Case Study: An Asian American Woman with Bipolar Disorder
The patient is a 26-year-old Asian female of Korean descent. She was recently hospitalized for acute onset of mania and was diagnosed with bipolar 1 disorder. The patient was discharged home on Lithium as she responded well to this treatment regimen.
However, the patient reports she has not been taking Lithium as prescribed. She presents to the clinic today for her first appointment. She is alert and oriented, her affect is broad, her speech is rapid, pressured, and tangential, and she self-reports euthymic mood.
The patient appears well-groomed but not appropriately dressed for the occasion. The patient exhibits denial and ineffective coping related to the new diagnosis, as evidenced by the patient stating, “they said I was bipolar, I don’t believe that do you?” The patient’s coping behavior may be based on health belief systems and cultural perceptions of normal and abnormal behavior.
The patient had medical work up and was deemed to be in good health overall. Gene sight testing revealed that the patient is positive for CYP2D6*10 allele. CYP2D6 is a polymorphic gene and is clinically important for the metabolism of numerous therapeutic drugs. According to Kim et al. (2018), it is the most common allele in the Asian population. CYP2D6*10 mutation in patients leads to reduced enzyme activity and a decrease in appropriate response to drug treatments. A CYP2D6 poor metabolizer will have (increased/decreased) toxicity with antipsychotics.
Race and genotype are among the factors that influence drug response. Understanding the variation in the enzyme metabolizers is crucial to decrease the prevalence of ADRs by using genomic info. The goal of Pharmacogenomics is to optimize drug therapy and limit drug toxicity based on a person’s DNA. The treatment decision tree for this patient will be based on her race and genomics.
Decision Point 1
Start the patient on Seroquel XR 300mg HS
Quetiapine (Seroquel), an atypical antipsychotic with documented therapeutic effectiveness, has been shown to be effective in treating bipolar disorder-related acute mania and depression (Kanba et al., 2019). Quetiapine is typically well-tolerated and successful in lowering manic episodes in adult patients with acute bipolar mania, whether used alone or in combination. The medicine is also effective as monotherapy in lowering depression symptoms in people with bipolar disorder.
In bipolar disorder, it is linked with a lower occurrence of extrapyramidal symptom-related side effects. According to Kanba et al. (2019), quetiapine alleviates symptoms of mania in bipolar mania by acting on neurotransmitter receptors, including serotonin and dopamine. It relieves both depressed and manic symptoms in bipolar illness. Quetiapine’s activities in bipolar are linked to its metabolite’s binding to the norepinephrine transporter.
Within 4 weeks, the client verbalizes which of their interpersonal actions are suitable and which are not. The client should also exhibit acceptable relationship skills as shown by a lack of, or a significant decrease in, manipulation of others to achieve their own objectives. The patient is anticipated to make significant progress within 4 weeks of therapy.
The patient should be able to carry out her everyday activities with little or no difficulty (Townsend & Morgan, 2018). Seroquel is the optimal choice for influencing mental action and improving the patient’s capacity to approach difficulties rationally. It is also predicted that the patient’s self-destructive behaviors and stress will decrease, and she will respond positively to her environment and social contacts as the young mania scale reduced from 22 to 18. The patient also complains of weight gain, constipation, dry mouth
The Difference Between Expected And Actual Outcomes
After four weeks, the patient returned to the clinic accompanied by her father, looking sedated and drowsy. Andersen et al. (2021) established that lethargy and sedation are among the major side effects of Seroquel. However, the client can articulate which of their interpersonal actions are suitable and which are not. The Client exhibits adequate interpersonal skills.
The patient’s father mentioned that the client had been drowsy for almost a week following the last visit. It should be noted that sedation is one of Seroquel’s adverse effects. Similarly, because the client is positive for the CYP2D6*10 allele, it is possible that she has a delayed rate of Seroquel clearance from her systems, resulting in higher than usual Seroquel levels in the blood. The patient further complains of dry mouth and constipation (Andersen et al., 2021).
