Assessing and Treating Patients With Bipolar Disorder NURS 6630
Sample Answer for Assessing and Treating Patients With Bipolar Disorder NURS 6630 Included After Question
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.
Resources
Be sure to review the Learning Resources before completing this activity.
Click the weekly resources link to access the resources.
WEEKLY RESOURCES
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
For this assignment, you will write a 5–6-page paper on the topic of bipolar and bipolar and related disorders. You will create this guide as an assignment; therefore, a title page, introduction, conclusion, and reference page are required. You must include a minimum of 3 scholarly supporting resources outside of your course provided resources.
In your paper, you will choose one of the following diagnoses: Bipolar I, Bipolar II, Cyclothymic Disorder, Substance/Medication-Induced Bipolar and Related Disorder, Bipolar and Related Disorder Due to Another Medical Condition. Your paper will include discussion for your chosen diagnosis of bipolar and related disorder on the following:
- Prevalence and Neurobiology of your chosen disorder
- Discuss the differences between your chosen disorder and one other bipolar and related disorders in relation to the diagnostic criteria including presentation of symptoms according to DSM 5 TR criteria
- Discuss special populations and considerations (children, adolescents, pregnancy/post-partum, older adult, emergency care) for your chosen bipolar and related disorder; demonstrating critical thinking beyond basics of HIPPA and informed consent with discussion of at least one for EACH category: legal considerations, ethical considerations, cultural considerations, social determinants of health
- Discuss FDA and/or clinical practice guidelines approved pharmacological treatment options in relation to acute and mixed episodes vs maintenance pharmacological treatment for your chosen bipolar and related disorder
- Of the medication treatment options for your chosen disorder discuss side effects, FDA approvals and warnings. What is important to monitor in terms of labs, comorbid medical issues with why important for monitoring
- Provide 3 examples of how to write a proper prescription that you would provide to the patient or transmit to the pharmacy.
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. The Sample Paper provided at the Walden Writing Center
Links to an external site. provides an example of those required elements (available at https://academicguides.waldenu.edu/writingcenter/templates/general#s-lg-box-20293632). All papers submitted must use this formatting.
By Day 7
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submission information
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Rubric
NURS_6630_Week5_Assignment_Rubric
| NURS_6630_Week5_Assignment_Rubric | ||||||
| Criteria | Ratings | Pts | ||||
| This criterion is linked to a Learning Outcome Write a 5–6-page paper on the topic of bipolar and bipolar related disorders: • Prevalence • Neurobiology |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome • Discuss the differences between your chosen disorder and one other bipolar and related disorders in relation to the diagnostic criteria including presentation of symptoms according to DSM 5 TR criteria. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome • Discuss special populations and considerations (children, adolescent, pregnancy/post-partum, older adult, emergency care) for your chosen bipolar and related disorder-be specific, not general and address at least one for EACH category demonstrating critical thinking beyond basics of HIPPA and informed consent: legal considerations, ethical considerations, cultural considerations, social determinants of health. |
|
20 pts | ||||
| This criterion is linked to a Learning Outcome • Discuss FDA and/or clinical practice guidelines approved pharmacological treatment options in relation to acute and mixed episodes vs maintenance pharmacological treatment for your chosen bipolar and related disorder • Of the medication treatment options for your chosen disorder discuss side effects, FDA approvals and warnings. What is important to monitor in terms of labs, comorbid medical issues with why important for monitoring. |
|
15 pts | ||||
| This criterion is linked to a Learning Outcome Provides three examples of how to write a proper prescription that would be provided to patient and/or transmitted to pharmacy. Prescription contains date, medication and strength, amount to be taken, route to be taken, frequency, indication, quantity, refills; providers signature. |
|
15 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting—Paragraph development and organization: Paragraphs make clear points that support well-developed ideas, flow logically, and demonstrate continuity of ideas. Sentences are carefully focused—neither long and rambling nor short and lacking substance. A clear and comprehensive purpose statement and introduction are provided that delineate all required criteria. |
|
5 pts | ||||
| This criterion is linked to a Learning Outcome Written Expression and Formatting—English writing standards: Correct grammar, mechanics, and punctuation; Includes title page and reference page with a minimum of 3 scholarly supporting resources outside of course provided resources; Paper is 5-6 pages not counting title page and reference page. |
|
5 pts | ||||
| Total Points: 100 | ||||||
A Sample Answer For the Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630
Title: Assessing and Treating Patients With Bipolar Disorder NURS 6630
A mental illness known as bipolar disorder is characterized by alternating episodes of mania and depression. However, mania or depression tend to have a greater impact on the majority of those who have this disorder. An intense stage of symptoms precedes the onset of the condition, which is subsequently followed by a cycle of remission and recurrence that occurs periodically (Carvalho et al., 2020). A period of time when a person’s mood is consistently expansive, high, or irritable as well as an apparent boost in energy is what is known as a manic episode. Hypomania is a milder form of mania that can occur in a patient and is characterized by a single episode lasting at least four days. Compared to experiences of mania or hypomania, episodes of depression often last longer (Carvalho et al., 2020). This essay’s goal is to describe a patient who has been diagnosed with bipolar disorder, her treatment strategy, and the ethical issues that may affect that strategy.
