Assessment and Management of Bipolar Disorder

Introduction

Bipolar disorders are a significant public health issue with 3.9% estimated prevalence in the general population of the United States. It is associated with a high risk of mortalities with approximately 11% of diagnosed patients committing suicide while 25% of patients attempting suicide (Grunze, 2015). Due to inadequate structures of services and treatment, patients with bipolar spectrum disorders have the highest rates of jailing. In this paper, the author discusses the management of an Asian girl of Korean Descent who was diagnosed with bipolar disorder. The author discusses three decisions concerning the patient’s pharmacological management including the expected outcomes of treatment, and potential differences between the actual and expected treatment outcomes. PMHNPs are a  major point of contact for many bipolar patients, with a critical role in diagnosis and treatment since the diverse nature of its symptoms can make the condition to remain unrecognized in most patients for long.Assessment and Management of Bipolar Disorder

Decision # 1

Decision Selected

Begin Risperdal 2mg orally BID

Reason for Selecting This Decision

            Risperidone is classified as an atypical antipsychotic and is approved to manage bipolar symptoms and associated irritability. As stated by López-Muñoz et al (2018), it acts by helping to maintain a balance of serotonin and dopamine in the brain to improve a patient’s mood, thoughts, and behavior. Seroquel could still be a good choice but has the side effects of constipation and weight gain that the patient clearly stated that she wouldn’t want to experience. Similarly, lithium could be an alternative but due to a previous history of defaulting, it can easily result in non-adherence with poor treatment outcomes.

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Expected Outcome

            By the next visit, it is expected that all the bipolar symptoms that manifest in this patient will gradually diminish. She will be able to function physically, socially, and occupationally well, she will be restful, and the self-destruction practices exhibited by the client will lessen.

Difference between Expected Outcome and Actual Outcome

            After four weeks, the client returned to the clinic reporting positive progress. She acknowledged being able to concentrate longer but was concerned about daytime drowsiness and lethargy. A significant side effect of Risperdal is that it causes sedation. Besides, based on a positive CYP2D6*10 allele report, it is inarguable that she has a   low clearance rate of Risperdal from her body (Chen et al, 2015). This ultimately contributes to high Risperdal levels in the blood which contributes to daytime lethargy/drowsiness.

Decision #2

Decision Selected

Decrease the dosage of Risperdal to 1mg orally HS

Reason for Selecting This Decision

            In the initial visit, although the patient showed immense positive progress,  she was concerned about daytime drowsiness/lethargy which based on currently existing scientific evidence,  was due to high doses of  Risperdal and a slow clearance rate from the body systems. Therefore, to attain the desired therapeutic goals, the best decision is to decrease the frequency and dosage` of Risperdal to 1mg HS with close monitoring and evaluation. However, to help the patient achieve her treatment goals, Shah, Grover & Rao (2017) recommends that, the PMHNP should give the patient support to adapt to an alternative dosage of the same drug (Risperdal to 1mg HS) which will improve her trust, dedication, and understanding. Changing the medication to lithium is not the best decision since the client had already developed some demeanor towards it as evidenced by a previous history of non-adherence.Assessment and Management of Bipolar Disorder

Expected Outcome

The PMHNP expected that the client will no longer report daytime drowsiness and lethargy but to continuously experience a decrease in the severity and frequency of bipolar symptoms of self-destructive behaviors, thought patterns and increased ease performing ADLs (López-Muñoz et al, 2018). It was also expected that close friends and family members will be able to notice the positive outcomes of treatment as evidenced by increased socialization, improved physical and occupational functioning.

Difference between Expected Outcome and Actual Outcome

After four weeks, the client returned to the clinic acknowledging immense progress which had no significant difference with the expected outcome. She also reported that she was able to tolerate the prescribed drugs with the adjusted doses. She further denied experiencing daytime drowsiness and lethargy which could be attributed to the initial adjustments that were made on the dosage of Risperdal. Her young mania rating scale had also decreased from 22 to 16, illustrating a 25% decrease in the severity of symptoms.

Decision #3

Decision Selected

Continue with the current dosage of Risperdal I’m orally HS.

Reason for Selecting This Decision

            The patient’s verbalization of her progress demonstrated the success of the prescribed therapy and any changes to the current frequency and dosing could not only destabilize the patient’s progress but also prevent the attainment of therapeutic goals. Therefore, at this point, the best course of action is to continuously assess and monitor the client. Going back to the initial dosage of Risperdal 1 mg BID will be detrimental to the patient’s progress and attainment of therapeutic goals with the same side effects of daytime drowsiness and lethargy. Changing to Latuda is not advisable since according to Shah, Grover & Rao (2017) the FDA only recommends using it for the management of bipolar I depression that significantly differs from the patient’s symptoms.

