Assessing and Treating Patients With Bipolar Disorder

Assessing and Treating Patients with Bipolar Disorder

Bipolar is a mood disorder that affects 1-4% of the population. The symptoms of the disorder vary depending on the type of disorder (i.e. manic or depressive). In the manic-depressive state, the individual feels confident and excited, while in the depressive state, he/she feels sad or depressed. Each episode is characterized by a fundamental shift in the patient’s behavior. Bipolar disorder causes extreme shifts in an individual’s mood and energy levels. People around the individual usually notice the changes in behavior. A recent study noted that 69% of patients with bipolar disorder are misdiagnosed as being unipolar depression(Shen, Zhang, Xu, Zhu, Chen, & Fang, 2018). A misdiagnosis increases the risk of inappropriate treatment with an antidepressant, which can cause manic episodes. For most patients, it takes time for healthcare professionals to come up with a proper diagnosis. The disorder is difficult to diagnose because most people look for help when they experience depressive episodes and do not present information on manic episodes. In many cases, patients are usually not bothered by the manic episodes. The symptoms of bipolar disorder are similar to other disorders, such as borderline personality disorder. Patients with bipolar disorder experience significant delays in diagnosis, which takes them longer to stabilize their lives. Therefore, nurse practitioners need to have a deep understanding of the disorder’s pathophysiology.

My Patient

The Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. The paper will present the safe and appropriate for the patient.

Decision One

Which Decision Did You Select?

The first decision to prescribe Risperdal 2mg twice a day.

Why Did You Select This Decision?

Risperdal was selected because it is effective in treating bipolar disorder in diverse patients. It has demonstrated effectiveness in treating mixed episodes in bipolar 1 disorder. The FDA approved Risperdal as a treatment because of its high tolerability. It is used to treat schizophrenia because of its effectiveness in stabilizing the brain. Researchers have shown that the receptor-binding profile of risperidone is effective in balancing dopamine and serotonin, consequently improving moods a behavior(Valdes, Bertolin, Qian, Wong, Lam, & Yatham,2019). Hirschfeld(n.d) argued that second-generation (atypical) antipsychotics could be used as an alternative to traditional stabilizers in mania treatment. According to the American Psychiatric Association (2010b), short-term adjunctive treatment with a benzodiazepine, such as Risperdal, can be effective.

Why Did You Not Select the Other Two Options Provided in The Exercise?

Starting with a dose of Lithium 300 mg is inappropriate because of the side effects. Similarly, beginning with Seroquel XR 100 mg is inadvisable because the patient is CYP2D6 positive. Prescribing decisions should focus on the safety of the patient. The patient is not severely ill and it is not necessary to start her with lithium(American Psychiatric Association, 2010b).

What Were You Hoping to Achieve by Making This Decision?

By starting the patient on Risperdal, she should experience a reduction in mania symptoms. For instance, she should be able to sleep and to concentrate on tasks. The drug is expected to create a balance in the brain that will result in improved moods. Risperdal is effective in treating mania in patients with bipolar disorder(Chopko& Lindsley, 2018). The patient’s score of 22 on the Young Mania Rating Scale indicates that she has moderate mania symptoms that need to be addressed.

Explain How Ethical Considerations May Impact Your Treatment Plan and Communication with Patients.

It is important to get patient consent before administering psychiatric medications. Informed consent can only be achieved if the patient is educated on the pharmacodynamics of the disease. The patient is from an ethnic minority background; therefore, she should receive culturally appropriate care, starting with culturally sensitive patient education.

Decision Two

Which Decision Did You Select?

The appropriate next step is not to discontinue Risperdal but to reduce the dose to 1mg daily, during hours of sleep.

Why Did You Select This Decision?

The patient has reported being drowsy. Drowsiness is a common side effect of Risperdal. Even more importantly, the patient tested positive for CYP2D6. In comparison to Caucasians, Asians have reduced CYP2D6 activity. According to Chen, Wang, Shi, Shen, & Hu (2015), polymorphism in CYP2D6 affects pharmacokinetics and tolerability of traditional antipsychotic drugs. It is problematic that the patient has been drowsy during the day.

Why Did You Not Select the Other Two Options Provided in The Exercise?

