Sample Answer for NURS 6630 Assessing and Treating Patients With Bipolar Disorder Assignment Included After Question
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:
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- 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.
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A Sample Answer For the Assignment: NURS 6630 Assessing and Treating Patients With Bipolar Disorder Assignment
Title: NURS 6630 Assessing and Treating Patients With Bipolar Disorder Assignment
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).
Conclusion NURS 6630 Assessing and Treating Patients With Bipolar Disorder Assignment
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).
References NURS 6630 Assessing and Treating Patients With Bipolar Disorder Assignment
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 disorders, 25(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 Psychiatry, 62(6), 680-700. https://doi.org/10.1111/jcpp.13305
NURS 6630 Assessing and Treating Patients With Bipolar Disorder 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 |
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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 | ||||||
NURS 6630 Assessing and Treating Patients With Bipolar Disorder Assignment Grading Rubric
| Performance Category | 100% or highest level of performance
100% 16 points |
Very good or high level of performance
88% 14 points |
Acceptable level of performance
81% 13 points |
Inadequate demonstration of expectations
68% 11 points |
Deficient level of performance
56% 9 points
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Failing level
of performance 55% or less 0 points |
| Total Points Possible= 50 | 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points |
| Scholarliness
Demonstrates achievement of scholarly inquiry for professional and academic topics. |
Presentation of information was exceptional and included all of the following elements:
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Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three or more of the following elements
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| 16 Points | 14 Points | 13 Points | 11 Points | 9 Points | 0 Points | |
| Application of Course Knowledge
Demonstrate the ability to analyze and apply principles, knowledge and information learned in the outside readings and relate them to real-life professional situations |
Presentation of information was exceptional and included all of the following elements:
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Presentation of information was good, but was superficial in places and included all of the following elements:
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Presentation of information was minimally demonstrated in the all of the following elements:
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Presentation of information is unsatisfactory in one of the following elements:
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Presentation of information is unsatisfactory in two of the following elements:
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Presentation of information is unsatisfactory in three of the following elements
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| 10 Points | 9 Points | 6 Points | 0 Points | |||
| Interactive Dialogue
Initial post should be a minimum of 300 words (references do not count toward word count) The peer and instructor responses must be a minimum of 150 words each (references do not count toward word count) Responses are substantive and relate to the topic. |
Demonstrated all of the following:
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Demonstrated 3 of the following:
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Demonstrated 2 of the following:
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Demonstrated 1 or less of the following:
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| 8 Points | 7 Points | 6 Points | 5 Points | 4 Points | 0 Points | |
| Grammar, Syntax, APA
Points deducted for improper grammar, syntax and APA style of writing. The source of information is the APA Manual 6th Edition Error is defined to be a unique APA error. Same type of error is only counted as one error. |
The following was present:
AND
AND
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
AND/OR
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The following was present:
AND/OR
AND/OR
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| 0 Points Deducted | 5 Points Lost | |||||
| Participation
Requirements |
Demonstrated the following:
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Failed to demonstrate the following:
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| 0 Points Lost | 5 Points Lost | |||||
| Due Date Requirements | Demonstrated all of the following:
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |
Demonstrates one or less of the following.
A minimum of one peer and one instructor responses are to be posted within the course no later than Sunday, 11:59 pm MT. |
Read Also: NURS 6630 Assessing and Treating Patients With Anxiety Disorders Assignment
A Sample Answer 2 For the Assignment: NURS 6630 Assessing and Treating Patients With Bipolar Disorder Assignment
Title: NURS 6630 Assessing and Treating Patients With Bipolar Disorder Assignment
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