Introduction to the Case
A female client of Korean heritage, age 26, is seeing a doctor for the first time to get her bipolar I disease under control. The customer is 110 pounds and 5′ 5″ tall. She claims to be in a wonderful mood and finds sleep to be dull. Her medical records show she is in generally good condition, and her blood results fall within the expected ranges. Despite this, she has the CYP2D6*10 allele, according to genetic tests. Lithium was last taken by her two weeks ago. She receives a 22 on the Young Mania Rating Scale (YMRS), which is administered by the PMHNP. Patient characteristics that may affect prescribing choices include past and present drugs, previous treatment response, physical and mental comorbidities, side effects of prior medications, and the patient’s treatment preferences (Carvalho et al., 2020). The current mood (mania/depression) will also affect the drug that is prescribed.
Decision 1
Lithium 300 mg orally BID.
Why is this decision appropriate?
Because lithium is the preferred medication for people with classic mania, it was chosen. Lithium has been a cornerstone of BD treatment for decades and is still regarded as first-line therapy, claim Baldessarini et al. (2019). Lithium has a short-term effect for acute mania in adult bipolar patients and lengthens the interval between any mood episode relapses.
Why not consider other two available options?
Because it is not advised for patients who have the CYP2D6*10 allele, Risperdal was a poor choice. According to Cui et al. (2020), people with the CYP2D6*10 allele have a slower metabolism for the drug risperidone. Risperdal clearance is decreased by the decreased metabolic rate, which leads to higher serum levels of the medication, drowsiness, and eventually low drug compliance. Seroquel’s metabolic side effects, which result in elevated levels of total cholesterol and triglycerides as well as weight gain, make it less than optimal (Butler et al., 2018). Seroquel would make the patient’s elevated BMI worse.
What is likely to be achieved when this decision is taken?
In four weeks, I believed that lithium would reduce the manic symptoms and bring the YMRS score down to less than 12. According to Butler et al. (2018), lithium reduces acute mania in the short term while lengthening the duration between relapses in the long term. It efficiently controls manic or depressive acute episodes and works to stop relapses in both conditions.
What are the Ethical Considerations when taking this decision?
The PMHNP took the ethical principles of beneficence, which promotes the greater good, into account while choosing the drug associated with the best treatment outcomes. Additionally, nonmaleficence was upheld by evaluating the adverse effects of available medications and choosing one with minimal side effects in order to protect the patient (Ostacher, 2019).
Decision 2
To identify the reason for noncompliance, evaluate the patient’s justifications. Then, educate the patient on the pharmacology and side effects of the medication.
Why is this decision appropriate?
The choice was made because the patient changed how often she took her prescription. Treatment had stalled because of noncompliance. According to Jawad et al. (2018), a number of reasons, such as drug side effects, a lack of knowledge of the prescription, complex drug regimens, unfavorable patient attitudes about medication, and concurrent substance usage, contribute to medication non-adherence. The hoped-for therapeutic advantages and outcomes are hampered by these circumstances.
Why not consider other two available options?
The patient’s noncompliance with treatment would have lasted if the underlying causes had not been addressed before I did not increase the Lithium dose to 450 mg. Furthermore, I refrained from switching to Depakote because we had not yet demonstrated Lithium’s effectiveness in the management of mania. If, despite adequate medication compliance, the desired impact is not realized, switching from lithium should be done with caution.