Expected Outcome

            After four weeks, the PMHNP expects that the patient’s self-destructive behaviors will decrease significantly with very minimal to no reports of the side effects of Risperdal. She will also demonstrate clear thinking patterns, conduct, social and physical functioning.

Difference between Expected Outcome and Actual Outcome

            After four weeks, the patient returned to the clinic reporting significant progress with no side effects of daytime lethargy and drowsiness. A further assessment helped to ascertain that the prescribed dosage and frequency of Risperdal had played a major role in attaining the therapeutic outcomes.

Ethical Considerations

Before initiating treatment with this patient, it is important to obtain the patient’s fully informed consent.  As highlighted by Ratheesh et al (2017), in most cases, PMHNPs tend to overlook the laws that emphasize the need to prioritize patient preferences to certain medications particularly in incidences where a patient has been diagnosed with a severe mental illness. Rather than overlooking a patient’s ability to make decisions in such scenarios, PMHNPs should implement advance directives. PHMPs should also respect patient autonomy when working with bipolar patients since most of them can present with cognitive deficits that may impair their understanding and judgment of information. Even in instances that they consent to treatment, Ratheesh et al (2017) note that it is not guaranteed that they clearly understand what they are consenting to. In such a scenario, the law generally allows PMHNPs to make a decision that is in the patient’s best interest on the patient’s behalf.

Conclusion

Bipolar disorders are a significant public health issue in the United States associated with a high risk of mortalities and suicide. PMHNPs are a  major point of contact for many bipolar patients, with a critical role in diagnosis and treatment since the diverse nature of its symptoms can make the condition to remain unrecognized in most patients for long. The best choice of drug to manage bipolar in the assigned case study is risperidone, an atypical antipsychotic approved by the FDA to manage bipolar symptoms and associated irritability. To reduce the severity of its side effects such as daytime drowsiness and lethargy, PMHNPs can decrease the dosage and frequency while continuing to assess patients for progress and attainment of therapeutic goals. PHMPs should also consider a patient’s ethnicity as it has a great influence on the pharmacokinetics and pharmacodynamics of drugs and therapeutic outcomes.   Assessment and Management of Bipolar Disorder

References

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.

Grunze, H. (2015). Bipolar disorder. In Neurobiology of brain disorders (pp. 655-673). Academic Press.

López-Muñoz, F., Shen, W. W., D’Ocon, P., Romero, A., & Álamo, C. (2018). A history of the pharmacological treatment of bipolar disorder. International journal of molecular sciences, 19(7), 2143.

Ratheesh, A., Cotton, S. M., Davey, C. G., Adams, S., Bechdolf, A., Macneil, C., & McGorry, P. D. (2017). Ethical considerations in preventive interventions for bipolar disorder. Early intervention in psychiatry, 11(2), 104-112.

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.

Assessing and Treating Patients with Bipolar Disorder

This is case scenario for Marcus an 18-year-old high school senior student who presents with difficulty sleeping and feeling sad. He has been exhibiting symptoms of irritability and risk-taking behavior. A diagnosis of bipolar disorder was made.

Bipolar or manic depressive illness is a common severe and prolonged mental disease. It is characterized by the spell of deep, lengthy, and profound depression that alternate with a period of excessively increased irritable mood, also known as mania (Baldessarini, et al, 2020). Episodes of mania occur after one week of continuous elation, irritability, and other mood disturbances.

Symptoms of bipolar are racing thoughts or flight of ideas, excessive talking or pressured speech, reduced need for sleep, extremely pleasurable activities, increased level of goal-focused activities, and clear evidence of distractibility (Baldessarini, et al, 2020).  Depressive episodes present with depressed mood, reduced pleasure or interest, weight loss, increased appetite, loss of energy or fatigue, excessive guilt or feeling of worthlessness, reduced concentration ability marked indecisiveness, insomnia, and suicidal attempt or ideation.

Mental status examination of a patient with bipolar disorder involves the appearance, the affect, mood, thought content, perception,  violence or aggression, judgment or insight, cognition, and physical health. Bipolar is diagnosed based on the patient’s history, clinical examination, and laboratory tests. The care provider should rule out other potential causes of patient’s signs and symptoms.

