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Case Study: An Asian American Woman With Bipolar Disorder

Case Study: An Asian American Woman With Bipolar Disorder

Case Study: An Asian American Woman With Bipolar Disorder

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”

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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.
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.

MENTAL STATUS EXAM

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.
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

SAMPLE SOLUTION PAPER: Case Study: An Asian American Woman With Bipolar Disorder

A person with bipolar disorder experiences considerable changes in their mood, sense of self, sleep patterns, and cognitive capacities. With an average beginning age of 25, bipolar disorder affects 2.6% of Americans, with close to 83% of cases being classified as severe (NAMI, 2018). Age 26 with a sudden onset of mania necessitating hospitalization, our case study patient seems to fit this description. Many people face social stigma, which affects both how severe the disease process is and how easy it is to lead a regular social and professional life. This assignment’s goal is to analyze potential influences on the patient’s pharmacokinetic and pharmacodynamic processes by comparing them to the recommendations made at the conclusion of each scenario and taking treatment’s ethical ramifications into account.

Decision #1

I chose to begin Lithium 300 mg orally BID since this is what she was prescribed while at the hospital which provides significant evidence that she responded well enough to the medication to be discharged with a maintenance dose.  Also, since the patient has the CYP2D6*10 reduced function allele which has a high frequency of occurrence in the Asian population (Chen, Wang, Shi, Shen, & Hu, 2014). This reduced function correlates to decreased metabolism/clearance of atypical antipsychotics mainly risperidone and would rule out Seroquel.  Genetic polymorphisms of CYP2D6 play a significant part in risperidone, 9-hydroxyrisperidone and ion plasma concentration variability, which were related to common side effects emphasising the significance of personalized dosing adjustments with risperidone treatment (Lisbeth, Vincent, Kristof, et al, 2016).

When restarting the Lithium, I was hoping to have the patient return to her immediate post discharge status.  According to Stahl’s Prescribers Guide the goal of Lithium treatment is complete remission of mania, treat until symptoms have subsided or improvements are stable continuing treatment with continued improvements seen and to continue the treatment indefinitely to avoid recurrence.  When she returned to the clinic after four weeks there was no change from her initial visit.  This was due to her noncompliance with taking the medication as directed.

Decision #2

At this point I chose to address the patient’s reasons for non-compliance and educated the patient on why she should take the medication.  I would emphasize would be the proven efficacy Lithium has had on her in the past which is why she began to feel euthymic. Also, I provide clear instructions that discontinuing the medication abruptly after use can cause recurrence of her mania which is what brought her to me in the first place.  Stopping stable patients with bipolar mood disorder, (BP-1 in her case since there is no evidence of depressive episodes) when taking lithium during stable maintenance has a high risk of early recurrence of symptoms, specifically mania (Faedda, Tondo, Baldessarini, Suppes, & Tohen, 1993).

With this decision I was hoping to gain compliance with the treatment regimen and see some improvements.  When she returned to the clinic she complained of nausea and diarrhea, two common side effects, and was still not consistently taking the mediation.  There was no report in symptom improvements.

Decision #3

At this point I had initially decided to change her to Depakote ER 500 mg at HS.  I chose to change thinking she may tolerate another medication better than the lithium to promote compliance. This planned improved compliance would have hopefully provide complete remission of her mania.  The student guidance stated that since the nausea and diarrhea are classic symptoms that changing the formulation to an extended release often prevents them from occurring.  I do agree that I should have addressed the symptoms since this is also covered in the Prescribers Guide. But at this point wanted to provide the patient with relief of her primary disorder.  In doing so I had also contradicted why I had initially started her on Lithium in the first place.  I was told by a doctor I worked with that if something is proven to work don’t stop it. That it is OK to tweak the dosages and add to it, but don’t stop since you have some control over the situation already.

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Ethical Consideration

Due to the prevalent symptoms associated with mania in bipolar disease, as evident with this patient, judgement is impaired during an acute phase.  With hypomania sufferers are able to function well during social and work situation (NAMI, 2017).  Since bipolar disease impacts the patient’s ability to make sound judgement and decision during significant episodes remains questionable.  Interventions present ethical questions for providers regarding the degree of the patient’s autonomy to participate in decision making regarding their medical care (Riha, Chammay, Dargel, Henry & Masson, 2018).

