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.
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.
Finally: 1. Complete the decision tree (keep track of what you selected. come up with a rational reason why you chose it. Come up with patient specific rational reason behind not choosing the other two options not chosen).
- Write paper addressing all section listed based on the decision tree.
Case Study: Bipolar Therapy for Client of Korean Descent/Ancestry:
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 weight 110 lbs. and is 5′ 5″
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 & activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6
Decisions Made and Outcomes (Needed to formulate the paper)
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
Choices for Decision 1: Select what the PMHNP should do: Begin Lithium 300 mg orally BID, Begin Risperdal 1 mg orally BID, or Begin Seroquel XR 100 mg orally at HS.
My decision: I chose to begin Lithium 300 mg orally BID.
Outcome: RESULTS OF DECISION POINT ONE: Client returns to clinic in four weeks
Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”
Today’s presentation is similar to the first day you met her
Choices for Decision 2: Select what the PMHNP should do:Increase Lithium to 450 mg orally BID, Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology, or Switch to Depakote ER 500 mg orally at HS.
My decision: I chose to switch to Depakote ER 500 mg orally at HS.
Outcome: RESULTS OF DECISION POINT TWO: Client returns to clinic in four weeks
Client reports that she has been compliant, and you notice a marked reduction in manic symptoms. Young Mania Rating Scale was 11 (50% reduction from first office visit)
Client reports that she has gained 6 pounds over the last 4 weeks and wants to stop the medication because of this Client returns to clinic in four weeks
Choices for Decision 3: Decision Point Three Select what the PMHNP should do next: Educate client regarding diet/weight loss and continue client on the same drug/dose, Decrease Depakote ER to 250 mg orally at HS, or Switch medication to Zyprexa 15 mg orally daily at HS
My decision: I choose to educate client regarding diet/weight loss and continue client on the same drug/dose
Outcome: Guidance to Student
The PMHNP should begin by educating the client regarding weight loss/and importance of diet/exercise while taking Depakote which can cause weight gain. Decreasing the dose of Depakote would not be appropriate as she still has symptoms and decreasing dose of Depakote may result in some weight loss, it may result in a return of manic symptoms. The PMHNP can switch to Zyprexa but if weight gain is the issue, then this will be compounded by Zyprexa which is associated with significant weight gain (up to 20 kg over a 24 month period).
Write on each decision. Make sure that this paper has at least 5 References. Please use in-text citations. Don’t forget the ethical considerations for this assignment. Make it a section by itself.
Brands
• Eskalith
• Eskalith CR
• Lithobid slow-release tablets
• Lithostat tablets
• Lithium carbonate tablets
• Lithium citrate syrup
• see index for additional brand names
Generic?
• Yes
Class
• Neuroscience-based Nomenclature: lithium enzyme interactions (Li-Eint)
• Mood stabilizer
Commonly Prescribed for
• (bold for FDA approved)
• Manic episodes of manic-depressive illness
• Maintenance treatment for manic-depressive patients with a history of mania
• Bipolar depression
• Major depressive disorder (adjunctive)
• Vascular headache
• Neutropenia
How the Drug Works
• Unknown and complex
• Alters sodium transport across cell membranes in nerve and muscle cells
• Alters metabolism of neurotransmitters including catecholamines and serotonin
• May alter intracellular signaling through actions on second messenger systems
• Specifically, inhibits inositol monophosphatase, possibly affecting neurotransmission via phosphatidyl inositol second messenger system
• Also reduces protein kinase C activity, possibly affecting genomic expression associated with neurotransmission
• Increases cytoprotective proteins, activates signaling cascade utilized by endogenous growth factors, and increases gray matter content, possibly by activating neurogenesis and enhancing trophic actions that maintain synapses
How Long Until It Works
• 1–3 weeks
If It Works
• The goal of treatment is complete remission of symptoms (i.e., mania and/or depression)
• Continue treatment until all symptoms are gone or until improvement is stable and then continue treating indefinitely as long as improvement persists
• Continue treatment indefinitely to avoid recurrence of mania or depression
If It Doesn’t Work
• Many patients have only a partial response where some symptoms are improved but others persist or continue to wax and wane without stabilization of mood
• Other patients may be nonresponders, sometimes called treatment-resistant or treatment-refractory
• Consider checking plasma drug level, increasing dose, switching to another agent or adding an appropriate augmenting agent
• Consider adding psychotherapy
• Consider the presence of noncompliance and counsel patient
• Switch to another mood stabilizer with fewer side effects
• Consider evaluation for another diagnosis or for a comorbid condition (e.g., medical illness, substance abuse, etc.)
