Assignment: Managing Bipolar Disorder Essay

Assignment: Managing Bipolar Disorder Essay

A Sample Answer For the Assignment: Assignment: Managing Bipolar Disorder Essay

Title: Assignment: Managing Bipolar Disorder Essay

Assignment: Managing Bipolar Disorder Essay

Bipolar disorder is a mood disorder that affects a person’s behaviors, attention, energy level and mood (Diniz et al., 2017). It present with recurring manic and depressive episodes that make it hard for a person to lead a stable, productive life. The depressive phase renders one unable to do anything at all whereas the manic phase makes one irresponsible and hyperactive. It is essential to get an early diagnosis and treatment to avoid the devastating effects of the disease. The procedures can be executed by an experienced mental health professional. To explore more on the management of bipolar disorder a case study will be used. The case is of a woman of Korean descent aged 26 years. She has been hospitalized for acute mania and appear “busy”. She has a rapid and pressured speech and she states that her hobbies are cooking, singing, dancing and talking.  She states that sleep is no fun and her health outlook is perfect. She, however, has a CYP2D6*10 allele and confesses that she stopped taking her lithium (Laureate Media, 2020). She is dressed oddly and has impaired insight. She, however, denies suicidal or homicidal ideation. The paper will use a decision tree to recommend pharmacological agents for the patient and will outline ethical considerations guiding the treatment plan.

Assignment: Managing Bipolar Disorder Essay
Assignment: Managing Bipolar Disorder Essay

Decision-Point One

Begin Risperdal 1mg orally BID

Why the Decision

Risperdal can be used as a monotherapy in the management of bipolar mania. The drug has demonstrated efficacy and generally good tolerability. It produces positive mood effects through its potent antagonism of the alpha-adrenergic receptors, dopamine D2 and serotonin 5-HT2A (Vasquez & Bobo, 2020). It works by treating mania and reducing mood switch from mania to depression or cycling. It has lower incidences of extrapyramidal systems and significantly delays the time to relapse of any mood episode compared to placebo. Lithium 300mg BID orally is avoided because of its adverse effects. It is linked to cognitive dysfunction which occurs as mental slowness and precipitates nonadherence (Berk et al., 2017). Additionally, the patient has confessed that she stopped taking lithium an indication of poor adherence to the medication. Seroquel is equally rejected due to its probability of inducing side effects via the muscarinic receptors (Berk et al., 2017). The drug causes weight gain, constipation, dizziness, sleepiness, sedation and dry mouth all of which may negatively impact the patient and result in compliance issues.

Expected Outcomes

The patient should improve adequately. She should report improved mood, behaviors, attention and energy levels (Vasquez & Bobo, 2020). She should be able to execute her activities of daily life. The medication should handle her symptoms and she should report no adverse events.

Differences between Expected and Actual Outcomes

The patient appears to be experiencing some adverse events towards the medication. The mother supports her into the clinic and she appears sedated and lethargic (Laureate Media, 2020). The mother reports that her condition has persisted in the last three weeks although her mood has improved. Sedation is a common side effect of Risperdal however the patient has a CYP2D6*10 allele which could be delaying the clearance of the medicine in her system (Jukic et al., 2019).

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Decision Point Two

The decision made is reducing Risperdal to 1mg HS

Why the Decision

Research indicates that patients who are positive for *10 alleles have decreased metabolism and clearance of risperidone (Jukic et al.,

2019). Generally, risperidone is cleared through CYP 2D6 alleles and CYP3A4 although to a lesser extent. Poor metabolizers have low CYP2D6 activity which results in less metabolic conversion. To optimize conversion and reduce the concentration of the drug is the blood system, there is a need to lower the dosage. With increased clearance, the adverse events experienced by the patient will reduce. Increasing the dosage to 2mg orally HS is avoided because of the poor conversion and metabolism. Increased dosage translates into increased accumulation of the drug resulting in increased lethargy and sedation. Changing the drug to lithium is also avoided because the patient has compliance issues. Risperdal is also normally tapered off rather than being stopped abruptly to avoid intense withdrawal symptoms (Vasquez & Bobo, 2020).

Expected Outcomes

The main aim of the second decision is to reduce the adverse symptoms experienced while handling the disease symptoms. The reduced dosage of Risperdal should optimize conversion and reduce accumulation in the body resulting in lesser episodes of sedation and lethargy (Jukic et al., 2019). The patient should report a better score on the YMRS scale with a reduction in symptoms of above 25%.