What is likely to be achieved when this decision is taken?
I was really optimistic that identifying the cause of non-compliance would help us identify the issues causing the patient to take her medication sporadically so that we could deal with them as soon as feasible. Butt et al. (2018) contends that in order to enhance the effectiveness of therapy, non-compliance must be adequately recognized and appropriate measures must be taken to achieve therapeutic objectives.
What are the Ethical Considerations when taking this decision?
The PMHNP observed the patient’s autonomy when the patient took part in the process of determining the factors that contributed to non-compliance (Ostacher, 2019). The patient’s involvement in the variables’ determination and treatment will increase compliance, which will improve health outcomes and maintain beneficence.
Decision 3
Switch to a sustained-release version of lithium at the same dose and frequency.
Why is this decision appropriate?
I changed the patient to a sustained-release type of lithium after the patient reported experiencing nausea and diarrhea as a result of the initial drug preparation. Due to lithium’s ability to stabilize mood, its formulation with continuous release lowers the drug’s side effects while still producing the desired results. Changing the formulation of lithium from one that has an instant release to one that has a sustained release has no effect on the efficacy of the treatment, claim Pelacchi et al. (2022).
Why not consider other two available options?
Because lithium had not been shown to be unsuccessful in treating bipolar symptoms, switching to Depakote was not in the patient’s best interests. Additionally, it is connected to the negative effects of hepatic and hematological dysfunction, all of which may have detrimental effects on one’s health. The fact that Trileptal is a treatment for the second line of defense, which is utilized when the first line of defense fails, also made it a poor choice.
What is likely to be achieved when this decision is taken?
I was quite optimistic that changing to a therapy formulation with a sustained release would lessen the unpleasant side effects of the medication, notably nausea and diarrhea, enhancing patient compliance and the desired results of the medication. Benefits of sustained-release formulations include decreased local adverse effects in the GI and negative effects associated with peak blood levels. Furthermore, these types of drugs promote compliance (Pelacchi et al., 2022).
What are the Ethical Considerations when taking this decision?
By switching to a formulation that was linked to fewer side effects, increasing patient compliance, and improving the quality-of-care patients got, beneficence and nonmaleficence were strengthened. Autonomy would have an impact on the treatment plan if the patient requested a change in the event of persistent negative effects (Ostacher, 2019).
Conclusion
The patient’s preferred treatment options, current medications, prior treatment response, medical and mental comorbidities, side effects of prior medications, and other factors all affect the patient’s treatment strategy. The first stage of the patient’s treatment was to start giving him 300 mg BD of lithium. Lithium was selected as the therapy since it is advised as a first-line therapy (Baldessarini et al., 2019). Risperdal was not chosen because it would cause the patient to become sedated, which would diminish the rate of compliance (Cui et al., 2020).
Seroquel was disqualified from consideration due to the addition of weight gain and an increase in total cholesterol and triglycerides brought on by the drug. The desired therapeutic effects of the treatment were not achieved because the patient repeatedly missed doses of the medication. As a result, it was decided to find the causes of the patient’s noncompliance with therapy and work on finding solutions.
We chose to convert from an instant formulation of lithium to a prolonged preparation of the drug because the patient had mentioned experiencing side effects like nausea and diarrhea. Lithium sustained release is associated with fewer side effects as well as higher compliance (Pelacchi et al., 2022). Ethics principles including beneficence, nonmaleficence, and autonomy were taken into account when constructing the treatment. Based on best practices that were linked to outstanding treatment outcomes, the PMHNP made recommendations about therapy.
References
Baldessarini, R. J., Tondo, L., & Vázquez, G. H. (2019). Pharmacological treatment of adult bipolar disorder. Molecular psychiatry, 24(2), 198–217. https://doi.org/10.1038/s41380-018-0044-2
Butler, M., Urosevic, S., Desai, P., Sponheim, S. R., Popp, J., Nelson, V. A., … & Sunderlin, B. (2018). Treatment for Bipolar Disorder in Adults: A Systematic Review.