Essential laboratory tests include thyroid hormone levels, blood creatinine, urea, nitrogen level, protein levels, alcohol and substance screening, and complete blood count. Before initiating treatment on patients with bipolar, it is vital to do electrocardiography, especially among the elderly. Pharmacologic therapy depends on the stage of bipolar disorder or manic depressive illness the patient is experiencing (Baldessarini, et al, 2020). Drugs prescribed for manic episodes are antipsychotics, valproate, and benzodiazepines. This paper will describe the medication’s decision to prescribe an 18-year-old male requiring bipolar therapy. It also involves the factors influencing pharmacokinetics, pharmacodynamics, the efficacy of the treatment plan, and the impact of ethical consideration in the treatment.

Decision one

Benzodiazepines

For this patient, benzodiazepines are the drug of choice because of his irritability, risk-taking behavior, and sleep disturbances. Benzodiazepines work on the neurotransmitter gamma-aminobutyric acid (Martin, et al, 2020). It increases the GABA hence having a relaxing and sedative effect that works to relieve anxiety and nervousness.

According to Martin, et al, (2020), benzodiazepines help relieve unusual anxiety, stress, and unprovoked anger, similar to bipolar. Unlike other medication listed above, benzodiazepines can be used as a single drug in the management of bipolar because it is effective on both the manic phase and depressive phase.

The achievement intended when making this decision was to stop the patient’s irritability and risky behaviors, enhance good sleeping patterns, and improve emotions of sadness. This has been achieved since benzodiazepines have been shown to improve the patient’s mania and depressive state.

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As a psychiatric nurse practitioner, principles and codes of ethics ensure patient and the practitioner’s safety. The nurse should provide effective treatment by observing the principle of beneficence and non-maleficence. The care provider should seek informed consent from the next of kin before initiating medication. It involves explaining the disease, its causes, treatment modality, and adverse effects of the drugs. Informed consent creates rapport for the patient, the relatives, and the care provider (Steardo, et al, 2020). It also ensures drug compliance leading to improvement of the illness. Beneficence and non-maleficence improve the patient’s treatment leading to a good disease prognosis.Assessment and Management of Bipolar Disorder

Decision two

Lithium

Tondo, et al, (2017) Lithium is an anti-psychiatric drug used to manage mood disorders like bipolar, mania, and depressive mood. This patient needs lithium to relive the sadness, irritability, and risky behaviors. Lithium is neuro-protective, works well in a patient with classical features of bipolar disorder, and is sufficient to prevent the recurrence of bipolar disorder.

Unlike the other two drugs, lithium can be used for both treatment and prophylaxis. It is more efficient as it responds efficiently due to its anti-maniac, antidepressant-augmenting effects, mood-stabilizing, and anti-suicidal effects. Lithium can be given together with antipsychotics such as haloperidol (Tondo, et al, 2017). It is also known to have minimum adverse effects making it easier to take and maintain compliance, unlike the other medication.

When initiating this medicine, the effect desired was to reduce the manic symptoms (sleeping disturbances, irritability, and risky behavior). The aim was also to stabilize the sad mood into jovial or happiness. To prevent worsening or poor prognosis of mood disorder that can be psychosis or suicidal ideation or attempt (Tondo, et al, 2017). The result achieved was correspondent to the expectation.

Ethical considerations are the principles that guide the nursing profession. Ethical principles include beneficence, non-maleficence, justice, and autonomy. These principles enable the nurses to perform with dignity, compassion, and respect for all patients (Steardo, et al, 2020). They keep the nurses committed to their patients and give them maximum attention. These ethical considerations ensure the nurse promotes and protects the patient’s safety during treatment. The patient benefits from this by getting quality care, a good relationship with the care provider, improved health condition, and the right to make a health decision.

Decision three

Amitriptyline

Amitriptyline is a tricyclic antidepressant that acts by blocking the reuptake of both serotonin and norepinephrine neurotransmitters. This drug is used on this patient to improve sleeping patterns, reduce irritability, and relieve sadness. It works by sedating the patient and increasing the anticholinergic properties.

Comparing mood stabilizers with benzodiazepines, antidepressants relieve the patient from depressive mood due to their anticholinergic effects. It also has sedative effects hence improving the sleeping patterns. Amitriptyline is effective when used as a monotherapy. It is well-tolerated and has minimum side effects, therefore increasing compliance.

When initiating amitriptyline, the desired effect is to relieve the depressive mood, enhance the patient’s normal functioning, and ensure drug compliance. The outcome desired was achieved within two weeks after initiating the treatment.

Ethical principles are universal rules of conduct that provides a practical basis. They are essential in healthcare because they focus on what pertains to the right and impaired decision-making (Steardo, et al, 2020). Ethical principles give a patient the right to make health decisions, know the treatment method, its benefits, and adverse effects. They also enable the care practitioners to make the right decision when in an ethical dilemma.