Difference between Expected and Actual Outcome

The client met the set expectations. The reduced dosage resulted in better clearance and helped in reducing sedation and lethargy. The patient also had a positive therapeutic response since her symptoms improved as indicated by the YMRS score of 16 (Laureate Media, 2020). The score indicated that the disease symptoms reduced by more than 25%.

Decision Point Three

Continue the dose of Risperdal and assess after four weeks

Why the Decision

The patient has positively responded to a reduced dosage of Risperdal. The presence of the CYP2D6*10 allele led to poor metabolism of Risperdal and increased its accumulation in the blood (Jukic et al., 2019). The overall effects were sedation and lethargy. Reverting the current dosage to the initial 1mg orally BID will induce sedation and lethargy which have already been managed. Maintaining the dosage is the best decision because it will help the client and clinician achieve the treatment goals which are reducing disease symptoms and managing drug side effects. Lastly, the introduction of Latuda is avoided because the patient has manic symptoms yet Latuda is approved for bipolar I depression (Burt & Nasrallah, 2016).  The drug is equally expensive and insurance companies reserve it as the last resort when other medications have failed.

Expected Outcomes

The disease symptoms should improve further. Additionally, the side effects experienced earlier should be gone. The patient should report better mood and behavior as well as enhanced daily functioning. Her YMRS score should reduce further.

Differences between Expected and Actual Outcomes

The patient presented as expected. The low dosage of Risperdal managed to reduce the plasma concentration of the drug in the blood and helped in arresting the bipolar symptoms. She scored 10 on the YMRS scale indicating that her symptoms had reduced beyond 50%.

Ethical Considerations

Autonomy, non-maleficence, and beneficence are the ethical considerations that govern the management of bipolar disorder (Salagre, Vieta & Grande, 2020). Medications are essential for bipolar patients to lead a stable, productive life. However, any medication selected should balance the risks with benefits. Informed consent should guide the choices to ensure that the patient understands available treatment options and their risk and benefits. Due to the cyclic nature of bipolar, patients have poor insight which reduces their ability to consent and make rational decisions (Salagre, Vieta & Grande, 2020). Additionally, disease symptoms like irritability and delusion can affect the therapeutic relationship and patients may feel relieved indicating a need to stop the treatment. All these factors create conflict between the treatment goals and patient autonomy and should be handled well.

In the provided case study, the 8-year-old Caucasian female patient came to the clinic accompanied by her parents for psychiatric evaluation. The patient’s teacher suggested that the patient might be having attention deficit hyperactivity disorder (ADHD). Their family physician also suggested that the patient should see a psychiatrist for further evaluation of her mental disorder. The patient parents came with a completed Conner’s Teacher Rating Scale-Revised screening tool, which revealed that the patient is easily distracted at school, and with a short attention span. The patient also displayed poor arithmetic, spelling, and reading skills in addition to being inattentive and forgetful most of the time. Her teacher claims that the patient even failing to complete her homework will lack interest in school activities. She also fails to follow instructions at times. Despite the patient’s parents being in denial that their daughter has ADHD, mental status examination results proved otherwise together with the Conner’s Teacher Rating Scale-Revised screening tool completed by the teacher, supporting the diagnosis of attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.

Developing a treatment plan for pediatric patients with mental disorders is quite challenging given the safety issues associated with this age group. However, appropriate prescriptive practice will involve considering patient-specific factors that might affect the pharmacokinetic and pharmacodynamic processes. Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. The purpose of this discussion is thus to demonstrate the appropriate decision-making process in the selection of the most appropriate intervention in the treatment of the 8-year-old attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.

