Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder Essay

Bipolar disorder is a mental disorder that affects behavior, energy level, attention, and mood. Bipolar disorder presents with recurring depressive and manic episodes that impact an individual’s functionality and the ability to lead a productive life. The depressive episode is characterized by symptoms such as sadness, social withdrawal, sleep problems, fatigue, appetite changes, anhedonia, among other symptoms. On the other hand, manic episodes are characterized by hyperactivity, high energy levels, lack of sleep, irresponsibility, and impulsivity (Chakrabarti, 2016). Bipolar type 1 disorder is specifically characterized by manic episodes that exist for around a week or serious manic symptoms necessitating immediate hospitalization. This paper will analyze a case study about a 26-year-old Korean woman who presented for her first assessment after being hospitalized for 21 days due to acute mania symptoms. The client reported that she was having sleepless nights and she was feeling fantastic. She appears “busy”, and has a paid speech. Her mood is broad affect and euthymic, while her insight appears impaired. However, her judgment is still intact. She denies any suicidal thoughts. She is in good health as indicated by the physical assessment and laboratory findings. She tests positive for the CYP2D6*10 allele and reveals that she is no longer taking the prescribed lithium medication. This paper will utilize a decision tree to select the appropriate medications for the client, and outline each ethical principle guiding the selected decisions.

Decision Point One

The client should start Risperdal 1 mg BID. The reason why Risperdal was chosen is because it is utilized as a monotherapy treatment for acute mania in patients with bipolar disorder. The mechanism of action of Risperdal is through balancing dopamine and serotonin in the brain, which improves the mood, thinking pattern, and behavior. Additionally, Risperdal has few extrapyramidal effects and hence it is well-tolerated and safe (Ashok et al., 2017). The option of lithium was not selected since the medication has serious and numerous side effects that may hinder the client’s adherence to treatment (Alda, 2015). This is indicated by the client’s nonadherence to lithium treatment, which is attributable to the medication’s side effects. Seroquel was not considered as it is associated with numerous side effects such as weight gain, dizziness, sedation, dry mouth. These side effects may hinder the client’s adherence to the treatment regimen (Chiang & Lan, 2018).

By selecting Risperdal, it is hoped that the client will have symptom improvement manifested by balanced energy levels, stable mood, and normal behaviors. This is attributable to the efficacy of Risperdal in improving mania symptoms (Ashok et al., 2017). Secondly, it is hoped she would not report severe side effects.

However, she only reported that her mood had improved, but other symptoms still persisted. She also reported that she was having side effects like sedation and fatigue. Sedation is a common side effect of Risperdal. The findings of genetic testing showed that she was positive for the CYP2D6 gene, indicating a decreased ability of Risperdal metabolism. This may increase the client’s risk of Risperdal’s side effects such as sedation (Puangpetch et al., 2016).

Beneficence and informed consent are ethical principles guiding this decision. It is important to educate the client about the medications to allow her to make an informed choice and also the practitioner should choose a decision that will lead to the best health outcomes for the client (Salagre, Vieta & Grande, 2020).

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Decision Point Two

Decision point two is to have the Risperdal dose reduced to 1mg HS. The rationale for this decision is because the client tested positive for the CYP2D6 gene, indicating a reduced ability to metabolize Risperdal and an increased risk to the medication’s side effects. Therefore, a lower Risperdal dose will reduce the medication’s concentration in the blood and hence reduce the side effects (Puangpetch et al., 2016). The option of increasing the Risperdal dose to 2 mg orally was not considered because the decision is likely to increase side effects for the client as she is positive for the CYP2D6 gene. The decision of changing to lithium was not selected because she was nonadherent to lithium medication.

By reducing the Risperdal dose, it is hoped that the side effects will reduce and hence improve tolerance because there will be less concentration of the medication in the blood (Puangpetch et al., 2016). It is also hoped that the client will exhibit symptom improvement due to the medication’s efficacy.

As expected, she reported fewer side effects as indicated by decreased fatigue and reduced sedative effects. This is attributable to improved clearance of Risperdal from the blood, leading to few side effects and hence improved tolerance to the medication (Jukic et al., 2019). Moreover, the client reported significant symptom improvement and the mania scale indicated a 25% symptom decrease.

Non-maleficence and beneficence ethical principles guided the selection of this above decision. This is because the treatment for bipolar disorder should facilitate a productive and stable life, and the medication should balance the associated risks with benefits (Salagre, Vieta & Grande, 2020).