Selected Decision No. 2
Discontinue Seroquel due to the patient’s assessment and complaints, the CYP2D6*10 allele, and the original choice of drug and start Geodon 40 mg BID with 500 caloric meal.
Reason for Choosing This Choice
Seroquel successfully achieved the therapeutic goals based on the patient’s development at the second meeting. The main considerations were sedation, constipation, dry mouth, weight gain, and its undesired side effects. To deal with the adverse effects, it is, therefore, preferable to switch to another medicine. Geodon 80 mg a day is the greatest option for reducing the considerable impact of the adverse effects of Seroquel (Findling et al., 2022). Because the client has already formed some attitude, switching to lithium may result in noncompliance.
Furthermore, the patient may develop a negative attitude toward all medications provided by the mental health practitioner. Giving the patient assistance in adapting to a different drug will increase their devotion, trust, and comprehension of the treatment goals. A 500 caloric meal will aid in the weight loss that the patient complains about.
Geodon has been shown to be beneficial in controlling the symptoms of bipolar illness by modulating serotonin and dopamine balance to assist address a patient’s self-destructive tendencies. Changing the drug to Geodon will significantly minimize the amount of weight gain and constipation, as well as the consequent adverse effects of lethargy and sleepiness (Townsend & Morgan, 2018).
By changing to Geodon, the patient would show some good development in terms of reduced self-destructive behaviors, ease in executing everyday tasks and thinking patterns, and minimal complaints of constipation and weight gain.
The Difference Between Expected And Actual Outcomes
The patient returned to the clinic four weeks later, accompanied by her mother. She was less drowsy and less sluggish, and her symptoms had much improved, with no weight gain and constipation. The young mania rating scale had also decreased from 22 to 11, indicating that symptoms were reduced by more than 50%, and these impacts were anticipated. According to Findling et al. (2022), Geodon is an effective treatment for bipolar illness; its side effects are controlled and aid in attaining treatment outcomes for bipolar patients.
Selected Decision No. 3
Increase Geodon to 60 mg orally with a 500 caloric meal
Reason for Making This Choice
The initial visit revealed that the client is making good progress in terms of minimizing self-destructive habits and managing the drug’s negative effects. Increasing this dosage and reevaluating the client after four weeks will help both the client and the accompanying mental health practitioner accomplish their treatment goals (Regan & Valcourt, 2020). The patient’s health had suffered due to the first dose of Seroquel and its side effects.
It is predicted that the patient will make significant progress in eliminating self-destructive behaviors within four weeks. Furthermore, she will report very few or no adverse effects. She will be in a healthy mental, behavioral, and cognitive condition. Geodon is an FDA-approved medication for the treatment of bipolar symptoms, and it has proven to be extremely effective with tolerable side effects.
The Difference Between Expected And Actual Outcomes
As anticipated, the patient has made significant progress with just minor side effects of lethargy and drowsiness (Regan & Valcourt, 2020). The review demonstrated that Geodon had properly aided in achieving the relevant therapeutic goals during the duration of therapy. Given Geodon’s pharmacological activity, these are undoubtedly the predicted consequences. Because the client has the CYP2D6*10 allele, Geodon may be clearing at a slower pace, resulting in higher-than-normal blood levels.
The three fundamental ethical issues in handling clients with bipolar illness are beneficence, nonmaleficence, and autonomy. Patients require therapy to live normal lives, but the side effects of the drugs utilized should be weighed against the corresponding advantages. To optimize the treatment, the nurse should offer the patient the drug with the least side effects.
The impairment of judgment, a characteristic of mania and mood episodes puts a patient in a position where they are unable to make informed treatment decisions. Maassen et al. (2018) show that clinical manifestations such as delusional thinking and irritability may pose a risk to the therapeutic bond that occurs between a client and mental healthcare professional.