Butt, H., Muzaffar, Z., Rasool, F., & Mohsin, M. (2018). Assessment Of Patient Compliance, Its Associated Factors, And Predictable Interventions. Value in Health, 21, S1. https://doi.org/10.1016/j.jval.2018.07.009
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar Disorder. The New England journal of medicine, 383(1), 58–66. https://doi.org/10.1056/NEJMra1906193
Cui, Y., Yan, H., Su, Y., Wang, L., Lu, T., Zhang, D., & Yue, W. (2020). CYP2D6 Genotype-Based Dose Recommendations for Risperidone in Asian People. Frontiers in pharmacology, 11, 936. https://doi.org/10.3389/fphar.2020.00936
Ostacher, M. J. (2019). Ethical Issues in the Diagnosis and Treatment of Bipolar Disorders. FOCUS, A Journal of the American Psychiatric Association, 17(3), 265-268. https://doi.org/10.1176/appi.focus.20190010
Pelacchi, F., Dell’Osso, L., Bondi, E., Amore, M., Fagiolini, A., Iazzetta, P., … & SALT Study Group. (2022). Clinical evaluation of switching from immediate‐release to prolonged‐release Lithium in bipolar patients, poorly tolerant to Lithium immediate‐release treatment: A randomized clinical trial. Brain and Behavior, e2485. https://doi.org/10.1002/brb3.2485
A Sample Answer For the Assignment: Assessing and Treating Patients With Bipolar Disorder NURS 6630
Title: Assessing and Treating Patients With Bipolar Disorder NURS 6630
Managing Bipolar Disorder in Adults
Bipolar disorder refers to a chronic psychiatric illness that causes a fluctuation in energy, mood, focus, concentration, and activity. Affected patients present with alternating episodes of mania or hypomania and depression as well as a mixture of manic and depressive features. It damages relationships, lower job performance, and increases suicidal ideations. Bipolar can be managed but residual clinical symptoms and dysfunction can continue making it imperative to continuously reevaluate and treat affected patients. For a deeper understanding of Bipolar disorder, this paper will examine an Asian-American woman diagnosed with the disease and make three decisions regarding her medication. The decisions will be based on pharmacokinetic and pharmacodynamic processes.
Case Study
The presented case outlines a 26-year-old Korean woman. She has Bipolar I disorder a diagnosis made after 21-day hospitalization due to an onset of acute mania. During her appointment, she is exceptionally “busy” as she shifts in her chair and plays with things on the desk (WU, 2022). She reports that she was informed of her bipolar diagnosis but she feels that it’s wrong because her hobbies are talking, dancing, singing, and cooking. Her BMI is normal because she weighs 110lbs and her height is 5’5”. She indicates that her mood is ‘fantastic’ and adds that she sleeps for five hours each night although she hates sleep because it’s no fun. Her health and lab studies are non -remarkable although she is positive for the CYP2D6*10 allele since all her medications were not working (WU, 2022). Her discharge was authorized after responding positively to Lithium but she states that she no longer takes the prescription as instructed. Her reasons for non-adherence are not offered. Her mental status exam reveals odd dressing because she is wearing an evening gown. She has a tangential, pressured, and rapid speech with a euthymic mood. Her affect is broad with no hallucinations, delusions, to suicidal ideations. She has intact judgment and impaired insight (WU, 2022). She scores 22 on the Young Mania Rating Scale (YMRS). Among the factors that will influence decisions made are her positive genetic test and her nonadherence history. It will be prudent to consider drugs that limit side effects to enhance compliance. The selected drug should also offer a positive therapeutic response to stabilize and manage her presenting symptoms.
Decision 1
Begin Seroquel XR 300 mg orally at HS
Reason for Selection
Seroquel XR 300 mg was selected because it is a bimodal mood stabilizer that effectively managed bipolar mania and depression. Seroquel blocks dopamine D2 receptors in the mesolimbic pathway resulting in an antipsychotic efficacy. XR 300mg is selected because it is within the recommended therapeutic range. A study by Kanba et al. (2019) outlines that administration of 300mg/day of quetiapine XR greatly reduces the Montgomery–Åsberg Depression Rating Scale score compared to a placebo. The dosage sustains long-term efficiency with no new safety concerns. Murasaki et al. (2018) also provide similar views in their multi-center, randomized, double-blind, placebo-controlled study. Patients were offered a monotherapy of Quetiapine XR 300Mg or a placebo for eight weeks. The research concluded that the dosage offered once daily, was effective and well-tolerated. The patient has reported non-adherence issues making a once-daily dosage ideal. Seroquel XR has a peak plasma of 5 hours and maintains sufficient therapeutic drug concentration as a single daily dose.
