Assessing and Treating Patients with Bipolar Disorder

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 evidence to show that a similar effect exists with lithium and other mood stabilizers, making it plausible for the use with the presenting patient.
Expected Treatment Goals
The overall goal of treatment for bipolar disorder is to eliminate all abnormal (manic) mood symptoms and prevent relapse (Stahl, 20089). The administration of treatment at the first decision point targets to realize a noted increase in mood stability. Response in the treatment of bipolar disorder is defined by a reduction of at least 50 percent in symptoms (Nierenberg, 2010). In the same light, this first step of treatment aims at realizing a 50 percent reduction in manic symptoms (represented by a reduced YMRS score from 22 to 11).
Actual Treatment Outcome
The 26-year-old returns to the PMHNP 4 weeks later with no notable change in symptoms from the first visit. She reports that she has been inconsistently taking the administered medication, often only when she feels that she needs it. The actual treatment outcome differs from what was expected as there is no notable change in response after four weeks of treatment. On a positive note, however, the patient does not report any side-effects from the administered treatment, and neither does she demonstrate worsening symptoms. One cannot effectively tell whether the lack of change in symptoms is due to the ineffectiveness of lithium or the patient’s non-compliance to medication. The PHMNP must have noted by this time, therefore, that the patient’s non-compliance would interfere with the treatment and needed to be addressed.
Decision Point 2
At decision point 2, the PHMNP faces three treatment options: increase lithium to 450 mg, assess rationale for non-compliance and educate the client on drug effects and pharmacology, or switch to Depakote ER 500mg. The PHMNP needs to maintain the current dosage of lithium, assess the rationale for non-compliance to identify potential reasons for the same, and then educate the client on drug effects and pharmacology.
Rationale for the Decision
The patient does not present with any adverse reactions to the administered treatment. Moreover, the treatment has been administered for only four weeks, albeit inconsistently. In their study, Bowden et al (1994) establish that an effective lithium treatment requires between 8 and 12 weeks for full remission of symptoms. As such, there may be no need to change the medication from lithium to Depakote, at least until lithium can be effectively ruled out as a failed treatment option. Further, there is no evidence to support the need to increase the dosage of lithium since with the inconsistent nature of the patient’s use of the medication, the PHMNP may not effectively tell whether the lack of change in symptoms is due to the ineffectiveness of the lithium dosage or the patient’s non-compliance. Moreover, as long as the reasons underlying the patient’s non-compliant behavior have not been addressed, there is no surety that she will still not fail to comply even if the dosage of lithium was to be increased or the mediation changed to Depakote.
In their study seeking to identify the effect of patient non-compliance on treatment outcomes among persons with chronic conditions, Brown and Bussell (2011) established that whereas 50 percent of patients do not take their medication as prescribed, medication adherence is not solely the patient’s responsibility (Brown & Russell, 2011). In their view, medication-taking behavior is a complex phenomenon requiring input from both the physician and the patient. The study found patient education to significantly improve BP control for patients with hypertension – in the researcher’s view, the more empowered a patient feels, the more likely they are to be motivated to adhere to treatment plans and manage their disease (Brown & Russell, 2011). Assessing the rationale for the patient’s non-compliance provides an opportunity for the PHMNP to identify potential reasons for non-adherence and then together with the patient, develop strategies for addressing the same.
Expected Treatment Outcome
The goal at this stage, like the first stage, is to reduce mood instability by 50 percent. Having administered patient education, the PHMNP expects the patient to fully adhere to the treatment plan by taking their medication as scheduled. With improved compliance on the patient’s part, the PHMNP would obtain a clear view of the medication’s potential in the presenting patient. If the patient abides to the treatment schedule and there is no remission in symptoms by the time of their next appointment, then the medication could be deemed ineffective and a switch or increase in dosage could be considered.
Actual Treatment Outcome
The 26-year-old returns to the clinic in 4 weeks reporting adverse reactions such as nausea and diarrhea. She reports that she stops taking the medication until the symptoms subside, at which points she takes them again, but experiences the symptoms again. The outcome matches expectation in regard to improving the patient’s adherence to medication. However, it also differs from what was expected to the extent that there is no notable change in symptoms and the patient is yet to report full compliance. Without full compliance, the efficacy of lithium can still not be adequately assessed. It is, however, evident that the patient’s non-adherence is due to the side effects that she is experiencing. The next treatment plan needs to, therefore, focus on reducing the severity of side effects as a way of inducing compliance.
Decision Point 3
At decision point 3, the PHMNP is to choose one of three treatment options: change to Depakote ER 500mg at HS, change lithium to sustained release preparation at same dose and frequency, or change to trileptal 300mg orally BID. The PHMNP needs to change lithium to sustained release preparation at same dose and frequency, and then schedule another appointment to review efficacy in four weeks.
Rationale for the Decision
Reducing side effects increases the chances of full adherence by the patient. Up until this point, non-adherence has made it difficult to assess the efficacy of lithium for the presenting patient. The PHMNP should not switch to a different medication until they have effectively proven lithium to be ineffective for the patient. However, they should remain watchful for serious reactions such as symptoms of thyroid and kidney disease, which have been associated with prolonged lithium use. If changing to sustained lithium does not alleviate the side effects, the PHMNPO could consider changing to Depakote, which has been shown to have fewer side effects than lithium with prolonged use.
Expected Treatment Outcome
The overall goal of the treatment remains to completely eliminate symptoms and prevent a relapse. The specific goal at this stage of treatment, however, is to induce full adherence to the medication on the patient’s part and in the 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 outcomes.
References
Bowden, C.L., Brugger, A., Swann, A., (1994). Efficacy of Divalproex vs Lithium and Placebo in the Treatment of Mania. JAMA, 271(12): 918-24.
Brown, M. T., & Bussell, J. K. (2011). Medication Adherence: WHO Cares. Mayo Clinic Proceedings, 86(4): 304-14.
Chen, R., Shi, J., Shen, K. &Hu, P. (2014). Cytochrome P450 2D6 Genotype Affects the Pharmacokinetics of Controlled-Release Paroxetine in Healthy Chinese Subjects: Comparison of Traditional Phenotype and Activity Score Systems. European Journal of Clinical Pharmacology, 71(7): 835-41.
Nierenberg, A. A. (2010). A Critical Appraisal of Treatments for Bipolar Disorder. Journal of Clinical Psychiatry, 12(1): 23-39.
NIMH (2020). Bipolar Disorder. National Institute of Mental Health (NIMH). Retrieved from https://www.nimh.nih.gov/health/publications/bipolar-disorder/19-mh-8088_152248.pdf
Sani, G., Perugi, G., & Tondo, L. (2017). Treatment of Bipolar Disorder in a Lifetime Perspective: Is Lithium still the Best Choice? Clin Drug Investig, 37(8): 713-27.
Vitiello, B. (2013). How Effective are the Current Treatments for Children Diagnosed with Manic/Mixed Bipolar Disorder. CNS Drugs, 27(1): 331-33.