It should also be mentioned that because bipolar illness is relapsing-remitting, there may be times when a patient feels well and questions the necessity to continue therapy. This puts the nurse’s treatment aims at odds with the patient’s decision-making autonomy.
Patients, carers, and society continue to bear a considerable burden as a result of bipolar. All healthcare employees, notably nurses, struggle with bipolar management. The significance of accurately identifying manic, hypomanic, and depressive episodes cannot be overstated. A number of pharmacological and nonpharmacological alternatives are accessible for acute and maintenance therapy.
Healthcare practitioners should be aware of the efficacy and safety characteristics of each of these drugs in order to make the most use of the therapeutic choices available to patients with bipolar. Understanding the components of bipolar, which is disease burden, diagnostic issues, and treatment options, can improve results in a large number of patients.
Andersen, F. D., Simonsen, U., & Andersen, C. U. (2021). Quetiapine and other antipsychotics combined with opioids in legal autopsy cases: A random finding or cause of fatal outcome? Basic & Clinical Pharmacology & Toxicology, 128(1), 66–79. https://doi.org/10.1111/bcpt.13480
Findling, R. L., Atkinson, S., Bachinsky, M., Raiter, Y., Abreu, P., Ianos, C., & Chappell, P. (2022). Efficacy, safety, and tolerability of flexibly dosed ziprasidone in children and adolescents with mania in Bipolar I Disorder: A randomized placebo-controlled replication study. Journal of Child and Adolescent Psychopharmacology, 32(3), 143–152. https://doi.org/10.1089/cap.2021.0121
Kanba, S., Murasaki, M., Koyama, T., Takeuchi, M., Shimizu, Y., Arita, E., Kuroishi, K., Takeuchi, M., & Kamei, S. (2019). Long-term mood/antidepressant effects of quetiapine extended-release formulation: an open-label, non-controlled extension study in Japanese patients with bipolar depression. BMC Psychiatry, 19(1), 198. https://doi.org/10.1186/s12888-019-2181-9
Kim, M.-J., Byeon, J.-Y., Kim, Y.-H., Kim, S.-H., Lee, C.-M., Jung, E. H., Chae, W. K., Lee, Y. J., Jang, C.-G., Lee, S.-Y., & Choi, C.-I. (2018). Effect of the CYP2D6*10 allele on the pharmacokinetics of clomiphene and its active metabolites. Archives of Pharmacal Research, 41(3), 347–353. https://doi.org/10.1007/s12272-018-1005-7
Maassen, E. F., Regeer, B. J., Regeer, E. J., Bunders, J. F. G., & Kupka, R. W. (2018). The challenges of living with bipolar disorder: a qualitative study of the implications for health care and research. International Journal of Bipolar Disorders, 6(1), 23. https://doi.org/10.1186/s40345-018-0131-y
Regan, A. S., & Valcourt, S. C. (2020). Metabolic syndrome in bipolar disorder: Review and management. Psychiatric Annals, 50(8), 334–339. https://doi.org/10.3928/00485713-20200713-01
Townsend, M., & Morgan, K. (2018). Pocket guide to psychiatric nursing, 10e (10th ed.). F.A. Davis.
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 â€œbusy,â€ playing with things on your desk and shifting from side to side in her chair. She informs you that â€œthey said I was bipolar, I donâ€™t believe that do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?â€ She weighs 110 lbs. and is 5â€™ 5â€ SUBJECTIVE Patient reports â€œfantasticâ€ mood. Reports that she sleeps about 5 hours/night to which she adds â€œI hate sleep, itâ€™s no fun.â€ 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. Decision tree â€¢ Decision 1: Lithium 300mg BID â€¢ Decision 2: Risperdal 1mg BID â€¢ Decision 3: Seroquel XR 300mg HS For each decision you select please address the following â€¢ Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature. â€¢ 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. â€¢ 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). â€¢ Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples. please dont do introduction/case study summary as i have already done that part-just complete