Decision Point One

Selected Decision and Rationale

            From the listed options, initiating Ritalin (methylphenidate) 10mg chewable tablets taken every morning was decided on as the initial intervention. Ritalin is recommended by most clinical guidelines as the first-line medication for the management of ADHD among both children and adults (Rodrigues et al., 2021). Despite the psychostimulant not being approved by the FDA, it has displayed great effectiveness in the management of ADHD with a desirable safety profile in most children from ages 6 to 15 years (American Psychiatric Association, 2013; Castells et al., 2021)). It has demonstrated a substantial impact in managing ADHD symptoms such as inattention, forgetfulness, impulsivity, diminished interest, and hyperactivity among children (Hodgkins et al., 2012). The chewable formulation is considered the best option for children with sweeteners to mask the bitter taste of the drug (Breaux et al., 2022). Consequently, the drug has a short onset of action of between 1 to 2 hours with a long duration of action of between 7.5 to 10.5 hours after oral administration (Mechler et al., 2021). This helps in the management of the patient’s symptoms all day long (Coghill et al., 2021).

Bupropion is associated with increased risks of seizures among children below the age of 10 years, hence not an appropriate decision (Coghill et al., 2021). Intuniv on the other hand is associated with cardiovascular side effects, hence should only be considered in case there is no other safer and more effective drug for use in the pediatric population (Rodrigues et al., 2021).

Expected Outcome

The patient will experience improved symptoms of ADHD in the next four weeks (Coghill et al., 2021). She should be able to improve her spelling, arithmetic, and language skills, in addition to being more attentive and able to concentrate on school work (Hodgkins et al., 2012). Her school performance will improve significantly within this period.

Ethical Considerations

            The patient is 8 years of age, which gives the parents legal responsibility of making decisions concerning the health of their child (American Psychiatric Association, 2013). As such, the PMHNP must educate them adequately regarding the patient’s diagnosis and potential treatment options, to promote sound decision-making in promoting the health of their child (Rodrigues et al., 2021).

Decision Point Two

Selected Decision and Rationale

            The second decision was to change the treatment regimen to long-acting Ritalin 20mg administered orally in the morning. Based on the treatment outcome, Ritalin displayed potential effectiveness given that the patient’s ADHD symptoms improved evidenced by her improved school performance (Breaux et al., 2022). However, since the medication was not able to manage the patient’s symptoms throughout the entire day, it was necessary to introduce a long-acting formulation to prolong the duration of action of the drug (American Psychiatric Association, 2013). Studies show that long-acting Ritalin lasts for between 8 to 12 hours hence, helps in managing the patient’s symptoms throughout the day (Castells et al., 2021). It is also administered once daily which is more convenient and much easier. The patient also reported a side effect of elevated pulse, which is a common self-limiting side effect of Ritalin that is expected to diminish with time (Coghill et al., 2021).

Continuing with the same drug at the same dosage was inappropriate as the patient would still exhibit ADHD symptoms later in the day, once the drug wears off from the body system (Mechler et al., 2021). Replacing Ritalin with Adderall is also inappropriate as Adderall is associated with increased incidences of suicidal events when used among children (Hodgkins et al., 2012).

Expected Outcome

            The long-acting formulation is expected to manage the patient’s symptoms all day long within the following four weeks (Breaux et al., 2022). The patient’s school performance will improve even further. The side effect of elevated heart rate will resolve completely within this time (Coghill et al., 2021).

Ethical Considerations

            In making this decision, the PMHNP had to consider several ethical principles including justice, beneficence, nonmaleficence, and respect for the patient’s autonomy (Breaux et al., 2022). The patient was quite comfortable with how the drug was working, but only concerned with the side effect, and effectiveness of the medication later in the day (Rodrigues et al., 2021). As such, it was necessary to respect the patient and display clinical judgment in making decisions that will promote the patient’s mental health.

Decision Point Three

Selected Decision and Rationale

            Maintaining the patient on the current medication and reevaluating after four weeks, seemed to be the most appropriate decision for the third intervention. The patient reported great effectiveness and tolerance to the medication, with resolved side effects of an elevated pulse (Mechler et al., 2021). Previous evidence shows that once the optimal dose of Ritalin has been attained, it can take between 8 to 12 weeks to completely manage the patient’s symptoms of ADHD (American Psychiatric Association, 2013; Castells et al., 2021). Consequently, at safe doses, long-term use of the drug has been associated with limited possibilities of side effects, hence the need to reevaluate the patient within 4 weeks (Hodgkins et al., 2012). Studies also show that long-term use of Ritalin normally reduces the risks of side effects as the patient will display further tolerance to the drug, enhancing its safety profile (Breaux et al., 2022).