Conclusion

Bipolar disorder is a mental health disorder that causes unusual shifts in moods, energy, and activity level. It is usually a period of intense emotions, changes in sleeping patterns, unusual behavior, and unique activities. The patient experiences an unexpected attack of depression and euphoria such that they cannot function appropriately in social settings. The onset of euphoria is during adolescence. It can be caused by drug or substance abuse or genetics. The manic include mood disturbances, irritability, and risky behaviors. The depressive mood presents with extreme sadness and suicidal ideation. Treatment methods are psychotherapy and pharmacological. Pharmacological treatment involves the use of antidepressants, mood stabilizers, and benzodiazepines.

Pharmacological treatment helps in relieving depression, stabilizing moods, and prophylaxis.  Benzodiazepines are essential in relieving the manic symptoms because of its sedative effects. For this patient, benzodiazepines will relieve irritability. Lithium is a mood stabilizer which prevents extreme sadness and also acts as a prophylaxis. Antidepressants such as amitriptyline, stops the depressive mood of the patient and sleep disturbances.Assessment and Management of Bipolar Disorder

Nursing practice is guided by the codes of conduct known as ethical principles. These principles ensure patient and practitioners safety. Ethical principles include beneficence, non-maleficence, autonomy, and justice. The patients are able to make decisions regarding healthcare, they are informed of their health condition and treatment, and they have a right to seek quality and effective healthcare services. These principles positively impact the patient and through compliance that improves the health outcome of the patient.

References

Baldessarini, R. J., Vázquez, G. H., & Tondo, L. (2020). Bipolar depression: a major unsolved challenge. International journal of bipolar disorders, 8(1), 1.

Jacob, L., Bohlken, J., & Kostev, K. (2020). Incidence of and factors associated with manic episodes and bipolar disorder in the decade following depression onset in Germany. Journal of Affective Disorders, 266, 534-539.

Martin, M. Z., Mesa, S. A., Peña, M. P. L., Martínez, I. Z., Pascual, J. P. C., & Pinto, A. M. G. (2020). Use of Benzodiazepines in Patients With Bipolar Disorder.

Steardo, L., Luciano, M., Sampogna, G., Zinno, F., Saviano, P., Staltari, F., … & Fiorillo, A. (2020). Efficacy of the interpersonal and social rhythm therapy (IPSRT) in patients with bipolar disorder: results from a real-world, controlled trial. Annals of General Psychiatry, 19(1), 1-7.

Tondo, L., Abramowicz, M., Alda, M., Bauer, M., Bocchetta, A., Bolzani, L., … & Müller-Oerlinghausen, B. (2017). Long-term lithium treatment in bipolar disorder: effects on glomerular filtration rate and other metabolic parameters. International Journal of Bipolar Disorders, 5(1), 27.

Assignment: Assessing and Treating Patients With Bipolar Disorder

Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for patients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) patients often present as depressive or manic but may have both; and 2) many symptoms of bipolar disorder are similar to other disorders. Misdiagnosis is common, making it essential for you to have a deep understanding of the disorder’s pathophysiology. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with bipolar disorder.

To prepare for this Assignment:

Review this week’s Learning Resources, including the Medication Resources indicated for this week.

Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients requiring bipolar therapy.

The Assignment: 5 pages

Examine Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. 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.Assessment and Management of Bipolar Disorder

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.

Note: Support your rationale with a minimum of five academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Reminder: The College of Nursing requires that all papers submitted include a title page, introduction, summary, and references.

Week 5: Therapy for Patients With Bipolar Disorders

Marcus, an 18-year-old high school senior, presents with symptoms of difficulty sleeping and feeling sad, which result in an initial diagnosis of depression. His mother later reports, however, that Marcus exhibits symptoms of irritability and risk-taking behaviors. (His little brother reported to his mother that they were driving over 90 miles an hour on the highway.) After further evaluation, Marcus’ psychiatric nurse practitioner diagnoses him with bipolar disorder.Assessment and Management of Bipolar Disorder

Cases like this are not uncommon with bipolar disorder, as initial assessments rarely provide all the information needed. In your role, as a psychiatric nurse practitioner, you must develop strategies for properly assessing and diagnosing these patients because treatments for bipolar disorder are significantly different than treatments for depression or other mood disorders.

This week, as you examine bipolar therapies, you explore the assessment and treatment of patients with bipolar disorder. You also consider ethical and legal implications of these therapies.

Learning Objectives

Students will:

Assess patient factors and history to develop personalized plans of bipolar therapy for patients

Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring bipolar therapy

Synthesize knowledge of providing care to patients presenting for bipolar therapy

Analyze ethical and legal implications related to prescribing bipolar therapy to patients across the life span

Learning 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. Assessment and Management of Bipolar Disorder