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Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Assignment: Assessing and Treating Clients with Bipolar Disorder

Assessing and Treating Clients with With Bipolar Disorder Assignment: 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.  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

 

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Assessing and Treating Clients with Bipolar Disorder Learning Objectives

Students will:
• Assess client factors and history to develop personalized plans of bipolar therapy for clients
• Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring bipolar therapy
• Evaluate efficacy of treatment plans
• Analyze ethical and legal implications related to prescribing bipolar therapy to clients across the lifespan  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

To prepare for this Assessing and Treating Clients with Bipolar Disorder Assignment:

• Review this week’s Learning Resources. Consider how to assess and treat clients requiring bipolar therapy.
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. Assessing and Treating Clients with Bipolar Disorder Assignment Paper

At each decision point stop to complete the following:

• Decision #1
o Which decision did you select?
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources.
o Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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• Decision #2
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. Assessing and Treating Clients with Bipolar Disorder Assignment Paper
o Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different?

• Decision #3
o Why did you select this decision? Support your response with evidence and references to the Learning Resources.
o What were you hoping to achieve by making this decision?  Assessing and Treating Clients with Bipolar Disorder Assignment PaperSupport your response with evidence and references to the Learning Resources.
o 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. Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Assessing and Treating Clients with Bipolar Disorder CASE STUDY
Bipolar Therapy: Client of Korean Descent/Ancestry

BACKGROUND INFORMATION

Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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″  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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.  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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. Assessing and Treating Clients with Bipolar Disorder Assignment Paper

The Young Mania Rating Scale (YMRS) score is 22

Assessing and Treating Clients with Bipolar Disorder 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 Assessing and Treating Clients with Bipolar Disorder Assignment Paper
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Decision Point One

Select what the PMHNP should do:

Begin Lithium 300 mg orally BID

Begin Risperdal 1 mg orally BID

Begin Seroquel XR 100 mg orally at HS Assessing and Treating Clients with Bipolar Disorder Assignment Paper

OPTION 1: Assessing and Treating Clients with Bipolar Disorder

Assessing and Treating Clients with Bipolar Disorder Bipolar Therapy: Client of Korean Descent/Ancestry

Decision Point One

Begin Risperdal 1 mg orally BID

RESULTS OF DECISION POINT ONE  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Client returns to clinic in four weeks
Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic
Client’s mother explains that “she has been like this since about a week after the last office visit” Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Decision Point Two

Decrease Risperdal to 1 mg at HS

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client is less sedate, less lethargic and shows symptom improvement
Young Mania Rating Scale has decreased from 22 to 16 (a bit more than a 25% decrease in symptoms)  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Decision Point Three

Continue at same dose of Risperdal and reassess in 4 weeks

Assessing and Treating Clients with Bipolar Disorder Guidance to Student

Assessing and Treating Clients with Bipolar Disorder Assignment Paper

At this point, the PMHNP may be wise to allow the client to remain at the same dose and reassess in 4 weeks. Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may have slower clearance of Risperdal from her system, which may have resulted in higher than normal levels of Risperdal in the blood, which in turn resulted in sedation. Therefore, if we were to increase back to 1 mg orally BID, she may have the same side effects. Latuda is FDA approved for bipolar I depression, which is not the presentation we are attempting to treat. Additionally, it is quite expensive and many insurance companies will not pay for it until other agents have been attempted and failed. Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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OPTION 2: Assessing and Treating Clients with Bipolar Disorder

 

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Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Assessing and Treating Clients with Bipolar Disorder- Bipolar Therapy: Client of Korean Descent/Ancestry

Decision Point One

Begin Seroquel XR 100 mg orally at HS

RESULTS OF DECISION POINT ONE Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Client returns to clinic in four weeks
Client is reporting that she sleeps a bit more at bedtime
Client states that she has gained about 2 or 3 pounds, which she does not like
Client also reports that she has been constipated since starting this medication
Client is also complaining of dry mouth which she does not like.
Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18
Client is reporting really good mood, but is asking for a different medication because of the weight gain Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Decision Point Two

Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client demonstrates a 50% decrease in score on the Young Mania Rating Scale (from 22 to 11)
Client denies any additional weight gain and denies any additional side effects Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Decision Point Three

Continue same dose and reassess in 4 weeks

Assessing and Treating Clients with Bipolar Disorder: Guidance to Student

The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as  the drug can cause dental problems as a result of dry mouth.  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects. Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended release may overcome the difficulties she was experiencing with side effects. The PMHNP would need to educate client regarding side effects of medication and need to maintain compliance. Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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OPTION 3: Assessing and Treating Clients with Bipolar Disorder

Assessing and Treating Clients with Bipolar Disorder: Bipolar Therapy: Client of Korean Descent/Ancestry  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Decision Point One

Begin Risperdal 1 mg orally BID

RESULTS OF DECISION POINT ONE

Client returns to clinic in four weeks
Client is accompanied today by her mother who must help the client into your office, the client looks very sedated and lethargic
Client’s mother explains that “she has been like this since about a week after the last office visit” Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Decision Point Two

Discontinue Risperdal and start Lithium sustained release 300 mg orally BID

RESULTS OF DECISION POINT TWO

Client returns to clinic in four weeks
Client no longer lethargic after the end of the first week
Client has a slight decrease in her Young Mania Rating Scale (from 22 to 19)
Client reports that her sleep is again decreasing, but that overall, she is happy  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Decision Point Three

Make no changes at this time & reevaluate in 4 weeks

Assessing and Treating Clients with Bipolar Disorder Guidance to Student

Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may be demonstrating slower clearance of Risperdal from her system, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The client responded well to the discontinuation of Risperdal and after about a week of drug cessation, she was no longer lethargic/sedate. However, in the following 3 weeks, she had experienced increased symptoms, although a slight improvement in YMSR score was noted. The PMHNP could make no changes at this time and allow the lithium to remain at its current dose for an additional 4 weeks and reassess. Conversely, the PMHNP can increase the lithium to 450 mg orally BID and then reassess in 4. The additional milligrams may hasten mood stabilization. Risperdal 0.5 mg orally BID may be appropriate if the clients’ symptoms are worsening, however, the PMHNP would need to have the client return to the office sooner than 4 weeks for an interim visit to assess effects of drug and presence of somnolence/lethargy.  Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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Assessing and Treating Clients with Bipolar Disorder Learning Resources

Note: To access this week’s required library resources, please click on the link to the Course Readings List, found in the Course Materials section of your Syllabus. Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Required Readings

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. Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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” Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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” Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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 Assessing and Treating Clients with Bipolar Disorder Assignment Paper

Note: Retrieved from Walden Library databases.

Assessing and Treating Clients with Bipolar Disorder Required Media

Laureate Education. (2016f). Case study: An Asian American woman with bipolar disorder [Interactive media file]. Baltimore, MD: Author Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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 Assessing and Treating Clients with Bipolar Disorder Assignment Paper

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