student paperStudent paper

Running head: PATIENT WITH BIPOLAR DISORDER 2

PATIENT WITH BIPOLAR DISORDER 2

Assessing and Treating Patients with Bipolar Disorder

Monique Moise

Walden University

NURS6630

January 01, 2022

Bipolar Disorder is a mental health disorder characterized through extreme

mood shifts that range from mania to depression. Sometimes patients experi- ence both mania and depression. Mania is when the patients’ behavior is elated and energized while depression is when the patient is sad, feels indifferent and hopeless (Carvalho, 2020). In this case study, the patient is a 26-year-old woman of Korean descent, who on her first appointment after 21 days of hospitalization has an onset of acute mania. The patient has bipolar disorder. The specific pa- tient characteristics that will influence my decision before prescribing any med- ications include the patient's hyperactivity. Upon arrival at the office, the patient appears to be quite busy. She constantly plays with things on the desk and shifts from side to side in her seat. Another factor that would influence my deci- sion is that the patients lack of insight of her disease. She says that she has been informed that she has bipolar, but she doesn’t believe it. She also has flight of ideas. On reviewing her medical records, she had been seen by a physi- cian who reported her to be in good health. All the lab works were within nor- mal limits. The patient had also undergone genetic testing in the hospital be- cause none of her medications seemed to work. She also tested positive for CYP2D6 10 allele. The positive results would also influence the decision on

which medication would be prescribed for the patient. The patient also con- fessed to having stopped taking the lithium that was prescribed to her two weeks ago. On performing a mental status exam, the patient is alert, oriented to person, place, time and event. Her speech is rapid, pressured, and tangential. Self-reported mood is euthymic. Affect is broad. She does not have visual or au- ditory hallucinations. She has no delusions, and the thought process is appar- ent. Judgement is intact and she has no suicidal or homicidal thoughts. When

given the Young Mania Rating Scale, her score was 22.

Decision # 1

Begin the patient on Lithium 300mg. Lithium is a mood stabilizer that is rec- ommended as a first line of defense when managing acute mania. Lithium

acts by downregulating the NMDA receptors. NMDA receptors are ion channel and glutamate protein receptors. Once they are downregulated, the levels of glutamate in the postsynaptic neurons increase while decreasing in the presy- naptic neurons. Glutamate is an excitatory neurotransmitter. During mania, the levels of glutamate are elevated. A decrease of glutamate in the presynaptic neurons reduce the excitatory effect that is caused by glutamate. Lithium also causes a decrease of dopamine activity in the presynaptic neurons. This also re- duces the excitatory neurotransmission in the brain, leading to a resolution of the manic episodes (Malhi, 2017). Apart from lithium being the first line of treat- ment for bipolar disorders, I also chose lithium because of its pharmacokinetics. Lithium works rapidly and completely absorbs. It has a peak serum concentra- tion of 1 to 2 hours. Most of the lithium is excreted in urine with few amounts excreted in feces and sweat. It has a half-life of 24 hours and a bioavailability of up to 5 days. I did not choose Risperidal 1 mg and Seroquel XR 100mg because the patient tested positive of cytochrome CYP2D6 10 allele. Risperidal and Sero- quel XR are metabolized by the enzyme CYP2D6 in the liver into their active metabolites while lithium is not affected by this enzyme. Once a drug has been metabolized, its therapeutic effect decreases (Lopez-Munoz, 2018). By selecting Lithium, I was hoping to calm the patient within a few hours. This is because lithium has a peak plasma concentration of 2 hours (Malhi, 2017). By selecting Lithium, I was hoping to calm the patient within a few hours. This is because lithium has a peak plasma concentration of 2 hours (Malhi, 2017). Ethical consid- erations such as autonomy and respect may impact my treatment plan and communication with patient. In autonomy, the patient might refuse my choice of medication, and this might negatively impact my treatment plan. The patient

should be communicated to with respect. Decision #2

For the second decision the dosage is increased from 300 mgs to 450 mgs.

