Assessing and Treating Patients with Bipolar Disorder
Bipolar disorder, also referred to as manic depression, is an episodic or chronic mental disorder characterized by fluctuating and often extreme changes in energy, mood, and activity levels, thus affecting a person’s focus and concentration. Whereas it is normal for humans to experience shifts in energy level and mood from time to time, the shifts for bipolar patients are extreme and can be rather severe (NIMH, 2020).

A patient could have any of three types of bipolar disorder: bipolar I disorder, bipolar II disorder, or Cyclothymic Disorder (NIMH, 2020). For bipolar I, a patient will present with severe manic symptoms, usually with separate depressive episodes that last at least fourteen days and often requiring hospitalization (NIMH, 2020). A bipolar II patient will present with a similar pattern of depressive and hypomanic episodes that are generally less severe (NIMH, 2020). A cyclothymic patient will present with persistent depressive and hypomanic symptoms that do not last long or are not intense enough to be classified as depressive or hypomanic episodes (NIMH, 2020). The diagnostic criteria for bipolar disorder requires a patient to experience manic/hypomanic as well as depressive episodes for at least four consecutive days, with the symptoms presenting nearly all day or most of the day. It is estimated that at least 2.8 percent of adults in the US suffer from bipolar disorder, while 4.4 percent have experienced the disorder at some point in life (NIHM, 2020). This assignment seeks to develop an individualized treatment plan for a patient presenting with symptoms of bipolar I disorder.

Summary of the Case

The patient is a 26-year-old Korean female diagnosed with bipolar I disorder and appearing for her first appointment after a 21-day hospitalization for acute manic episodes. Weighing 110 lbs. and 5’5’’, the patient self-reports being in a ‘fantastic’ mood. Her hospital records indicate that lab studies are within normal range and she is in overall good health. As none of the medications administered seemed to be working, the patient had been subjected to genetic testing at the hospital, which showed that she was positive for CYP2D6*10 allele. Lithium was prescribed, but the patient had not taken her medication for two weeks since leaving the hospital. An examination of the patient’s mental status reveals that she is oriented to events, time, place, and person; and is generally alert. She displays a broad affect, though self-reports being in a euthymic mood and denies experiencing hallucinations or suicidal thoughts. She does not exhibit overt delusional thought processes and her judgment is intact. However, her speech is pressured and tangential and insight evidently impaired. The administered YMRS yields a score of 22, indicating mild mania.

Decision Point 1

At the first decision point, the Psychiatric Mental Health Nurse Practitioner (PMHNP) is faced with three treatment options: begin lithium 300mg orally BID, begin Risperdal 1 mg orally BID, or begin Seroquel XR 100mg orally at HS. As the patient’s PMHNP at this decision point, I would opt to begin Lithium 300mg orally BID in the first step of pharmacological treatment.

Rationale for Selected Decision

The PMHNP needs to select a treatment option that will help stabilize the patient’s mood, with minimal adverse effects given their history of non-compliance. The US Food and Drugs Administration (FDA) approve the use of all three medications - lithium, Risperdal, and Seroquel in the treatment of bipolar disorder for both children and adults (Nierenberg, 2010). Studies have shown all three drugs to have a significant positive effect on mood stabilization for patients with bipolar I disorder (Vitiello, 2013; Nierenberg, 2010). Evidence from randomized clinical trials, in fact, shows both Risperdal and Seroquel to be have higher efficacy than lithium in reducing abnormal mood symptoms among bipolar patients as evidenced by at least 50% reductions in YMRS scores (Vitiello, 2013; Nierenberg, 2010).

In this case, however, it is important that the treatment option selected has minimal adverse effects to minimize the risk of non-compliance, which has already been established on the patient’s part. Weight is particularly relevant to this patient given their orientation to events and people, and an evident need to maintain their body shape (110 lbs and BMI of 18.3). Whereas Risperdal and Seroquel have higher efficacy, they have been shown to significantly increase the risk of weight gain and insulin sensitivity, as compared to lithium, making lithium the more ‘tolerant’ of the three (Vitiello, 2013; Nierenberg, 2010). Moreover, although lithium had been prescribed at the hospital and seemed not to have a significant effect on the patient’s symptoms, it is not to be ruled out as ineffective yet. Studies have shown that most patients taking lithium continue to show residual manic symptoms even after 3 weeks of treatment (Bowden et al., 1994). Studies contend, therefore, that an extended period of treatment (of between 8 and 12 weeks) is required for full remission with lithium (Bowden et al., 1994). Our patient has been on lithium treatment for just about three weeks while at the hospital, which may not be sufficient time for full remission. Studies have shown the CYP2D6*10 allele to inhibit the efficacy of Paroxetine in patients of Asian descent (Chen et al., 2015). However, there is no...…process, reduce the severity of symptoms. It is hoped that the patient reports reduced side effects, full compliance, and a notable remission of symptoms by the time of their next appointment. A switch or increase in dosage could be considered at the next appointment if there is a reduction in side effects and no notable remission of symptoms.

Actual Patient Outcome

The patient returns for review in four weeks. We expect a reduction in the severity of side effects, higher compliance levels, and a reduction in the severity of symptoms. We would expect the patient’s symptoms to have been fully eliminated at this point with the intensity of the administered treatment. This may, however, not be the case as a consequence of the interference posed by patient’s consistent non-adherence to the treatment plan. At the next appointment, the PHMNP will make a decision on whether to change the medication or increase the dosage of lithium based on the observations they make. If there is a notable reduction in symptoms and side effects, then it would be plausible to maintain the lithium treatment, with minor changes in dosage as the treatment progresses. Lithium has been indicated to be the most effective long-term treatment for bipolar disorder with proper management of adverse effects (Sani, Perugi & Tondo, 2017).

Conclusion

This case illuminates the fact that health care providers will always be required to balance the risks and benefits of treatment plans in their determination of the most effective treatment options for patients. Successful treatment largely depends on the ability to pick the treatment plan or option that best addresses the patient’s needs. In this case, the provider had to move beyond the normal prescription modalities to conduct patient education with the aim of getting them to understand the effects of drug use and pharmacology. This exemplifies the idea that besides doing the right thing on one’s part, a provider also has a duty to ensure that their patient cooperates as patient cooperation is key to effective treatment. The provider in this case confronts a high risk of suicide particularly because of the frustrations resulting from a lack of remission of symptoms despite continued treatment. However, it is important to note that one form of medication may work for one client and fail to work for another. The solution may not always lie in changing medications or increasing dosages. There is a need to take time to identify the unique needs of patients, empower the patient to understand the effects of drug use and their role in the treatment plan, and then work with them collaboratively towards desired…