Despite Lithium being a cornerstone of therapy for bipolar disorder, the drug is rejected because of non-compliance. As Pelacchi et al. (2022) explain, the therapeutic window of the drug is narrow yet it has a high incidence of adverse effects and requires repeated serum level controls. It induces side effects like diarrhea, weight gain, polydipsia, polyuria, and tremor which can cause low treatment compliance. Öhlund et al. (2018) executed a retrospective cohort study to understand why patients with bipolar disorder discontinue the medication. Among 873 patients recruited in the study, 561 reported lithium discontinuations. 62% of the discontinuations were linked to adverse events, 44% to psychiatric reasons, and 12% to physical reasons.
Risperdal was rejected because of the patient’s positive genetic test. The patient is positive for the CYP2D6*10 allele a crucial factor when recommending Risperdal. Risperidone is metabolized in the liver through the enzyme CYP2D6 (Cui et al., 2020). Research indicates that the presence of the CYP2D6*10 allele results in higher levels of dose-corrected concentration of risperidone and an active moiety within 12 weeks (Chavan et al., 2018). CPIC classifies the CYP2D6*10 allele as a decreased function allele with an activity value of 0.25. The allele makes patients poor metabolizers of the drug and increases the risk of adverse effects due to prolonged exposure to plasma risperidone. The gene increases the elimination half-life from 3 hours to around 20 hours.
Expectations
The clinician expects a positive therapeutic response with no reported adverse events. Research outline that Seroquel is well-tolerated and effective when handling manic episodes (Kanba et al., 2019). The dosage should adequately reduce the excited mental states outlined by the patient. There should be a reduction in impulsive behaviors, decreased need for sleep, pressured speech, and racing thoughts (APA, 2010b). Unfortunately, the patient partially meets the expectations. The patient reports a good mood, and better sleep, and her YMRS score reduce from 22 to 18 (WU, 2022). She reports adverse events like weight gain, constipation, and dry mouth. She requests a change of medication due to the weight gain.
Ethical Considerations
The first ethical consideration would be to inform the patient of the benefits and risks linked to the medication (APA, 2010b). Active listening as well as respecting autonomy are needed to reinforce the therapeutic relationship between the patient and the clinician. The approach allows the clinician to act as a trusted intermediary who offers relevant medical knowledge that resonates with the patient’s state values and priorities. Counseling to enhance medication adherence is needed since nonadherence contributes to medication nonresponse and increases relapses. The patient was actively listened and her desire not to get lithium medication was honored. She was informed of the need to adhere to medication despite any adverse events. She followed the instruction and despite experiencing weight gain, constipation, and dry mouth she continued with the prescribed medication.
Decision 2
Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal
Reason for Selection
Seroquel has induced unacceptable adverse events and may increase nonadherence if not discontinued. The binding of the drug metabolite norquetiapine to the muscarinic receptors has induced anticholinergic side effects (Kadakia et al., 2021). The metabolite is generated after hepatic metabolism and catalyzed by the enzyme CYP3A4. Switching to Geodon is ideal because it has a comparatively neutral metabolic profile compared to Seroquel and is an effective treatment alternative if a patient cannot tolerate Seroquel or experiences weight gain. Geodon cannot cause similar side effects as Seroquel because one-third of its oxidative metabolism is linked to CYP3A4 and CYP1A2 alleles while two-thirds is linked to aldehyde oxidase (WU, 2022). It has a low affinity for histaminergic1, muscarinic1, and α1-noradrenergic receptors (Gardner et al., 2013). O’shea et al. (2018) explain that Geodon should be taken with food because, in a fasted state, it displays nonlinear pharmacokinetics while the inclusion of a 500-kcal meal doubles the drug absorption.
Increase of Seroquel to 400mg orally at HS and maintenance of 300mg Seroquel with counseling are rejected because of reduced tolerance. Antipsychotics should always be provided in the lowest effective dose and therefore increasing Seroquel to 400mg would be counterproductive and exacerbate the current adverse events (Keks et al., 2019). Further, maintaining a 300mg dosage will keep inducing constipation, dry mouth, and weight gain resulting in non-compliance.