The dosage was increased because the patient was still experiencing the same symptoms that she had experienced two weeks ago. Patient also reports that

she has been on and off lithium. The rationale behind non-compliance was the lack of insight. The patient has been told that she has bipolar disorder but doesn’t believe that she has it. The patient also states that the drugs make

her feel nauseated and gives her diarrhea. When she takes the medication her physical symptoms are present and when she stops taking her medication the physical symptoms abate. The patient is switched to Depakote 500 mgs orally. This is because Depakote has lesser side effects (Tondo, 2017).

The patient is educated on the effects of not complying with the treatments. If she is not compliant with the medications, it might worsen the symptoms of the Bipolar. She is also at a risk of developing resistance to the drug whereby whenever she will be taking the drug it might not have any effect. Non-compli- ancy can also lead to adverse effects of lithium which include tremors, increase in creatinine levels, weight gain and diabetes insipidus (Petro, 2020). The ethical considerations that may impact the treatment plan on how to communicate with the client at this point includes informed consent, respect and non-malefi- cence. When the patient has been fully informed of the side effects of not ad- hering to the treatment, this knowledge may influence their decision on follow- ing the treatment regimen. In non-maleficence, the drugs should not cause harm to the patient. This decision will impact the treatment plan and would lead to the need to change the medication if the patient cannot tolerate lithium. The

patient should be informed all of these with respect. Decision #3

To change the Lithium medication to a sustained release at the same dose and frequency. Since the patient is experiencing nausea and diarrhea which are the classic symptoms of lithium therapy, changing the patient to an extended- release formulation can prevent these symptoms from occurring and at the same time can benefit the patient's mood stabilizing properties to lithium. An- other reason for using sustained release is that lithium is a good choice for the management of mania and adding to its benefits, it also decreases the chances for suicide (Malhi, 2017). Depakote may be another option if changing to sus- tained release formulation of lithium does not help alleviate the symptoms. Ox-

carbazepine can also be an option, but it is a second line therapy, and it is not

appropriate for this patient because she has not had an adequate trial of first line agents (Bojic, 2017). The patient has not been compliant with taking her lithium medications so second line agents cannot be administered, especially if we are not sure if the lithium can resolve the patients' symptoms. Ethical con-

siderations while changing the patient’s medication is non maleficence and au- tonomy. The sustained release formulation of lithium should not cause any harm to the patient. The patient also has the right to make decisions of chang- ing their medication. All information regarding the new formulations or med-

ications should be communicated to the patient. This will have an impact on the treatment plan because the patient will be able to make an informed choice.

Conclusion

In conclusion, lithium is the best choice in the management of bipolar disor-

der. It acts in the central nervous system and decreases the levels of the excita- tory hormones responsible for manic episodes of bipolar. Lithium is also recom- mended for this patient because it is not metabolized by enzyme cytochrome CYP2D6. Nonadherence to lithium therapy may aggravate the symptoms of Bipolar. In alleviating the side effects of lithium, an extended-release formula- tion of lithium can be administered. Depakote can also be used as an alternative medicine for lithium. Ethical considerations that may impact treatment plan and

communication include respect, autonomy, and non-maleficence.

References

Bojic, S., & Becerra, R. (2017). Mindfulness-based treatment for bipolar dis-

order: A systematic review of the literature. Europe's journal of psychology, 13(3), 573. Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66. DePetro, E. (2020). Medication

non-compliance: Compliance to psychotropic medications within community mental health. López-Muñoz, F., Shen, W. W., D’ocon, P., Romero, A., & Álamo, C. (2018). A history of the pharmacological treatment of bipolar disorder. In- ternational journal of molecular sciences, 19(7), 2143. Malhi, G. S., Gessler, D., & Outhred, T. (2017). The use of lithium for the treatment of bipolar disorder:

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Source MatchesSource Matches ( (3737))

Student paper 80%

Student paper 94%

recommendations from clinical practice guidelines. Journal of affective disor- ders, 217, 266-280. Tondo, L., Abramowicz, M., Alda, M., Bauer, M., Bocchetta, A., Bolzani, L.,... & Baldessarini, R. J. (2017). Long-term lithium treatment in bipo-

lar disorder: effects on glomerular filtration rate and other metabolic parame- ters. International journal of bipolar disorders, 5(1), 1-12.