Conclusion

Bipolar disorder is a dehabilitaing condition that effects a small but significant portion of the U.S. population with and onset in early adult hood.  Patients suffer from extreme highs and lows as they age and if the disorder progresses from bipolar-1 onward. Many must overcome the stigma of mental illness especially at a professional level where loss of status and discrimination are prevalent (Riha, Chammay, Dargel, Henry & Masson, 2018).  During this exercise to determine the appropriate plan of care and treatment regimen this young woman it was evident that epigenetics can play a role in making these determinations.  I had never really grasped the concept of genotypes effects of pharmokinetics until I spent some time researching the significance of the CYP2D6*10 allele in this case study.  In the end it is important to determine the patient’s ability to safely make decisions regarding their treatment and consider the ethical deterrents in doing so when one’s judgment is skewed due to significant change in mood.

References:
  • 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
  • Faedda GL, Tondo L, Baldessarini RJ, Suppes T, Tohen M. (1993). Outcome after rapid vs gradual discontinuation of lithium treatment in bipolar disorders. Archives of General Psychiatry. 50(6), 448-55. Abstract retrieved from https://www.ncbi.nlm.nih.gov/pubmed/8498879
  • Lisbeth, P., Vincent, H., Kristof, M. et al. (2016). European Journal of Clinical Pharmacology 72, 175. https://doi.org/10.1007/s00228-015-1965-1
  • National Alliance on Mental Illness (NAMI). (2017).  Bipolar Disorder. Retrieved from https://www.nami.org/Learn-More/Mental-Health-Conditions/Bipolar-Disorder
  • Richa, S., Chammay, R., Dargél, A., Henry, C., & Masson, (2018). Ethical considerations in bipolar disorders. L’Encéphale. 44. 10.1016/j.encep.2017.12.005.

THE ASSIGNMENT – Case Study: An Asian American Woman With Bipolar Disorder

NURS 6630 Week 4 Assignment: Assessing and Treating Clients with With Bipolar Disorder

Bipolar disorder is a unique disorder that causes shifts in mood and energy, which results in depression and mania for clients. Proper diagnosis of this disorder is often a challenge for two reasons: 1) clients 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 client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with bipolar disorder.

Case Study: An Asian American Woman With Bipolar Disorder

Required Readings for Case Study: An Asian American Woman With Bipolar Disorder

Note: All Stahl resources can be accessed through the Walden Library using this link. This link will take you to a log-in page for the Walden Library. Once you log into the library, the Stahl website will appear.

Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York, NY: Cambridge University Press.

To access the following chapters, click on the Essential Psychopharmacology, 4th ed tab on the Stahl Online website and select the appropriate chapter. Be sure to read all sections on the left navigation bar for each chapter.

Chapter 6, “Mood Disorders”

Chapter 8, “Mood Stabilizers”

Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. New York, NY: Cambridge University Press.

To access the following chapters, click on the Illustrated Guides tab and then the Mood Stabilizers tab.

Chapter 4, “Lithium and Various Anticonvulsants as Mood Stabilizers for Bipolar Disorder”

Chapter 5, “Atypical Antipsychotics as Mood Stabilizers for Bipolar Disorder”

Vitiello, B. (2013). How effective are the current treatments for children diagnosed with manic/mixed bipolar disorder? CNS Drugs, 27(5), 331-333. doi:10.1007/s40263-013-0060-3

Note: Retrieved from Walden Library databases.

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

Note: Retrieved from Walden Library databases.

Required Media

Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author

Note: This case study will serve as the foundation for this week’s Assignment.

Optional Resources

Mostafavi, A., Solhi, M., Mohammadi, M., Hamedi, M., Keshavarzi, M., & Akhondzadeh, S. (2014). Melatonin decreases olanzapine induced metabolic side-effects in adolescents with bipolar disorder: a randomized double-blind placebo-controlled trial. Acta Medica Iranica, 52(10), 734-739.

Retrieved from http://acta.tums.ac.ir/index.php/acta

To prepare for this Assignment:

Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.

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The Assignment

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.

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?
  • 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.

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