Assessing and Treating Patients With Bipolar Disorder

Bipolar disorder is a prevalent psychiatric condition that affects many individuals. Approximately 1-2 % of the adult population suffers from this chronic and severe mental condition (World Health Organization, 2019). The signs and symptoms that the patient presents differ on whether the patient has mania or depression. During an episode of bipolar disorder, individuals act differently from their normal moods, their attitudes change, and their thinking and behavior are highly altered. Bipolar disorder affects people from all areas and does not discriminate against the millions of individuals it affects globally (WHO, 2019). It is not a respecter of the socioeconomic status. The onset of this condition is around 25 years, but it can also affect teenagers. The National Institute of Mental Health (2017) states that 2.6 % of the US population suffers from this condition. If not properly treated, it can be fatal. A nurse practitioner must thus be able to diagnose these patients and formulate a care plan correctly.

This essay will outline the decision tree in managing an Asian American female diagnosed with bipolar disorder. This woman is aged twenty-six years, and she presented to the clinic after twenty-one days of being hospitalized. The diagnosis by the nurse practitioner is bipolar I disorder. The nurse practitioner will consider the patient-specific patients throughout the decision tree. The nurse practitioner will evaluate the safety, cost, and efficacy of the medications they select during the decision tree. The clinician will also consider the legal and ethical issues that impact patient communication and management of bipolar disorders and other mental conditions. The nurse practitioner must thus have extensive clinical knowledge and use evidence-based guidelines when managing the patient in the case study.

Decision Point One

The first decision would be to initiate the client on Lithium 300mg orally twice every day. Lithium acts as a mood stabilizer, and it is the first-line drug in managing bipolar disorders (Wolz, 2020). The medical history of the patient indicated that she was previously on Lithium. The patient, however, stopped using the drug after being discharged from the hospital. Lithium was effective in managing her bipolar symptoms during her hospitalization. She, however, stopped using the medication after the relapse of the symptoms.

The nurse practitioner did not select Risperdal since the patient tested positive for the CYP2D6 allele. Because of the CYP2D6 allele, the client will slowly clear the drug from her body, leading to higher drug levels in her bloodstream. This will cause sedation (Seripa et al., 2018). This is why the nurse practitioner did genetic testing to confirm the presence of the allele. The nurse practitioner decided not to initiate the patient on Seroquel since it has the side effects of blurred vision, mouth dryness, stomach upset, and constipation (Seripa et al., 2018). This drug is an atypical antipsychotic that works by restoring the neurotransmitters’ balance in the brain. It increases patient concentration and lowers the hallucinations. It helps patients think positively about themselves (National Alliance on Mental Illness, 2021). It also reduces nervousness and enables individuals to participate in daily life activities actively. This medication can also enhance energy levels and moods while preventing severe mood swings.

By initiating the patient on Lithium, the nurse practitioner hoped to stabilize the client’s mood. It will bring the client to symptomatic recovery. The nurse practitioner was also hoping to prevent symptoms relapse, lower the subthreshold symptoms, and enhance the patient’s occupational and social functions (Wolz, 2020).

Decision Point Two

The client returned to the clinic four weeks later, informing the nurse practitioner that she did not consistently take the Lithium. She further stated that she only took the drug when she felt like she needed it. She presented with the same symptoms she had when she first came to the clinic four weeks ago. The nurse practitioner evaluated her reasons for non-compliance to determine why the patient did not consistently take the medication. The patient was then to be educated on drug pharmacology and the effects of medications. Non-compliance can result in severe consequences such as poor disease prognosis, reoccurrence, and relapse. The common reason bipolar patients are non-compliant is the stigma linked with bipolar disorder, substance abuse, and manic symptoms (Azadforouz et al., 2016).

The nurse practitioner did not increase the lithium dosage to 450mg since it would increase the side effects, such as lithium toxicity (Azadforouz et al., 2016). The client is not complying with medications, and she should not have more reasons for not taking the drug, such as lithium toxicity. The nurse practitioner did not give the patient Depakote ER 500 because it causes weight gain, leading to non-compliance (Wolz, 2020). The patient should not be changed to other medications since she is non-compliant due to medication side effects.

By selecting this decision, the nurse practitioner hoped that the patient would be compliant with the medications to manage her bipolar disorder effectively. The nurse practitioner also expected to ensure that the patient tolerated the drug with minimal adverse effects. The clinician hoped to reduce the manic symptoms.

Decision Point Three

The patient returned to the office four weeks later. She stated the medication gave her nausea and vomiting. She further narrated that she stopped taking the medication until the symptoms were resolved. She says that she started taking the drug but stopped when the symptoms reappeared. The final decision was to change the drug to a sustained-release drug with the same dosage and frequency as the previous lithium medication. The client experiences nausea and vomiting because of the immediate release of Lithium; hence, it is necessary to give the patient a sustained-release formulation. Studies indicate that the sustained-release formulation lowers the prevalence of side effects compared to the immediate-release formulation (Gitlin, 2016).