Since Risperdal has proven to be effective in reducing bipolar disorder symptoms, it is advisable to continue using it. Lithium and Seroquel XR 100 mg have side effects that would adversely impact the health of the patient. It is important to note that adding another drug, to make it a combination of medications, increases the side effect burden, toxicity, or drug-drug interactions (American Psychiatric Association, 2010b).

What Were You Hoping to Achieve by Making This Decision?

A reduction in the dose to Risperdal 1 mg can help reduce the adverse effect, and the shift to hours of sleep will improve the patient’s functionality during the day. The patient will enjoy the benefits of the drug while experiencing minimal side effects.

Explain How Ethical Considerations May Impact Your Treatment Plan and Communication with Patients.

The effect of the drug on the Asian drugs should be a focal point in decision-making. The NP should take all precautions necessary to reduce harm to the patient. By understanding the psychodynamics of Risperdal in Asian patients, the NP is able to promote patient safety.

Asians are impacted differently by some antipsychotic medications. NPs are required to prescribe drugs that have been proven to work in diverse patients.

Decision Three

Which Decision Did You Select?

The decision is to continue Risperdal 1 mg orally, HS.

Why Did You Select This Decision?

The drug has helped to achieve the desired result. It would not be clinically prudent to tamper with the dose because it could negatively impact the patient destabilize her moods.

Why Did You Not Select the Other Two Options Provided in The Exercise?

There is nothing that justifies a change in drugs or dosage at this point in the treatment plan. The patient has demonstrated tolerance for Risperdal. The two other options present too many unknowns in the treatment of this patient. It is important to continue with Risperdal to ensure the mental stability of the patient.

What Were You Hoping to Achieve by Making This Decision?

In the long-term, treatment with Risperdal will help to maintain a reduction in bipolar symptoms. The patient will experience long-term mood stability without adverse effects. The patient is expected to improve relationships with family and friends. In addition, the patient will have the ability to concentrate on her career. Also, the patient is expected to remain on the same medication until the next medical appointment.

Explain How Ethical Considerations May Impact Your Treatment Plan and Communication with Patients.

There is an ethical obligation to consider the pharmacodynamics of a drug before and during the treatment of bipolar. The prescribed drug should provide the best possible treatment outcomes. The patient should be educated on the side effects and the drug’s long-term impact (Traeger, Brennan, & Herman, 2016).In severe psychiatric illnesses, the law allows NPs to overlook the patient’s treatment preferences. It is the NP’s responsibility to consider the moral weight of each decision to ensure that the patient does not experience harm as a result of the treatment being provided. Monitoring a patient on antipsychotic medication is an ethical requirement. In this case, educating family members on the medication and its potential side effects can help in improving the monitoring of the patient.

Conclusion

There are a number of medications that can be used in the treatment of bipolar disorder. NPs are trained to select the best possible medication for the patient. Notably, genetics affect the absorption, distribution, and metabolism of drugs. The Asian patient with positive CYP2D6 will experience a side effect different from patients who are CYP2D6 negative. As a matter of fact, dosage in patients of Asian descent should be guided by genetic testing. Risperdal is an effective first-line treatment of bipolar disorder. It is more effective in treating mania. The patient had a score of 22 on the Young Mania Rating Scale. Clearly, the patient needed a drug that will help to reduce mania symptoms. Some Asian patients have a low tolerance to traditional mood stabilizers such as lithium and Seroquel XR and may have adverse side effects that can lead to a lack of compliance. The drug has fewer reported side effects in comparison to typical antipsychotic medications. The treatment of Asian patients should be done in accordance with FDA guidelines. The paramount concern of nurse practitioners should be the safety of the patient and their family. Risperdal is recommended in treating mania because it provides a balance between efficacy, safety, and cost-effectiveness.

References

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

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

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.

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

Chopko, T. C., & Lindsley, C. W. (2018). Classics in chemical neuroscience: risperidone. ACS Chemical Neuroscience, 9(7), 1520-1529.

Shen, H., Zhang, L., Xu, C., Zhu, J., Chen, M., & Fang, Y. (2018). Analysis of misdiagnosis of bipolar disorder in an outpatient setting. Shanghai Archives Of Psychiatry, 30(2), 93.

Valdes, M., Bertolin, S., Qian, H., Wong, H., Lam, R. W., & Yatham, L. N. (2019). Risperidone adjunctive therapy duration in the maintenance treatment of bipolar I disorder: A post hoc analysis. Journal of Affective Disorders, 246, 861-866.

 

 

 

 

 


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