Treating Clients with Bipolar Disorder
Treating Clients with Bipolar Disorder
Bipolar Therapy
Client of Korean Descent/Ancestry
BACKGROUND INFORMATION
The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.
Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”
She weights 110 lbs. and is 5’ 5”
SUBJECTIVE
Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”
You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work. Treating Clients with Bipolar Disorder
Genetic testing reveals that she is positive for CYP2D6*10 allele.
Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago. Treating Clients with Bipolar Disorder
The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation. Treating Clients with Bipolar Disorder
The Young Mania Rating Scale (YMRS) score is 22
RESOURCES
§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). 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), 835-841. doi:10.1007/s00228-015-1855-6
Decision Point One
Begin Seroquel XR 100 mg orally at HS
RESULTS OF DECISION POINT ONE
- Client returns to clinic in four weeks
- Client is reporting that she sleeps a bit more at bedtime
- Client states that she has gained about 2 or 3 pounds, which she does not like
- Client also reports that she has been constipated since starting this medication
- Client is also complaining of dry mouth which she does not like.
- Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18
- Client is reporting really good mood, but is asking for a different medication because of the weight gain
Decision Point Two
Treating Clients with Bipolar Disorder
Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal
RESULTS OF DECISION POINT TWO
- Client returns to clinic in four weeks
- Client demonstrates a 50% decrease in score on the Young Mania Rating Scale (from 22 to 11)
- Client denies any additional weight gain and denies any additional side effects
Decision Point Three
Continue same dose and reassess in 4 weeks
Guidance to Student
The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.
Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects. Treating Clients with Bipolar Disorder
Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended release may overcome the difficulties she was experiencing with side effects. The PMHNP would need to educate client regarding side effects of medication and need to maintain compliance. Treating Clients with Bipolar Disorder
Assignment: Assessing and Treating Patients With Bipolar Disorder
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. Treating Clients with Bipolar Disorder
To prepare for this Assignment: Treating Clients with Bipolar Disorder
- 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: Treating Clients with Bipolar Disorder
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. Treating Clients with Bipolar Disorder
At each decision point stop to complete the following:
- Decision #1
- Which decision did you select?
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? Treating Clients with Bipolar Disorder
- Decision #2
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?
- Decision #3
- Why did you select this decision? Support your response with evidence and references to the Learning Resources.
- What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
- 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.
Conclusion (1 page)
- Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature. Treating Clients with Bipolar Disorder
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.
By Day 7
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Submission and Grading Information: Treating Clients with Bipolar Disorder
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Grading Criteria: Treating Clients with Bipolar Disorder
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