W4PsychoPharmaco
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W4PsychoPharm. Decision tree. 26 year old Korean woman. You can choose the same decisions of the old student paper if you like. But just take the matching away, and make it sound good.
Click on the link below to access the case study. Or copy and paste on your browser.
https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/04/mm/bipolar_therapy/index.html
The Assignment
Write the purpose of the paper.
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 clients 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.
Note:
Support your rationale with a minimum of three academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement.
READINGS
Required Readings
Note: All Stahl resources can be accessed through this link provided.
Stahl, S. M. (2013). Stahls 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). Stahls 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
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
Required Media Running head: Bipolar Disease 1
8
Bipolar Disease
Assessing and Treating Clients with Bipolar Disorder
Psychopharmacologic Approaches to Treatment of Psychopathology
J
September
Introduction
According to the American Psychiatric Association, 2013, Bipolar disorder (BD) is an affective disorder in which patients experience episodes of elevated or irritable mood, known as mania or hypomania, which fluctuate with episodes of depression (Daigneault et al., 2015). Bipolar disorder (BD) is one of the most severe of the major mental illnesses, and recent estimates place its lifetime prevalence (including BD spectrum) at about 4.4% in the U.S. population (Vieira, Manji, & Zarate, 2010).
Bipolar disorder is associated with higher risk of hospitalizations if left on untreated or if not properly diagnosed. It can also cause psychosocial impairment, comorbidities, suicide attempts, and treatment refractoriness or mixed/rapid states in patients suffering from this disorder. Therefore, its early and accurate diagnosis is essential to a proper and timely treatment intervention, aiming to provide patients with maximal functionality (Daigneault et al., 2015).
The purpose of the paper is to examine a twenty-six year old woman of Korean descent with Bipolar Disorder. It will discuss three decisions that are made concerning the medications prescribed for this patient will considering factors that might impact the patients pharmacokinetic and pharmacodynamic processes. The paper will also discuss ethical consideration that might impact patient treatment.
Decision One: Begin Lithium 300 mg BID Orally Daily
Reason of Choice
My first decision for this patient is to start this patient on 300mg of Lithium twice a day. This is because lithium has been and continues to be the mainstay of bipolar disorder (BD) pharmacotherapy for acute mood episodes, switch prevention, prophylactic treatment, and suicide prevention. Lithium is also the definitive proof-of-concept agent in BD, (Vieira, Manji, & Zarate, 2010). Lithium has been used in the treatment of acute bipolar mania for over 50 years, and has demonstrated superiority over placebo in several controlled clinical trials (Vieta & Moreno, 2008). According to Stahl, 2013, studies have shown that Lithium is effective in treating manic episodes and maintaining reoccurrence of manic episodes and its even though its an older drug, it is still an excellent first-line treatment option to stabilize mood in individuals (Stahl, 2014b). This patient was also just discharged from the hospital two weeks ago and was ordered Lithium which she was non-compliant with after discharge. Lithium usually takes one to three weeks before it starts to work with the goal to reach complete remission of all manic and depressive symptoms (Stahl, 2014b).
I will not be starting the patient on either Risperdal or Seroquel listed in this case because at this point I do not know whether the lithium has had any effect on her yet or not. Also, both these medications are considered antipsychotic medications used to treat schizophrenia among other psychotic disorders and as an adjunct with lithium in treating acute/mixed mania or for bipolar maintenance (stahl, 2014b). It appears to be most, effective in patients with classic (euphoric) mania which is appropriate for this patient. It is imperative to educate the patient about drug adherence at this point as well. It has been acknowledged that lithium compliance is still the most successful in reducing manic episodes and preventing recurrent episodes
Goal
Due to my patient been in manic state during her visit as evidenced by the way she was dressed, rapid speech, poor insight about her illness, diminished need for sleep, increased energy level, my goal for her is to rapidly stabilize her mood and behavioral symptoms, alongside efforts to help her regain their premorbid level of functioning. Within the next four weeks, I expect her to improve if she is complaint with her medications.
Results
At the four weeks visit, the patient reports taking her medication off and on only when she feels like she needs it. She is still presenting with a presentation is similar to her previous visit. At this point the goal for this patient has not been achieved. She is still manic and she hasnt been compliant with her medication regimen as prescribed.
Decision two: Assess Rationale for Non-Compliance
Reason of choice
At this point, rather than either switching the patients medication or increasing the medication, it would reasonable to assess the patients rationale for non-compliance since this is the second time she is incompliant with her medication regimen. The patient was discharged was stabilized with Lithium while she was at the hospital and was eventually discharged to go home and continue with it which she not compliant with and therefore the therapeutic levels werent reached. To this point, due to her non-compliance, it will be fair to say that Lithium has not been proven to be ineffective and therefore, increasing the Lithium to 450mg, BID or switching to Depakote 500mg ER QHS would not be good option. The case here is not whether Lithium is working but why she is no been complaint with the medication regimen.
Therefore, I will need to explore further the reasons why this patient is not complying with the medication regimen in order to improve her clinical outcome. According to the study by Peselow, et. al, 2016, bipolar patients who discontinued lithium was due to feeling averse to the indefinite length of medication treatment, the stigma associated with mental illness, having their moods controlled by medication, receiving purely pharmacologic treatment, the side effects of medication, and the idea of having a chronic illness (page 3). Also, because of the patients descent, a study by Fancher et al., 2014, showed that fewer than half of Asian-Americans prescribed psychotropic medications adhere to their medication regimen. This is due to factors influenced by cultural beliefs about medication, mental illness, and stigma that surrounds mental illness within the Asian-American community.
