Assignment: An Asian American Woman with Bipolar Disorder
Assignment: An Asian American Woman with Bipolar Disorder
Bipolar disorder refers to a mental illness that makes one experience a dramatic shift in mood, energy, and ability to think clearly. The disease causes a high and low mood referred to as mania and depression. The average age onset of bipolar is 25 years and it affects about 2.8% of adults in the United States (Grunze, 2015). The disease worsens without treatment but with proper management, one can execute daily tasks with ease. To explain more on bipolar management, this paper will review a 26-year-old Korean woman diagnosed with bipolar I disorder. The patient was hospitalized for acute mania. The patient appears to be busy and states she likes to talk, dance, sing and cook. Her mood is fantastic and she asserts that she hates sleep. Medications are not working on her and she is positive for the CYP2D6*10 allele (Laureate media, 2020). She reports that she stopped taking her lithium. She has a rapid, pressured and tangential speech with a broad affect. She denies delusions, hallucinations or suicidal ideation. She has a score of 22 on the Young Mania Rating Scale (YMRS). The paper will use a decision tree to prescribe psychopharmacological agents for the patient. The paper will also outline ethical considerations guiding the treatment protocol.
Decision -1
Begin Seroquel XR 100 mg orally at HS
Reason for Selection.
Seroquel XR 100 is selected because of its efficacy in the management of the bipolar disorder. As an atypical antipsychotic, it works by interacting with serotonin 5-HT2 receptors and dopamine D2 receptors. The main mechanism behind Seroquel’s antipsychotic efficacy is the blockade of the dopamine D2 receptor in the mesolimbic pathway (Muneer, 2015). The drug can modify the systems of dopaminergic, serotonergic and noradrenergic neurotransmission. The drug has a liner kinetic and an elimination half-life of approximately 7 hours. Seroquel XR has a peak plasma of 5 hours and sustains higher plasma levels for long allowing for once-daily dosing. Minimal metabolism occurs through CYP2D6 thus the patient’s positive allele will not affect the drug. The drug has minimal side effect profile, it’s well-tolerated and requires no therapeutic plasma monitoring.
Risperdal 1mg orally BID is avoided because the patient is positive for the CYP2D6*10 allele. The allele makes her a “poor metabolizer” with a decreased capacity to metabolize risperidone. She is therefore at a higher risk of adverse effects caused by increased exposure to plasma risperidone (Puangpetch et al., 2016). Equally lithium 300 mg orally BD is avoided because research indicates that it has limited clinical efficacy in severe manic and mixed episodes. It also has a narrow therapeutic index which calls for frequent plasma determination to avoid toxicity and adverse effects (Muneer, 2015).
Expected Results
The clinician expects that the patient will report improvement in symptoms. Seroquel efficiently improves mood, thinking, and behaviors and thus it will stabilize the patient increased energy, enhance her sleep, reduce nervousness and enhance her social life (Muneer, 2015). Her tolerance for the medication should also be better. The YMRS score should also decrease.
Difference between Expected and Actual Results
After four weeks, the patient stated that she slept more at bedtime, had a good mood and her YMRS score reduced from 22 to 18 (Laureate media, 2020). All these were in line with the clinician’s expectations. However, she indicated that she had gain 2-3 pounds, was constipated and had a dry mouth. The presentation is in line with frequent adverse events seen when using Seroquel which are dry mouth, sedation, constipation, increased appetite, dizziness and somnolence (Muneer, 2015). The client requested for a change of medication.
Decision 2
Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal
The need to maintain a strong therapeutic relationship prompted the change of the drug. The patient experienced adverse events from
Assignment An Asian American Woman with Bipolar Disorder
Seroquel. Geodon is backed up by research on reducing weight and generating better lipid profiles. A third of Geodon is cleared via CYP-3A4, 1A2 alleles while the rest is cleared via aldehyde oxidase and thus will not cause the adverse effects like Seroquel (Bahar, Setiawan, Hak & Wilffert, 2017). The major pathway of metabolizing Geodon is 3A4 while 2D6 acts as a minor pathway for metabolism. The meal is added to assure adequate absorption of the drug. Increasing Seroquel to 300mg is avoided because it will exacerbate the adverse events resulting in compliance issues. Additionally maintaining the current drug and counseling on constipation will not help because the major concern of the patient is weight loss.
Expected Results
The patient is expected to report improved disease symptoms. Her bipolar symptoms should be better and weight gain should not be a problem anymore. An improvement in symptoms will be indicated by a better YMRS score.
Difference between expected and actual results
After four weeks, the patient had improved remarkably. Her YMRS score was 11, an indication that her disease symptoms reduced by 50% (Laureate Media, 2020). She tolerated the medication well and reported that weight gain was no longer an issue.
