Treating Clients with With Bipolar Disorder

Bipolar disorder (BD) is a chronic recurrent mental health problem associated with high co morbidities that lead to poor health outcome and lower quality of life .It presents with episodes of mania, hypomania, and depression alternating with normal mood (euthymia). Also, it has high genetic predisposition and significantly affects patients, their family, and community. Effective management of BD requires that the PMHN understands the condition, its acute/immediate, maintenance and long term treatment. Management of acute episodes aims at symptom reduction and thereafter full remission. Maintenance therapy aims at preventing the recurrences. Assessment of bipolar patient is done to help choose treatment that is effective and safe (McCormick, U., Murray, B., & McNew, B., 2015). Mood stabilizers are the drugs of choice in the treatment of BD. In addition, psychotherapy is done for these patient and electroconvulsive therapy for severe depressive episodes. Ongoing assessment and follow up is important to monitor response to treatment, significant side effects, drug adherence, and other health related needs ( Janusz K ,2017). The paper examines a case of 26-year-old woman of Korean descent with bipolar disorder 1 and her medication prescription options. The treatment decision and outcome is carefully considered for proper management of this patient. Factors likely to affect the pharmacokinetic and pharmaco-dynamic processes are considered Treating Clients with With Bipolar Disorder.

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Late-life depression is a serious illness accompanied by medical morbidity, cognitive decline, and risk of suicide. Antidepressant medications are a cornerstone of treatment for depressed elders. Although they are optimally provided in conjunction with psychotherapy, in many cases they are used alone. In recent years concerns have developed about modern antidepressant medications, including concerns about their ultimate efficacy and particular risks that may be seen in older adult populations. Ultimately antidepressant medications are effective for many individuals and continue to play an important role in treating depressed elders, although the potential risks must be weighed with the patient and their families. Current data do not support restriction of their use and untreated depression has serious negative health consequences. Our patients need treatments with better efficacy and safety, including new pharmacological options and better access to and dissemination of nonpharmacological treatment.Keywords: Depressive disorder, aging, geriatrics, antidepressant, adverse events, side effects, suicide, treatment, psychotropic medications

Decision Point One

Selected Decision

Begin with lithium 300 mg orally BID.

Reason for Selection

Lithium is an effective prototype mood-stabilizer considered specifically in the treatment of BD. Research confirms that lithium has anti-suicidal, immune modulatory, and neuro-protective properties (Severus E, Taylor MJ, Sauer C, et al., 2014). Risperdal and seroquel are atypical antipsychotics drugs used in management of schizophrenia and bipolar disorder. They are not considered as the first line treatment of BD. Therefore, lithium 300mg orally BID is the best option for this patient Treating Clients with With Bipolar Disorder.

Expected Results

Lithium is used in first line treatment for acute mania and prevention of recurrent BD episodes.

The full clinical effects of lithium are felt after a few weeks when lithium plasma level is maintained between 0.6 and 1.0mmol/L. The patient was expected to have some improvements in the symptoms such as less pressured speech, normal mood, and normal sleeps patterns and improved insight (Severus E, Taylor MJ, Sauer C, et al., 2014).A less than 22 YMS score was expected with the use of lithium 300mg.

Differences between Expected Results and Actual Results

Full clinical effects can be achieved when the patient complies with the medication and the plasma lithium levels in the body is kept at a constant level of 0.6 and 1.0mmol/L. The patient returned after four week and reported that she had been taking medication off and on and when she feels like. This noncompliance could have been the reasons for the patient presenting with the initial features. Also, lithium has a narrow therapeutic index, increased risks for new manic or depressive episodes and significant side effects and a. These factors could have limited the clinical effectiveness of lithium in the patient (Janusz K, 2017). In lithium non response and dose related side effects, it’s recommended to reduce the dose or change to other medications (Shah N., Grover S., & Rao G. P., 2017). Non drug adherence greatly contributes to BD poor treatment outcome. Assessing reasons for non compliance and educating the patient on drug effects and pharmacology is important. However, since the patient is still in acute phase, has been on lithium for long and non-compliant, change of drug is required.

Decision Point Two

Selected Decision

Change to depakote ER 500mg orally at HS.

Reason for Selection

Depakote (valproic acid) is efficacious in the management acute mania and mixed BD episodes. Despite not being robust in acute management compared to lithium, it is useful in maintenance phases for prevention of mania and depression (Shah N., Grover S., & Rao G. P., 2017). Genetic testing reveals that she is positive for CYP2D6*10 allele indicating that the body can metabolize and tolerate various drugs.

Expected Results

The patient had expected results. Depakene is efficacious in treatment acute mania phases and as a maintenance therapy .Its associated with less side effects compared to lithium, thus has less chances of non-adherence (Shah N., Grover, S., & Rao G. P., 2017).She reported compliance to the medication and marked reductions in the manic symptoms .The Young Mania Rating scale score was 11 indicating a 50% reduction.. Patient compliance to medication will improve.