Student paper PATIENT WITH BIPOLAR DISORDER 2 PA- TIENT WITH BIPOLAR DISORDER 2 As- sessing and Treating Patients with Bipo- lar Disorder

Original source The patient has bipolar disorder The pa- tient has bipolar disorder Assessing and Treating Patients with Bipolar Disorder

Student paper Bipolar Disorder is a mental health dis- order characterized through extreme mood shifts that range from mania to depression. Sometimes patients experi- ence both mania and depression. Mania is when the patients’ behavior is elated and energized while depression is when the patient is sad, feels indifferent and hopeless (Carvalho, 2020). In this case study, the patient is a 26-year-old woman of Korean descent, who on her first appointment after 21 days of hospi- talization has an onset of acute mania.

Original source Bipolar is a mental health disorder char- acterized with extreme mood shifts that range from mania to depression Some- times patients experience both mania and depression Mania is when the pa- tients` behaviors are elated and ener- gized while depression is when the pa- tient is sad, feels indifferent and hope- less (Carvalho, 2020) In this case study, the patient is a 26-year-old woman with a Korean descent, who on her first ap- pointment after 21 days of hospitaliza- tion has an onset of acute mania

Student paper 87%

Student paper 88%

Student paper 89%

Student paper The patient has bipolar disorder. The specific patient characteristics that will influence my decision before prescribing any medications include the patient's hyperactivity. Upon arrival at the office, the patient appears to be quite busy. She constantly plays with things on the desk and shifts from side to side in her seat.

Original source The patient has bipolar disorder The specific patient characteristics that will influence my decision before prescribing medications include the patient being hyperactive Upon arrival at the office, the patient is quite busy She plays with things on the desk and she shifts from side to side in her desk

Student paper Another factor that would influence my decision is that the patients lack of in- sight of her disease. She says that she has been informed that she has bipolar, but she doesn’t believe it. She also has flight of ideas. On reviewing her medical records, she had been seen by a physi- cian who reported her to be in good health.

Original source Another factor that will influence my de- cision is that the patient lacks insight of her disease She says that she was in- formed that she has bipolar but she doesn`t believe that She also has flight of ideas On reviewing her medical records, she had been seen by a physi- cian who reported her to be in good health

Student paper All the lab works were within normal lim- its. The patient had also undergone ge- netic testing in the hospital because none of her medications seemed to work.

Original source All the lab works were within normal lim- its The patient had also undergone ge- netic testing in the hospital because none of her medications seemed to work and she tested positive for CYP2D6 10 allele

Student paper 95%

Student paper 88%

Student paper 100%

Student paper She also tested positive for CYP2D6 10 allele.

Original source She tested positive for CYP2D6*10 allele

Student paper The positive results would also influence the decision on which medication would be prescribed for the patient. The pa- tient also confessed to having stopped taking the lithium that was prescribed to her two weeks ago. On performing a mental status exam, the patient is alert, oriented to person, place, time and event. Her speech is rapid, pressured, and tangential.

Original source This will also influence the decision on medication for the patient Patient also confessed to have stopped taking lithi- um which was prescribed for her two weeks ago On performing a mental sta- tus exam, the patient is alert, oriented to person, place, time and event Her speech is rapid, pressured and tangential

Student paper Self-reported mood is euthymic. Affect is broad. She does not have visual or audi- tory hallucinations. She has no delu- sions, and the thought process is apparent.

Original source Self-reported mood is euthymic Affect is broad She does not have visual or audi- tory hallucinations She has no delusions, and the thought process is apparent

Student paper Judgement is intact and she has no suici- dal or homicidal thoughts.

Original source Judgement is intact and she has no suici- dal or homicidal thoughts

Student paper 80%

Student paper 79%

Student paper 96%

Student paper 97%

Student paper When given the Young Mania Rating Scale, her score was 22.

Original source The Young Mania Rating Scale score is 22

Student paper Begin the patient on Lithium 300mg.