Decision Three
Increase Geodon to 60 mg orally BID with a 500 calorie meal
Reason for Selection
The patient responded positively to Geodon. Her disease symptoms improved and her weight gain problem resolved. Geodon can be adjusted depending on tolerability and efficacy within the range of 40-80mg twice daily (Wecker, Currier & Catalano, 2018). The increased dosage will offer significant symptomatic improvement. Nevertheless, there is a risk of adverse events. Maintaining the patient on the current dosage and assessing after four weeks is also an option. However bipolar patients require rapid relief of symptoms to prevent and minimize mood cycling (Murray et al., 2017). Augmenting the current medication with lithium is avoided because it is only an option when the plan is to stop the antipsychotic therapy and initiate a lithium monotherapy. The patient also indicated that she stopped taking Lithium initially before visiting the clinic meaning that she will have compliance issues unless educated about its side effects.
Expected Results
The increased dosage is expected to result in rapid relief of symptoms and significant symptomatic improvement. The patient should YMRS score should reduce by 75% and she should report a balanced mood, better concertation, clear thoughts, normal sleep, and positive behaviors.
Differences between Expected and Actual Results
As per the clinician’s expectation, the patient went to remission. She tolerated the medication well and she scored 7 on her YMRS. She executed her daily activities normally and her social life improved.
Ethical Considerations
When managing bipolar patients, it is the duty of the clinician to ensure rapid relief of symptoms because it is a cyclic disorder. One should strive to have a positive therapeutic relationship with the patient. Additionally, informed consent should be followed to ensure that the patient understands the risk and benefits of medication used as well as alternative psychopharmacological therapies that can be used (Ratheesh et al., 2017). Evidence-based research should guide the therapies used. For the current patient, she was started on a drug that has a research backup on its efficacy on the management of bipolar. However, due to adverse events, she requested a change of drug. As a way of creating a therapeutic alliance and resolving the patient’s concerns, the clinician offered a different drug. The patient was taken through the risks and benefits of the new drug and consented on the use of the drug. Additionally, since the patient had a therapeutic response without any adverse events, the new drug dosage was increased to get a rapid relief of symptoms. The patient improved and went to remission.
The Assignment
Examine Case Study: An Asian American Woman With Bipolar Disorder
You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes.
I want you to answer the questions given to you (decision points one, two, and three) before you click on the option. The answers will be based on your decisions made and patient outcomes during the decision tree. I am looking for an essay that is long enough to cover the topic BUT short enough to keep my interest. I do not need you to tell me the treatment options available to you – I am very familiar with the cases. Remember this is a Pharmacology class that incorporates Pharmacotherapy and not a class on diagnosing disease. I want you to tell me why you selected an option (why is it the best option- using clinically relevant and patient specific data) AND why you did not choose the other options (with clinically relevant and patient specific data).
At each decision point stop to complete the following:
* Decision #1
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different?
* Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
* Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different?
Also include how ethical considerations might impact your treatment plan and communication with clients.
**reminder that I require five references based on the grading rubric**
Due date: Monday by 02:00 EST
Good luck!!
Please do not wait until the last minute to complete assignments, discussions or quizzes as we all know technology can be quirky from time to time. This is a GRADUATE LEVEL program and you should be managing your time effectively by this point in your academic and professional career.
1st decision
I started her on Lithium 300 mg orally BID because that’s what she was given in the hospital, which is good indication that she responded well enough to the drug to be discharged on a maintenance dose. Furthermore, because the patient possesses the CYP2D6*10 low function allele, which is common in the Asian population (Chen, Wang, Shi, Shen, & Hu, 2014). Seroquel would be ruled out because of this diminished function, which is linked to poor metabolism/clearance of atypical antipsychotics, primarily risperidone. Risperidone, 9-hydroxyrisperidone, and ion plasma concentration variability are all affected by CYP2D6 genetic variants, which have been linked to frequent side effects, highlighting the importance of personalized dose changes with risperidone treatment (Lisbeth, Vincent, Kristof, et al, 2016).
I was hoping to have the patient return to her post-discharge status as soon as the Lithium was restarted. The goal of Lithium treatment, according to Stahl’s Prescribers Guide, is complete remission of mania, treating until symptoms have disappeared or improvements are stabilized, maintaining medication with continuous improvements noted, and continuing treatment indefinitely to avoid recurrence. After four weeks, she returned to the clinic with no changes from her first appointment. This was owing to her failure to take the medication as prescribed.