Increasing the dose of Ritalin to 30mg was not necessary at this point, as studies suggest that low effective doses are safer to use to promote positive outcomes, with reduced risks of side effects (Mechler et al., 2021). Consequently, obtaining EKG at this point was not necessary given that the patient’s pulse had already resolved back to normal for her age, with a recording of 92 during the current visit (Rodrigues et al., 2021).

Expected Outcome

            With great compliance to the treatment regimen, the patient will report even further management of the ADHD symptoms over the following two weeks (Breaux et al., 2022). Her academic performance is also expected to improve (American Psychiatric Association, 2013). No side effects are expected.

Ethical Considerations

            The nurse’s main objective is to promote the health of the patient and not harm. At this point, the patient was satisfied with the treatment outcome (Hodgkins et al., 2012). It was thus necessary to respect the patient’s autonomy and maintain the dose for further evaluation of the treatment outcome (Mechler et al., 2021).

Assignment: Managing Bipolar Disorder Essay Conclusion

The 8-year-old patient in the case study presented with symptoms of ADHD. Formulating a treatment plan for the patient involved consideration of certain patient-specific factors which affect her pharmacokinetic and pharmacodynamic processes (American Psychiatric Association, 2013). Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. Based on these factors, the first decision was to initiate a 10mg Ritalin chewable table once daily as recommended by most clinical guidelines given its effectiveness in the management of ADHD and safety for pediatric use (Coghill et al., 2021). Intuniv and bupropion were neglected because of their increased risks of side effects among children as reported by most studies (Mechler et al., 2021). After 4 weeks, the patient came back to the clinic reporting improved symptoms but with side effects of increased pulse rate. The second decision was thus to change the treatment regimen to long-acting Ritalin 20mg once daily in the morning, to prolong the duration of action of the medication throughout the day (Castells et al., 2021). Maintaining the dose would still lead to ineffectiveness, while Adderall display increased risks of suicidality hence neglected (Breaux et al., 2022).

The patient reported further improvement in ADHD symptoms all day long, with resolved side effects of elevated pulse, which led to the final decision of maintaining the treatment regimen and reevaluating the patient after 4 weeks. Obtaining EKG and increasing the dose of Ritalin was not necessarily due to safety issues (Hodgkins et al., 2012). Finally, the PMHNP encountered several ethical considerations in each decision process with the observation of ethical principles such as justice, respect for patient autonomy, not harm, and beneficence (Rodrigues et al., 2021).

Assignment: Managing Bipolar Disorder Essay References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Breaux, R., Dunn, N. C., Swanson, C. S., Larkin, E., Waxmonsky, J., & Baweja, M. D. (2022). A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD. Frontiers in Psychiatry, 151. https://doi.org/10.3389/fpsyt.2022.794044

Castells, X., Ramon, M., Cunill, R., Olivé, C., & Serrano, D. (2021). Relationship between treatment duration and efficacy of pharmacological treatment for ADHD: a meta-analysis and meta-regression of 87 randomized controlled clinical trials. Journal of attention disorders25(10), 1352-1361. https://doi.org/10.1177/1087054720903372

Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., … & Simonoff, E. (2021). The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). European Child & Adolescent Psychiatry, 1-25. https://doi.org/10.1007/s00787-021-01871-x

Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. https://doi.org/10.2165/11599630-000000000-00000

Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2021). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940

Rodrigues, R., Lai, M. C., Beswick, A., Gorman, D. A., Anagnostou, E., Szatmari, P., … & Ameis, S. H. (2021). Practitioner Review: Pharmacological treatment of attention‐deficit/hyperactivity disorder symptoms in children and youth with autism spectrum disorder: a systematic review and meta‐analysis. Journal of Child Psychology and Psychiatry62(6), 680-700. https://doi.org/10.1111/jcpp.13305

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I understand this is a lot of information to cover in 5 weeks, however, the Bible says in Philippians 4:13 that we can do all things through Christ that strengthens us. Even in times like this, we are encouraged by God’s word that we have that ability in us to succeed with His strength. I pray that each and every one of you receives strength for this course and life generally as we navigate through this pandemic that is shaking our world today. Relax and enjoy the course!

Hi Class,

Please read through the following information on writing a Discussion question response and participation posts.

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Important information on Writing a Discussion Question

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  • Do not include quotes—instead summarize and paraphrase the information
  • Follow APA-7th edition
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Participation –replies to your classmates or instructor

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