Original source Begin Lithium 300mg

Student paper Lithium acts by downregulating the NMDA receptors. NMDA receptors are ion channel and glutamate protein re- ceptors. Once they are downregulated, the levels of glutamate in the postsynap- tic neurons increase while decreasing in the presynaptic neurons. Glutamate is an excitatory neurotransmitter.

Original source Lithium acts by downregulating the NMDA receptors NMDA receptors are ion channel and glutamate protein re- ceptors Once they are downregulated, the levels of glutamate in the postsynap- tic neurons increases while it decreases in the presynaptic neurons Glutamate is an excitatory neurotransmitter

Student paper During mania, the levels of glutamate are elevated. A decrease of glutamate in the presynaptic neurons reduce the exci- tatory effect that is caused by glutamate. Lithium also causes a decrease of dopamine activity in the presynaptic neurons. This also reduces the excitato- ry neurotransmission in the brain, lead- ing to a resolution of the manic episodes (Malhi, 2017).

Original source During mania, the levels of glutamate are elevated A decrease of glutamate in the presynaptic neurons, reduces the ex- citatory effect caused by glutamate Lithi- um also causes a decrease of dopamine activity in the presynaptic neurons This also reduces the excitatory neurotrans- mission in the brain, leading to a resolu- tion of the manic episodes (Malhi, 2017)

Student paper 88%

Student paper 97%

Student paper Apart from lithium being the first line of treatment for bipolar disorders, I also chose lithium because of its pharmaco- kinetics. Lithium works rapidly and com- pletely absorbs. It has a peak serum concentration of 1 to 2 hours. Most of the lithium is excreted in urine with few amounts excreted in feces and sweat.

Original source Apart from lithium being the first line of treatment for bipolar, I also chose lithi- um because of its pharmacokinetics Lithium is rapidly and completely ab- sorbed It has a peak serum concentra- tion of 1 to 2 hours Most of the lithium is excreted in urine with few amounts in feces and sweat

Student paper It has a half-life of 24 hours and a bioavailability of up to 5 days. I did not choose Risperidal 1 mg and Seroquel XR 100mg because the patient tested posi- tive of cytochrome CYP2D6 10 allele. Risperidal and Seroquel XR are metabo- lized by the enzyme CYP2D6 in the liver into their active metabolites while lithi- um is not affected by this enzyme. Once a drug has been metabolized, its thera- peutic effect decreases (Lopez-Munoz, 2018).

Original source It has a half-life of 24 hours and a bioavailability of up to 5 days I did not choose Risperdal 1 mg and Seroquel XR 100mg because the patient tested posi- tive of cytochrome CYP2D6 10 allele Risperdal and Seroquel XR are metabo- lized by the enzyme CYP2D6 in the liver into their active metabolites while lithi- um is not affected by this enzyme Once a drug has been metabolized, its thera- peutic effect decreases (Lopez-Munoz, 2018)

Student paper 100%

Student paper 80%

Student paper By selecting Lithium, I was hoping to calm the patient within a few hours. This is because lithium has a peak plasma concentration of 2 hours (Malhi, 2017). By selecting Lithium, I was hoping to calm the patient within a few hours. This is because lithium has a peak plasma concentration of 2 hours (Malhi, 2017).

Original source By selecting Lithium, I was hoping to calm the patient within a few hours This is because lithium has a peak plasma concentration of 2 hours (Malhi, 2017) By selecting Lithium, I was hoping to calm the patient within a few hours This is because lithium has a peak plasma concentration of 2 hours (Malhi, 2017)

Student paper Ethical considerations such as autonomy and respect may impact my treatment plan and communication with patient. In autonomy, the patient might refuse my choice of medication, and this might negatively impact my treatment plan. The patient should be communicated to with respect.

Original source Ethical considerations such as autonomy and respect may impact my treatment plan and communication with patient In autonomy, the patient might refuse my choice of medication and this might neg- atively impact my treatment plan The patient should be communicated to with respect

Student paper The dosage was increased because the patient was still experiencing the same symptoms that she had experienced two weeks ago. Patient also reports that she has been on and off lithium. The ratio- nale behind non-compliance was the lack of insight.