Second choice
At this point, I decided to address the patient’s reasons for non-compliance and educate her about the importance of taking the medication. The demonstrated efficacy of Lithium on her in the past, which is why she became euthymic, is something I’d want to underline. I also make it clear that stopping the drug too soon after starting it can lead to a relapse of her mania, which is what brought her to me in the first place. Stopping lithium during stable maintenance in stable patients with bipolar mood disorder (BP-1 in her instance because there is no indication of depressive episodes) has a high risk of early recurrence of symptoms, particularly mania (Faedda, Tondo, Baldessarini, Suppes, & Tohen, 1993).
I hoped that by making this decision, I would be able to stick to the treatment plan and see some results. She complained of nausea and diarrhea, two frequent side effects, when she returned to the clinic, and she was still not taking the medication consistently. There was no mention of symptom relief.
3rd Choice
I had originally wanted to switch her to Depakote ER 500 mg at HS at this point. I made the decision to switch because I believed she would handle another drug better than the lithium and that this would help with compliance. Her madness would have been cured completely if she had followed the plan to increase her cooperation. The student advise indicated that because nausea and diarrhea are common side effects, switching to an extended release formulation typically avoids them from developing. Since this is also mentioned in the Prescribers Guide, I agree that I should have addressed the symptoms. However, at this time, I wanted to help the patient with her major problem. I had also contradicted why I had started her on Lithium in the first place by doing so. A doctor I worked with once told me that if something has been demonstrated to work, don’t quit doing it. It’s fine to adjust the dosages and add more, but don’t quit now that you have some control over the situation.
| Excellent
Point range: 90–100 |
Good
Point range: 80–89 |
Fair
Point range: 70–79 |
Poor
Point range: 0–69 |
|
|---|---|---|---|---|
| Introduction to the case (1 page)
Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient. |
9 (9%) – 10 (10%)
The response accurately, clearly, and fully summarizes in detail the case for the Assignment.
The response accurately and clearly explains in detail the specific patient factors that impact decision making when prescribing medication for this patient. |
8 (8%) – 8 (8%)
The response accurately summarizes the case for the Assignment.
The response accurately explains the specific patient factors that impact decision making with prescribing medication for this patient. |
7 (7%) – 7 (7%)
The response inaccurately or vaguely summarizes the case for the Assignment.
The response inaccurately or vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient. |
0 (0%) – 6 (6%)
The response inaccurately and vaguely summarizes the case for the Assignment, or is missing.
The response inaccurately and vaguely explains the specific patient factors that impact decision making with prescribing medication for this patient. |
| Decision #1 (1–2 pages)
• Which decision did you select? |
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.
The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided. |
16 (16%) – 17 (17%)
The response accurately explains the decision selected.
The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided. |
14 (14%) – 15 (15%)
The response inaccurately or vaguely explains the decision selected.
The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided. |
0 (0%) – 13 (13%)
The response inaccurately and vaguely explains the decision selected.
The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing. |
| Decision #2 (1–2 pages)
• Which decision did you select? |
18 (18%) – 20 (20%)
The response accurately and clearly explains in detail the decision selected.
The response accurately and clearly explains in detail why the decision was selected, with specific clinically relevant resources that fully support the decision selected. The response accurately and clearly explains in detail why the other two responses were not selected, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that fully support the response. The response accurately and clearly explains in detail how ethical considerations impact the treatment plan and communication with patients. Examples provided fully support the decisions and responses provided. |
16 (16%) – 17 (17%)
The response accurately explains the decision selected.
The response explains why the decision was selected, with specific clinically relevant resources that support the decision selected. The response accurately explains why the other two responses were not selected, with specific clinically relevant resources that support the response. The response accurately explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that support the response. The response accurately explains how ethical considerations impact the treatment plan and communication with patients. Examples provided support the decisions and responses provided. |
14 (14%) – 15 (15%)
The response inaccurately or vaguely explains the decision selected.
The response inaccurately or vaguely explains why the decision was selected, with specific clinically relevant resources that inaccurately or vaguely support the decision selected. The response inaccurately or vaguely explains why the other two responses were not selected, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that inaccurately or vaguely support the response. The response inaccurately or vaguely explains how ethical considerations impact the treatment plan and communication with patients. Examples provided may support the decisions and responses provided. |
0 (0%) – 13 (13%)
The response inaccurately and vaguely explains in detail the decision selected.
The response inaccurately and vaguely explains why the decision was selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains why the other two responses were not selected, with specific clinically relevant resources that do not support the decision selected, or is missing. The response inaccurately and vaguely explains the outcome the student was hoping to achieve with the selected decision, with specific clinically relevant resources that do not support the response, or is missing. The response inaccurately and vaguely explains how ethical considerations impact the treatment plan and communication with patients, or is missing. Examples provided do not support the decisions and responses provided, or is missing. |
| Decision #3 (1–2 pages)
• Which decision did you select? |
18 (18%) – 20 (20%)
The response accurate
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