In evaluating physical complaints from any specific patient, three factors should always be considered: misattribution of symptoms for side effects, the effect of the mood state itself specifically depression on subjective side effect burden and the additive effect of multiple pharmacotherapies on side effect rates (Gitlin, 2016).
After identifying the factors that is causing patient non-adherence, it is important to find ways to help patient maneuver these issues through education, family involvement and even finding support groups for patients with similar illness and background.
Goal
My goal for this patient is to be med compliant in order to reach more than forty-percent reduction in her symptoms or full remission at next her four weeks visit to the clinic.
Results
At the four weeks visit, the patient reports that she tried to be compliant with her medication but started experiencing nausea and diarrhea. She stated that she stopped taking the medication for a while which caused the nausea and diarrhea to subside but they returned as soon as she started taking it again. At this point, she is showing attempts to adhere to her medication but just bothered by the side effects that she is suffering from taking the medications.
Gastrointestinal side effects typically nausea and/or diarrhea are relatively common side effects from lithium. Nausea, is usually seen in ten to twenty percent of lithium treated patients and tends to be more prominent early in treatment while diarrhea increases in prevalence through the first six months of treatment and is associated with serum lithium levels >0.8 mEq/l, (Gitlin, 2016).
Decision Three
Change Lithium to Sustained Release (SR) Preparation
Since the patient issue at this point the side effects of nausea and diarrhea she is suffering from taking lithium, it can be addressed by changing Lithium to sustained release preparation with the same frequency and dosage. Changing the lithium to a different preparation from capsules to sustained release is useful for side effects affected by absorption such as gastrointestinal side effects (Gitlin, 2016). Changing Lithium to extended release formulation would help resolve the patient side effects and while still benefiting from the lithiums mood stabilizing properties.
Choosing Depakote would only be an option if the patient is still suffering from the side effects after changing it to sustained release formulation and the patient is still suffering from her manic symptoms. Trileptal takes several weeks to months to optimize an effect on mood stabilization, therefore, it is usually used as a second-line augmenting agent in treating bipolar disorder (Stahl, 2014b). Therefore, trileptal would not be an option at this time since patient has not had an adequate trial of the first line agents. Also both Depakote and trileptal also have the same GI side effects.
The goal at this point is that switching to sustained release formula will alleviate the GI side effects and that patient will achieve much greater improvements in her manic symptoms or full remission.
Ethical Considerations
An informed consent should be obtained from the patient before starting any psychotropic medications. The risks and benefits of the medication should be fully explained to the patients before she signs it. She should be allowed to participate fully in her treatment plan and given the opportunity to make informed decisions at each point. Healthcare providers should be also be aware when treating patients with an Asian background that traditionally oriented Asians believe in the concept of maintaining balance(yin and yang, mind and body, hot and cold), and that this balance is integral to good health. Health care providers should use this concept of balance to explain how medication can help (Chen, Barron, Lin, & Chung, 2002). The patient should not at any point in her treatment feel a sense of discrimination or bias due to her ethnicity or gender.
Conclusion
Bipolar disorder is a lifelong illness that is complicated by high comorbidity and risk of poor health outcomes, making the primary care physician’s role vital in improving patient quality of life. The management of acute mood episodes should focus first on safety, should include psychiatric consultation as soon as possible, and should begin with an evidence-based treatment that may be continued into the maintenance phase. Long-term management focuses on maintenance of euthymia, requires ongoing medication, and may benefit from adjunctive psychotherapy (Daigneault et al., 2015).
References
Chen, J., Barron, C., Lin, K., & Chung, H. (2002). Prescribing medication for Asians with mental disorders. The Western Journal Of Medicine, 176(4), 271-275.
Daigneault, A., Duclos, C., Saury, S., Paquet, J., Dumont, D., & Beaulieu, S. (2015). Research report: Diagnosis of bipolar disorder in primary and secondary care: What have we learned over a 10-year period? Journal of Affective Disorders, 174225-232. doi:10.1016/j.jad.2014.10.057
Gitlin, M. (2016). Lithium side effects and toxicity: prevalence and management strategies. International Journal of Bipolar Disorders, 4(1), 1. doi:10.1186/s40345-016-0068-y
Peselow, D. E., Long, R., Steiner, J. A., Pizano, R.D., Naghdechi, L., Akladios, N., & IsHak. W. W. (2016). Factors Affecting Long-term Lithium Compliance in Bipolar Patients. International Neuropsychiatric Disease Journal. 7(4): 1-8. doi:10.9734/INDJ/2016/26987
Stahl, S. M. (2014b). The prescribers guide (5th ed.). New York, NY: Cambridge University Press.
Vieira, M. R., Manji, K. H., & Zarate, A. C. (2010). The role of lithium in the treatment of bipolar disorder: convergent evidence for neurotrophic effects as a unifying hypothesis. National Center for Biotechnology Information, U.S. National Library of Medicine. 11(2): 92109. doi: 10.1111/j.1399-5618.2009.00714.x