Original source This is because the patient still presents with the same symptoms, she had two weeks ago Patient also reports that she has been on and off lithium The ratio- nale behind noncompliance was the lack of insight

Student paper 84%

Student paper 99%

Student paper The patient also states that the drugs make her feel nauseated and gives her diarrhea. When she takes the medica- tion her physical symptoms are present and when she stops taking her medica- tion the physical symptoms abate. The patient is switched to Depakote 500 mgs orally. This is because Depakote has lesser side effects (Tondo, 2017).

Original source The patient also states that the drugs make her feel nauseated and gives her diarrhea When she stops taking the medicine, the symptoms abate, and when she starts taking the medication, the symptoms start again The patient is switched to Depakote 500mgs orally This is because Depakote has lesser side ef- fects (Tondo, 2017)

Student paper The patient is educated on the effects of not complying with the treatments. If she is not compliant with the medica- tions, it might worsen the symptoms of the Bipolar. She is also at a risk of devel- oping resistance to the drug whereby whenever she will be taking the drug it might not have any effect. Non-compli- ancy can also lead to adverse effects of lithium which include tremors, increase in creatinine levels, weight gain and dia- betes insipidus (Petro, 2020).

Original source The patient is educated on the effects of not complying with the treatments If she is not compliant with the medications, it might worsen the symptoms of the Bipolar She is also at a risk of developing resistance to the drug whereby whenev- er she will be taking the drug it might not have any effect Non-compliance can also lead to adverse effects of lithium which include tremors, increase in crea- tinine levels, weight gain and diabetes insipidus (Petro, 2020)

Student paper 90%

Student paper 98%

Student paper The ethical considerations that may im- pact the treatment plan on how to com- municate with the client at this point in- cludes informed consent, respect and non-maleficence. When the patient has been fully informed of the side effects of not adhering to the treatment, this knowledge may influence their decision on following the treatment regimen. In non-maleficence, the drugs should not cause harm to the patient. This decision will impact the treatment plan and would lead to the need to change the medication if the patient cannot tolerate lithium.

Original source The ethical considerations that may im- pact the treatment plan and how to communicate with the client at this point include informed consent, respect and non-maleficence When the patient has been fully informed of the side ef- fects of not adhering to the treatment, they may influence their decisions on following the treatment regimen In non- maleficence, the drugs should not cause harm to the patient This decision will im- pact the treatment plan and will have to change the medications if the patient cannot tolerate lithium

Student paper The patient should be informed all of these with respect.

Original source The patient should be informed all these with respect

Student paper 95%

Student paper 89%

Student paper To change the Lithium medication to a sustained release at the same dose and frequency. Since the patient is experi- encing nausea and diarrhea which are the classic symptoms of lithium therapy, changing the patient to an extended-re- lease formulation can prevent these symptoms from occurring and at the same time can benefit the patient's mood stabilizing properties to lithium. Another reason for using sustained re- lease is that lithium is a good choice for the management of mania and adding to its benefits, it also decreases the chances for suicide (Malhi, 2017). De- pakote may be another option if chang- ing to sustained release formulation of lithium does not help alleviate the symptoms.

Original source To change Lithium to a sustained release at same dose and frequency Since the patient is experiencing nausea and diar- rhea which are the classic symptoms of lithium therapy, changing the patient to an extended-release formulation can prevent these symptoms from occurring and at the same time the patient will benefit from lithium`s mood stabilizing properties Another reason for using sus- tained release is that lithium is a good choice for the management of mania and adding to its benefits, it also de- creases the chances for suicide (Malhi, 2017) Depakote may be an option if changing to sustained release formula- tion of lithium does not alleviate the symptoms

Student paper Oxcarbazepine can also be an option, but it is a second line therapy, and it is not appropriate for this patient because she has not had an adequate trial of first line agents (Bojic, 2017). The patient has not been compliant with taking her lithi- um medications so second line agents cannot be administered, especially if we are not sure if the lithium can resolve the patients'

Original source Oxcarbazepine can also be an option but it is a second line therapy and it is not appropriate for this patient because she has not had adequate trial of the first line agents (Bojic, 2017) The patient has not been compliant with taking her lithium medications so second line agents cannot be given especially if we are not sure if lithium could have re- solved the patient`s symptoms

Student paper 93%

Student paper 100%

Student paper Ethical considerations while changing the patient’s medication is non malefi- cence and autonomy. The sustained re- lease formulation of lithium should not cause any harm to the patient.

