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 emphasizing 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 Prescriber’s 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 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 of 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 lithium to promote compliance. This planned improved compliance would have hopefully provided complete remission of her mania.

The student guidance stated that since nausea and diarrhea are classic symptoms, 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 Prescriber’s 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.

Ethical Consideration

Due to the prevalent symptoms associated with mania in bipolar disease, as evident with this patient, judgment is impaired during an acute phase. With hypomania sufferers are able to function well during social and work situations (NAMI, 2017).

Since bipolar disease impacts the patient’s ability to make sound judgment 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 debilitating condition that affects a small but significant portion of the U.S. population with an onset in early adulthood. 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 for 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 pharmacokinetics until I spent some time researching the significance of the CYP2D6*10 alleles 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.