 

Decision Point Three

The appropriate decision is to maintain the current Risperdal dose and assess her after four weeks. The rationale for selecting this decision is because the client responded to the dose as manifested by reduced symptoms and she also reported reduced side effects. The option of increasing the Risperdal dose to 1 mg was not considered due to the possible side effects that the client earlier reported with this dose. She tested positive for the CYP2D6 gene, indicating a decreased ability of Risperdal metabolism (Puangpetch et al., 2016). The decision to change the treatment from Risperdal to Latuda was not considered because Latuda is appropriate for the treatment of depressive symptoms, but the client has manic symptoms (Burt & Nasrallah, 2016).

The treatment goal of this decision is that the client will continue manifesting symptom reduction and finally attain complete symptom remission. This is due to the efficacy of Risperdal in treating manic symptoms (Puangpetch et al., 2016). It is also anticipated that she will continue tolerating the medication.

The ethical principles that guided this decision included non-maleficence and beneficence. The principle of beneficence ensured that the treatment decision focused on the best health outcomes for the client, while the principle of non-maleficence balanced the benefits and risks associated with the selected treatment decision (Salagre et al., 2020).

Conclusion

The diagnosis for the client was bipolar type 1 disorder with acute mania. The initial treatment decision was for the client to start Risperdal 1 mg orally BID as the medication has been demonstrated to be effective in the treatment of mania symptoms for people with bipolar disorder. However, there was no significant symptom improvement with this decision and the client also reported side effects like sedative effects and lethargy, which are common side effects with Risperdal, especially now that the client is positive for CYP2D6 gene, indicating a decreased ability of Risperdal metabolism. Therefore, the second decision involved reducing the dose to Risperdal 1 mg HG. With the reduced dose, the client manifested a 25% symptom reduction and also reported decreased side effects. With the reduced Risperdal dose, the was a reduced concentration of the medication in the blood, leading to a few side effects. Therefore, the third decision involved continuing with the same Risperdal dose and evaluate her after four weeks. The rationale for maintaining the same dose is because the client manifests a satisfactory response with the dose, with minimal side effects. It is expected that she will continue manifesting symptom improvement and eventually attain complete symptom remission. The ethical principles that guided the selected decision include informed consent, and non-maleficence and beneficence ethical principles. The client was educated about the medications before the prescription, and the selection of medications focused on the client’s best health outcomes while balancing the involved risks and benefits.

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References

Alda M. (2015). Lithium in the treatment of bipolar disorder: pharmacology and pharmacogenetics. Molecular psychiatry, 20(6), 661–670. https://doi.org/10.1038/mp.2015.4

Ashok, A. H., Marques, T. R., Jauhar, S., Nour, M. M., Goodwin, G. M., Young, A. H., & Howes, O. D. (2017). The dopamine hypothesis of bipolar affective disorder: the state of the art and implications for treatment. Molecular psychiatry, 22(5), 666–679. https://doi.org/10.1038/mp.2017.16.

Burt, V. K., & Nasrallah, H. A. (2016). Bipolar depression diagnosis: confounding factors. Current Psychiatry, 15(1), S1-S1.

Chakrabarti S. (2016). Treatment-adherence in bipolar disorder: A patient-centered approach. World J Psychiatry, 6(4), 399–409.

Chiang, S. T., & Lan, C. C. (2018). Quetiapine Related Acute Paralytic Ileus in a Bipolar I Disorder Patient with Successful Low Dose Amisulpride Substitution: A Case Report. Clinical psychopharmacology and neuroscience: the official scientific journal of the Korean College of Neuropsychopharmacology, 16(2), 228–231. https://doi.org/10.9758/cpn.2018.16.2.228.

Jukic, M. M., Smith, R. L., Haslemo, T., Molden, E., & Ingelman-Sundberg, M. (2019). Effect of CYP2D6 genotype on exposure and efficacy of risperidone and aripiprazole: a retrospective, cohort study. The Lancet Psychiatry, 6(5), 418-426.

Vasquez, A. R., & Bobo, W. V. (2020). Mood Stabilizers: Risperidone for Treating Bipolar Disorders in Adults. NeuroPsychopharmacotherapy, 1-32.

 

You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.
At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.
Introduction to the case (1 page)

• Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
• Decision #1 (1 page)
• Which decision did you select?
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)
• Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
• What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
• Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)
• Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

PLEASE DON\’T USE SERTRALINE

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