Original source Ethical considerations while changing the patient`s medication is non malefi- cence and autonomy The sustained re- lease formulation of lithium should not cause any harm to the patient

Student paper All information regarding the new for- mulations or medications should be communicated to the patient. This will have an impact on the treatment plan because the patient will be able to make an informed choice.

Original source All information regarding the new for- mulations or medications should be communicated to the patient This will have an impact on the treatment plan because the patient will be able to make an informed choice

Student paper In conclusion, lithium is the best choice in the management of bipolar disorder. It acts in the central nervous system and decreases the levels of the excitatory hormones responsible for manic episodes of bipolar. Lithium is also rec- ommended for this patient because it is not metabolized by enzyme cytochrome CYP2D6. Nonadherence to lithium thera- py may aggravate the symptoms of Bipolar.

Original source In conclusion, lithium is the best choice in the management of bipolar disorder It acts in the central nervous system and decreases the levels of the excitatory hormones responsible for manic episodes of bipolar Lithium is also rec- ommended for this patient because it is not metabolized by enzyme cytochrome CYP2D6 Nonadherence to lithium thera- py may aggravate the symptoms of Bipolar

Student paper 100%

Student paper In alleviating the side effects of lithium, an extended-release formulation of lithi- um can be administered. Depakote can also be used as an alternative medicine for lithium. Ethical considerations that may impact treatment plan and commu- nication include respect, autonomy, and non-maleficence.

Original source In alleviating the side effects of lithium, an extended-release formulation of lithi- um can be administered Depakote can also be used as an alternative medicine for lithium Ethical considerations that may impact treatment plan and commu- nication include respect, autonomy and non-maleficence

Student paper Bojic, S., & Becerra, R.

Original source Bojic, S., & Becerra, R

Student paper Mindfulness-based treatment for bipolar disorder: A systematic review of the liter- ature. Europe's journal of psychology, 13(3), 573.

Original source Mindfulness-based treatment for bipolar disorder A systematic review of the liter- ature Europe's journal of psychology, 13(3), 573

Student paper F., Firth, J., & Vieta, E.

Original source F., Firth, J., & Vieta, E

Student paper New England Journal of Medicine, 383(1), 58-66.

Original source New England Journal of Medicine, 383(1), 58-66

Student paper 100%

Student paper Medication non-compliance: Compliance to psychotropic medications within com- munity mental health. López-Muñoz, F., Shen, W. W., D’ocon, P., Romero, A., & Álamo, C.

Original source Medication non-compliance Compliance to psychotropic medications within com- munity mental health López-Muñoz, F., Shen, W W., D’ocon, P., Romero, A., & Álamo, C

Student paper A history of the pharmacological treat- ment of bipolar disorder. International journal of molecular sciences, 19(7), 2143.

Original source A history of the pharmacological treat- ment of bipolar disorder International journal of molecular sciences, 19(7), 2143

Student paper S., Gessler, D., & Outhred, T.

Original source S., Gessler, D., & Outhred, T

Student paper The use of lithium for the treatment of bipolar disorder: recommendations from clinical practice guidelines. Journal of affective disorders, 217, 266-280. Ton- do, L., Abramowicz, M., Alda, M., Bauer, M., Bocchetta, A., Bolzani, L.,...

Original source The use of lithium for the treatment of bipolar disorder recommendations from clinical practice guidelines Journal of af- fective disorders, 217, 266-280 Tondo, L., Abramowicz, M., Alda, M., Bauer, M., Bocchetta, A., Bolzani, L.,

Student paper 100%

Student paper Long-term lithium treatment in bipolar disorder: effects on glomerular filtration rate and other metabolic parameters. International journal of bipolar disor- ders, 5(1), 1-12.

Original source Long-term lithium treatment in bipolar disorder effects on glomerular filtration rate and other metabolic parameters International journal of bipolar disor- ders, 5(1), 1-12