Expectations
The clinician expects a positive therapeutic response and a reduction in the current adverse events. In line with the expectations, the patient records a 50% reduction in her YMRS score (WU, 2022). She is also happy that she has not gained weight or experienced additional side effects.
Ethical Considerations
At this juncture, the patient project intact cognition, insight, and judgment. An ethical option is to engage in shared decision-making. A shared decision will allow the clinician and the patient to work together to select the ideal drug that does not induce adverse events (APA, 2010b). In the current case, the clinician and the patient worked together to select Seroquel. The two discussed the risks and benefits of the available therapy and concluded that Seroquel offers a therapeutic response without the adverse events linked to Seroquel. Education on the need for compliance is also important.
Decision 3
Continue the same dose and reassess in 4 weeks
Reason for Selection
Switching from Seroquel to Geodon generated positive results. The patient reported a positive therapeutic response and her weight gain was arrested. Maintaining the current dose is ideal to establish if the patient will record more improvement. Increasing Geodon to 60mg is also appropriate and can enhance symptom improvement however, it may induce side effects and thus is rejected (WU, 2022). Use of the lowest effective dose is advised with research showing that more than 10% of patients report lightheadedness, nausea, dizziness, and drowsiness. At least 5% of patients report side effects like weight gain, constipation, skin rash, and anxiety among others (Bai et al., 2019). The past medication has induced similar adverse events prompting the clinician to discontinue the drug therapy. With a positive response from the patient, it is not practical to augment her dosage with Lithium. The approach would only apply if the intention was to discontinue Geodon and initiate the patient on Lithium monotherapy. Further, the patient reported nonadherence to lithium due to adverse events nevertheless, as Pelachi et al (2022) explain the use of sustained-release lithium could dissipate the previous side effects related to the immediate release Lithium.
Expectations
The clinician expects more improvement in the patient’s symptoms and a reduction in the Young Mania Rating Scale (YMRS) score. A score of below 7 is expected to indicate remission and minimal manic symptoms.
Ethical Consideration
A reinforcement of the information offered on medication side effects and adherence is needed. The patient has a positive response and compliance to the stated medication will result in a more therapeutic response. The patient was taken through the side effects of Geodon and advised to maintain compliance to go into remission.
Conclusion
Bipolar disorders present with mood swings that range from depressive lows to manic highs. An example is the 26-year-old Korean woman with a fantastic mood and positive for the CYP2D6*10 allele. She is not compliant with her medication and her YMRS score is 22. To treat her, she initiated Seroquel 300mg. The drug is selected based on primary research that asserts its ability to induce a therapeutic response compared to a placebo (Kanba et al., 2019). The decision is also made because the patient has recorded noncompliance with Lithium. Lithium has a narrow therapeutic window increasing incidences of adverse events (Pelachi et al., 2022). Further, the use of Risperdal is not ideal as the patient is positive for the CYP2D6*10 allele. The allele has a decreased function yet CYP2D6 is the major component that metabolizes risperidone in the liver (Cui et al., 2020). It would therefore cause sustained exposure to plasma risperidone increasing the risk of adverse effects. Unfortunately, Seroquel induced unacceptable adverse events despite a positive therapeutic response. The patient reported constipation, dry mouth, and weight gain. She assertively requested a change of drug. To honor her request and execute a shared decision, the patient is discontinued from Seroquel and started on Geodon 40mg orally BID. Geodon has a low affinity for the muscarinic receptors and therefore will not cause similar side effects as Seroquel (Gardner et al., 2013). It has a neutral metabolic profile and its metabolism does not entirely depend on the enzyme CYP3A4. The patient is instructed to consume the drug with food to double its absorption. An increase or maintenance of Seroquel is avoided to limit adverse events that would affect compliance. Geodon offers a positive therapeutic response with no adverse effects. The patient’s YMRS score reduces by 50% and her weight gain is arrested. To continue with the therapeutic response and limit side effects the patient is maintained on Geodon 40mg for 4 weeks. An increment to 60mg is avoided to reduce risks of adverse events although the dosage would hasten improvements. Augmentation with lithium is also avoided because the plan is not to discontinue Geodon and initiate Lithium. The decision-making process is governed by ethical considerations with the patient giving their consent to the medication, actively listening, integrated into the decision-making process, and educated on side effects and compliance.