Best Augmenting Combos for Partial Response or Treatment Resistance
• Valproate
• Atypical antipsychotics (especially risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole)
• Lamotrigine
• Antidepressants (with caution because antidepressants can destabilize mood in some patients, including induction of rapid cycling or suicidal ideation; in particular consider bupropion; also SSRIs, SNRIs, others; generally avoid TCAs, MAOIs)
Tests
• Before initiating treatment, kidney function tests (including creatinine and urine specific gravity) and thyroid function tests; electrocardiogram for patients over 50
• Repeat kidney function tests 1–2 times/year
• Frequent tests to monitor trough lithium plasma levels (about 12 hours after last dose; should generally be between 1.0 and 1.5 mEq/L for acute treatment, 0.6 and 1.2 mEq/L for chronic treatment)
• Initial monitoring: every 1–2 weeks until desired serum concentration is achieved, then every 2–3 months for the first 6 months
• Stable monitoring: every 6–12 months
• One-off monitoring after dose change, other medication change, illness change (not before 1 week)
• Since lithium is frequently associated with weight gain, before starting treatment, weigh all patients and determine if the patient is already overweight (BMI 25.0–29.9) or obese (BMI ≥30)
• Before giving a drug that can cause weight gain to an overweight or obese patient, consider determining whether the patient already has pre-diabetes (fasting plasma glucose 100–125 mg/dL), diabetes (fasting plasma glucose >126 mg/dL), or dyslipidemia (increased total cholesterol, LDL cholesterol, and triglycerides; decreased HDL cholesterol), and treat or refer such patients for treatment, including nutrition and weight management, physical activity counseling, smoking cessation, and medical management
• Monitor weight and BMI during treatment
• While giving a drug to a patient who has gained >5% of initial weight, consider evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider switching to a different agent
VALPROATE
THERAPEUTICS
Brands
Depakene
Depacon
Depakote, Depakote ER
Stavzor
see index for additional brand names
Generic?
Yes
Class
Neuroscience-based Nomenclature: glutamate (Glu); yet to be determined
Anticonvulsant, mood stabilizer, migraine prophylaxis, voltage-sensitive sodium channel modulator
Commonly Prescribed for
(bold for FDA approved)
Acute mania (divalproex) and mixed episodes (divalproex, divalproex ER, valproic acid delayed-release)
Complex partial seizures that occur either in isolation or in association with other types of seizures (monotherapy and adjunctive)
Simple and complex absence seizures (monotherapy and adjunctive)
Multiple seizure types, which include absence seizures (adjunctive)
Migraine prophylaxis (divalproex, divalproex ER, valproic acid delayed-release)
Maintenance treatment of bipolar disorder
Bipolar depression
Psychosis, schizophrenia (adjunctive)
How the Drug Works
Blocks voltage-sensitive sodium channels by an unknown mechanism
Increases brain concentrations of gamma-aminobutyric acid (GABA) by an unknown mechanism
How Long Until It Works
For acute mania, effects should occur within a few days depending on the formulation of the drug
May take several weeks to months to optimize an effect on mood stabilization
Should also reduce seizures and improve migraine within a few weeks
If It Works
The goal of treatment is complete remission of symptoms (e.g., mania, seizures, migraine)
Continue treatment until all symptoms are gone or until improvement is stable and then continue treating indefinitely as long as improvement persists
Continue treatment indefinitely to avoid recurrence of mania, depression, seizures, and headaches
If It Doesn’t Work (for bipolar disorder)
Many patients have only a partial response where some symptoms are improved but others persist or continue to wax and wane without stabilization of mood
Other patients may be nonresponders, sometimes called treatment-resistant or treatment-refractory
Consider checking plasma drug level, increasing dose, switching to another agent or adding an appropriate augmenting agent
Consider adding psychotherapy
Consider the presence of noncompliance and counsel patient
Switch to another mood stabilizer with fewer side effects
Consider evaluation for another diagnosis or for a comorbid condition (e.g., medical illness, substance abuse, etc.)
Best Augmenting Combos for Partial Response or Treatment Resistance (for bipolar disorder)
Lithium
Atypical antipsychotics (especially risperidone, olanzapine, quetiapine, ziprasidone, and aripiprazole)
Lamotrigine (with caution and at half the dose in the presence of valproate because valproate can double lamotrigine levels)
Antidepressants (with caution because antidepressants can destabilize mood in some patients, including induction of rapid cycling or suicidal ideation; in particular consider bupropion; also SSRIs, SNRIs, others; generally avoid TCAs, MAOIs)
Tests
Before starting treatment, complete blood counts, coagulation tests, and liver function tests
Consider coagulation tests prior to planned surgery or if there is a history of bleeding
During the first few months of treatment, regular liver function tests and platelet counts; this can be shifted to once or twice a year for the remainder of treatment
Plasma drug levels can assist monitoring of efficacy, side effects, and compliance
Since valproate is frequently associated with weight gain, before starting treatment, weigh all patients and determine if the patient is already overweight (BMI 25.0–29.9) or obese (BMI ≥30)
Before giving a drug that can cause weight gain to an overweight or obese patient, consider determining whether the patient already has pre-diabetes (fasting plasma glucose 100–125 mg/dL), diabetes (fasting plasma glucose >126 mg/dL), or dyslipidemia (increased total cholesterol, LDL cholesterol, and triglycerides; decreased HDL cholesterol), and treat or refer such patients for treatment, including nutrition and weight management, physical activity counseling, smoking cessation, and medical management
Monitor weight and BMI during treatment
While giving a drug to a patient who has gained >5% of initial weight, consider evaluating for the presence of pre-diabetes, diabetes, or dyslipidemia, or consider switching to a different agent
References
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