Differences between Expected Results and Actual Results

Despite great improvements of the patient due to depakote, she reports a 6 pounds increase in weight over the last four weeks. This is undesired effect though expected. Dapakote is associated with weight gain and other metabolic abnormalities (Shah N., Grover S., & Rao G. P., 2017)

Decision Point Three

Selected Decision

Educate the patient of side effects of depakote such as weight gain, importance of dietary changes and physical exercises, and continue with the same drug dosage Treating Clients with With Bipolar Disorder.

Reason for Selection

This is a better decision because decreasing the depakote dosage to 250 mg may make the patient relapse into the initial acute mania phase. Usually dapakote is started in low doses of 250 mg BD and increased upwards to achieve the full clinical effects. Dietary restrictions are recommended for increase appetite and weight gain (Shah N., Grover S., & Rao G. P., 2017).Though decreasing the dosage may result to weight reduction. Zyrexa (olanzapine) is atypical antipsychotic. Changing the class of drug is not appropriate at this stage and at the same time, zyrexa may lead to significant weight gain. Weight gain is a serious and common side effect of mood stabilizers like depakote and lithium. It has been associated with non-compliance to medication and treatment cessation (McCormick U., Murray B., & McNew B., 2015). Educating the patient on dietary changes and regular physical exercises is vital in weight reduction. Regular monitoring of lipid profile, blood glucose and anthropometric measurements is required (Shah N., Grover S., & Rao G. P., 2017).

Expected Results

Dietary changes and regular physical exercises while taking depakote helps in weight reduction. Therefore, the patient will have remission of manic symptoms due to continued use of depakene.YMR scale score is expected to reduce further to less than 11. Also, the patient is expected to reduce her weight back to normal. This will also help her achieve normal BMI range of 18.5 to 25.

Differences between Expected Results and Actual Results

Maintaining depakote dosage and employing weight reduction strategies –dietary changes and regular physical exercises- will likely lead to remission of manic symptom and weight reduction respectively (Shah N., Grover S., & Rao G. P., 2017).

Impact of Ethical Considerations on Treatment Plan

The purpose of treatment of BD is to do good to the patient and avoid harm thus PMHN seeks to help the patients get well. Bipolar medications have side effects. Therefore, the PMHN should carefully assess the patient and choose medications which are effective and safe. Also, the cognitive functioning of bipolar patient is usually affected. This makes the patient unable to provide informed consent to treatment posing the ethical and moral issue of forced treatment. The PMHN has the responsibility of providing information on treatment options, their indications and side effects information to improve the decision making ability and voluntarism of the patient (Gutheil TG, 2015). Also educating and involving the family members and caregiver at the initial of treatment helps establish trust and get informed consent dialogue with them in cases where the patient is unable to consent. Adoption of medication plan involves a complete thorough assessment of the patient to come up with evidence based efficacious and safe treatment options. The treatment plan for BD should be closely monitored for effectiveness and any adverse effects and patient follow up done regularly Treating Clients with With Bipolar Disorder.

Conclusion

Bipolar disorder is a common debilitating mental problem associated with substantial patient, and community burden. Accurate identification acute mania, hypomania, and depressive or mixed phases is essential in deciding the treatment options. Various pharmacological treatments are used for acute and maintenance management. Mood stabilizers are used as first line treatment of BD. Non pharmacological approaches such as ECT in depressive episodes and psychotherapy are used in the management of BD. Careful assessment of the individual patient is necessarily to help make decisions on the efficacious and safe treatment. Also, decision on dose increase or reduction, change of drug antidepressants should be made carefully to prevent relapse and treatment failures.

References

Gutheil TG.(2015). Ethical Issues in Psychopharmacology. Session presented at the U.S. Psychiatric and Mental Health Congress; San Diego, CA.

Rybakowski, J. K. (2017). Recent advances in the understanding and management of bipolar disorder in adults. F1000Research, 6, 2033. http://doi.org/10.12688/f1000research.12329.1

McCormick, U., Murray, B., & McNew, B. (2015). Diagnosis and treatment of patients with bipolar disorder: A review for advanced practice nurses. Journal of the American Association of Nurse Practitioners, 27(9), 530–542. http://doi.org/10.1002/2327-6924.12275

Severus E, Taylor MJ, Sauer C, et al. (2014). Lithium for prevention of mood episodes in bipolar disorders: systematic review and meta-analysis. Int J Bipolar Disord. 2014;2:15. 10.1186/s40345-014-0015-8[PMC free article] [PubMed] [Cross Ref] F1000 Recommendation

Shah, N., Grover, S., & Rao, G. P. (2017). Clinical Practice Guidelines for Management of Bipolar Disorder. Indian Journal of Psychiatry, 59(Suppl 1), S51–S66. http://doi.org/10.4103/0019-5545.196974 Treating Clients with With Bipolar Disorder.

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