The clinician did not select Trileptal and Depokate since these are second-line medications and should not be utilized in the acute management stage until it is determined that the patient is non-responsive to the first-line agents (Gitlin, 2016). By selecting this decision, the nurse practitioner hoped to prevent and reduce the nausea and vomiting symptoms that the patient presented with. The clinician also wanted to stabilize the patient’s mood. Lithium is also effective in lowering suicidal ideations and controlling mania (Gitlin, 2016).

Ethical Considerations

Lithium has a narrow therapeutic index. Hence, it is critical to constantly monitor the patient to ensure the patient does not suffer from lithium toxicity and the adverse side effects (Nederlof et al., 2018). The nurse practitioner must thus monitor this patient to minimize the side effects. The nurse practitioner must educate the patient on the side effects of Lithium. Nurse practitioners must inform their patients and monitor them to reduce potential treatment risks. Patients must receive informed treatment before initiating treatment (Clement, 2016). Many times, the preferences of patients with psychiatric conditions are always overlooked. The nurse practitioner must thus practice the principle of autonomy (Clement, 2016).

Conclusion

This essay outlined the treatment decision tree for a twenty-six-year-old Asian American female diagnosed with bipolar I disorder. The first decision was to initiate the patient on Lithium, a first-line drug in treating bipolar disorders (Wolz, 2020). The clinician did not put the patient on Risperdal because of her CYP2D6 allele, leading to slow clearance of Risperdal, leading to sedative side effects. Four weeks later, the patient returned to the clinic with no improvement due to not complying with the medications. The clinician assessed the reasons for non-compliance and advised the patient on the benefits of medication adherence. Four weeks later, the client returned to the clinic with symptoms of diarrhea and nausea. This was because of the immediate-release lithium formulation, and thus, the medication was changed to the sustained-release formulation to minimize the side effects.

Nurse practitioners should consider patient factors such as genetics when initiating a treatment plan. They must also be aware of medication side effects that cause non-compliance. They must then address this issue with the patient. The nurse must also follow ethical principles while caring for mental health patients.

References

Azadforouz, S., Shabani, A., Nohesara, S., & Ahmadzad-Asl, M. (2016). Non-compliance and related factors in patients with bipolar I disorder: A six-month follow-up study. Iranian Journal of Psychiatry and Behavioral Sciences, In Press(In Press). https://doi.org/10.17795/ijpbs-2448

Clement, I. (2016). Code of ethics in nursing. Textbook on Professional Trends and Adjustments in Nursing, 44-44. https://doi.org/10.5005/jp/books/12786_8

Gitlin, M. (2016). Lithium side effects and toxicity: Prevalence and management strategies. International Journal of Bipolar Disorders, 4(1). https://doi.org/10.1186/s40345-016-0068-y

National Alliance on Mental Illness. (2021). Quetiapine (Seroquel). NAMI: National Alliance on Mental Illness. https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Quetiapine-(Seroquel)

National Institute of Mental Health. (2017, November). NIMH » bipolar disorder. https://www.nimh.nih.gov/health/statistics/bipolar-disorder.shtml

Nederlof, M., Heerdink, E. R., Egberts, A. C., Wilting, I., Stoker, L. J., Hoekstra, R., & Kupka, R. W. (2018). Monitoring of patients treated with Lithium for bipolar disorder: An international survey. International Journal of Bipolar Disorders, 6(1). https://doi.org/10.1186/s40345-018-0120-1

Seripa, D., Lozupone, M., Miscio, G., Stella, E., La Montagna, M., Gravina, C., Urbano, M., Di Mauro, L., Daniele, A., Greco, A., Logroscino, G., Panza, F., & Bellomo, A. (2018). CYP2D6 genotypes in revolving door patients with bipolar disorders. Medicine, 97(37), e11998. https://doi.org/10.1097/md.0000000000011998

Wolz, A. (2020). Bipolar disorder. Family Practice Guidelines. https://doi.org/10.1891/9780826153425.0022c

World Health Organization. (2019, November 28). Mental disorders. WHO | World Health Organization. https://www.who.int/news-room/fact-sheets/detail/mental-disorders

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Question

https://cdnfiles.laureate.net/2dett4d/Walden/NURS/6521/05/mm/decision_trees/week_04/index.html. case study link.

The Assignment: 5 pages

Examine Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this patient. Consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

Assessing and Treating Patients With Bipolar Disorder

At each decision point, you should evaluate all options before deciding and moving throughout the exercise. Before you make your decision, make sure that you have researched each vote and that you assess the conclusion that you will select. Be sure to research each option using the primary literature.

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.

Decision #1 (1 page)

Which decision did you select? Why did you choose this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your requests and support your response with clinically relevant and patient-specific resources, including the primary literature.

Assessing and Treating Patients With Bipolar Disorder