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
Bai, Y., Liu, T., Xu, A., Yang, H., & Gao, K. (2019). Comparison of common side effects from mood stabilizers and antipsychotics between pediatric and adult patients with bipolar disorder: a systematic review of randomized, double-blind, placebo-controlled trials. Expert opinion on drug safety, 18(8), 703-717. https://doi.org/10.1080/14740338.2019.1632832
Chavan, B. S., Kaur, G., Gupta, D., & Aneja, J. (2018). A prospective study to evaluate the effect of CYP2D6 polymorphism on plasma level of risperidone and its metabolite in North Indian patients with schizophrenia. Indian Journal of Psychological Medicine, 40(4), 335-342. https://doi.org/10.4103/IJPSYM.IJPSYM_83_18
Cui, Y., Yan, H., Su, Y., Wang, L., Lu, T., Zhang, D., & Yue, W. (2020). CYP2D6 Genotype-Based Dose Recommendations for Risperidone in Asian People. Frontiers in pharmacology, 11, 936. https://doi.org/10.3389/fphar.2020.00936
Dodsworth, T., Kim, D. D., Procyshyn, R. M., Ross, C. J., Honer, W. G., & Barr, A. M. (2018). A systematic review of the effects of CYP2D6 phenotypes on risperidone treatment in children and adolescents. Child and adolescent psychiatry and mental health, 12(1), 1-10. https://doi.org/10.1186/s13034-018-0243-2
Kadakia, A., Dembek, C., Heller, V., Singh, R., Uyei, J., Hagi, K., … & Loebel, A. (2021). Efficacy and tolerability of atypical antipsychotics for acute bipolar depression: a network meta-analysis. BMC psychiatry, 21(1), 1-16. https://doi.org/10.1186/s12888-021-03220-3
Kanba, S., Murasaki, M., Koyama, T., Takeuchi, M., Shimizu, Y., Arita, E., … & Kamei, S. (2019). Long-term mood/antidepressant effects of quetiapine extended-release formulation: an open-label, non-controlled extension study in Japanese patients with bipolar depression. BMC psychiatry, 19(1), 1-10. https://doi.org/10.1186/s12888-019-2181-9
Keks, N., Schwartz, D., & Hope, J. (2019). Stopping and switching antipsychotic drugs. Australian Prescriber, 42(5), 152. https://doi.org/10.18773%2Faustprescr.2019.052
Murasaki, M., Koyama, T., Kanba, S., Takeuchi, M., Shimizu, Y., Arita, E., … & Kamei, S. (2018). Multi-center, randomized, double-blind, placebo-controlled study of quetiapine extended-release formulation in Japanese patients with bipolar depression. Psychopharmacology, 235(10), 2859-2869. https://doi.org/10.1007/s00213-018-4977-6
Öhlund, L., Ott, M., Oja, S., Bergqvist, M., Lundqvist, R., Sandlund, M., … & Werneke, U. (2018). Reasons for lithium discontinuation in men and women with bipolar disorder: a retrospective cohort study. BMC psychiatry, 18(1), 1-10. https://doi.org/10.1186/s12888-018-1622-1
O’Shea, J. P., Holm, R., O’Driscoll, C. M., & Griffin, B. T. (2019). Food for thought: formulating away the food effect–a PEARRL review. Journal of Pharmacy and Pharmacology, 71(4), 510-535. https://doi.org/10.1111/jphp.12957
Pelacchi, F., Dell’Osso, L., Bondi, E., Amore, M., Fagiolini, A., Iazzetta, P., … & SALT Study Group. (2022). Clinical evaluation of switching from immediate‐release to prolonged‐release lithium in bipolar patients, poorly tolerant to lithium immediate‐release treatment: A randomized clinical trial. Brain and Behavior, 12(3), e2485. https://doi.org/10.1002/brb3.2485
Walden University (2022). Case Study: An Asian American Woman with Bipolar Disorder. https://cdn-media.waldenu.edu/2dett4d/Walden/NURS/6630/DT/week_04/3.html