Assignment: Decisions on Medication Options for Treating Bipolar Disorder in a Female Patient of Korean Descent

Assignment: Decisions on Medication Options for Treating Bipolar Disorder in a Female Patient of Korean Descent

Assignment: Decisions on Medication Options for Treating Bipolar Disorder in a Female Patient of Korean Descent

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?”

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She weights 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 did well enough on Lithium to be discharged from the hospital but admits she has not been taking it as prescribed. When further questioned on the subject, she provides no additional details.

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 and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6

Decision Point One
Select what the PMHNP should do:

Begin Lithium 300 mg orally BID
Begin Risperdal 1 mg orally BID
Begin Seroquel XR 300 mg orally at HS

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”
Decision Point Two
Select what the PMHNP should do next:

Discontinue Risperdal and start Lithium sustained release 300 mg orally BID
Decrease Risperdal to 1 mg at HS
Change Risperdal to 2 mg at HS

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”
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)
Decision Point Three
Select what the PMHNP should do next:

Continue at same dose of Risperdal and reassess in 4 weeks
Increase Risperdal back to 1 mg orally BID
Change to Latuda 40 mg orally daily

Examine Case Study: An Asian American Woman. Diagnosis-Bipolar Disorder. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
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.
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).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
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.
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).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
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.
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).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Conclusion (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

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Decisions on Medication Options for Treating Bipolar Disorder in a Female Patient of Korean Descent

            In the DSM-5, Bipolar and Related Disorders is a distinct diagnostic category of mental illnesses recognized and appreciated by their unique diagnostic criteria. Apart from bipolar I disorder, other conditions in this category and that share some similarities in presentation are bipolar II disorder and cyclothymic disorder (APA, 201; Sadock et al., 2015). According to the National Institute of Mental Health, 2.6% or 5.7 million adult Americans are suffering from bipolar disorder. Its symptoms characteristically start showing around the age of 25 years. The disorder has no racial, socioeconomic, age, or geographical, or cultural bias. The statistics indicate that women often get more mixed episodes of bipolar disorder than men do (DBSA, 2022). There are some similarities in symptoms between bipolar I disorder and other conditions in the DSM-5 such as the psychoses and depressive disorders. This means a lot of care must be exercised when making the diagnosis in order that the diagnosis is not missed. The case presented for this paper is that of a 26 year-old female of Korean descent that is diagnosed with bipolar I disorder. This paper is therefore about the appropriate medication choices that can be made to treat her condition effectively.

The Young Mania Rating Scale (YMRS)

            This client had been discharged from hospital with lithium (Eskalith) but proved to be non-compliant with medication. At the time of follow up, she confessed that she had not been taking the lithium for two weeks now. At presentation she was dishevelled, had poor insight, unaffected judgment, and euthymic affect. She did not have suicidal or homicidal thoughts. The criteria of presentation clearly pointed out to a diagnosis of bipolar I disorder APA, 2013; Sadock et al., 2015). This was reinforced by her psychiatric history.

            In order to gauge and classify the severity of mania in bipolar disorder, the Young Mania Rating Scale or YMRS is often used by PMHNPs. This is a psychometric test that has scores that range from 0 to 60. The first time this client was subjected to the test she scored 22 points. This showed that she was suffering from mild mania according to the interpretation of the psychometric test (Mohammadi et al., 2018). This test would be used again to assess whether the client is improving or not. In the scoring of this psychometric test, 38-60 points scored mean severe mania, 26-37 points scored mean moderate mania, and 20-25 points scored mean mild mania (Mohammadi et al., 2018). This client therefore resented with mild mania according to the test.

Decision Point 1

            At this first decision point, three choices of medications are presented for selection to treat this client. These are lithium (Eskalith) 300 mg orally twice a day, risperidone (Risperdal) 1 mg orally twice a day, or quetiapine (Seroquel XR) 100 mg orally at bedtime (Stahl, 2017). The choice made at this first point was to put her on lithium 300 mg orally twice a day. This choice was informed by the efficacy and effectiveness of the lithium as per evidence-based practice. The drug is actually FDA-approved to treat the mania of bipolar disorder (Stahl, 2017). Evidence shows that it is this drug that has the potential to not only reduce the symptoms but also lessen the chances of suicidal ideation.

            Laski et al. (2019) report that a 2013 meta-analysis of 48 RCTs (randomized controlled trials) with a total of 6,674 subjects proved that lithium was the most efficacious and effective in reducing the rate of suicides and deaths in those with bipolar disorder. This is scholarly evidence on its efficacy in managing the symptoms of the disease. In a randomized double-blinded controlled trial by Young et al. (2017), the fact of lithium efficacy in treating the mania of bipolar disorder was also proven. Comparing lithium and divalproex, Young et al. (2017) found that lithium emerged superior by bringing about a greater reduction in mania scores (by using the YMRS) over a period of just nine weeks. 

            Because the client has a positive for the gene CYP2D6*10, starting her on risperidone would have been detrimental. Thus risperidone was not chosen because the client has two inactive copies of the gene and is hence a “poor metabolizer” of the drug. The risk of adverse effects is high (Lu et al., 2021). The action would have also violated the bioethical principle of nonmaleficence (“do no harm”) or primum non nocere (Haswell, 2019). Because the CYP2D6*10 gene is ineffective in this Korean woman at facilitating the protein synthesis (translation phase) of the cytochrome P450 isoenzyme 2D6; metabolism (catabolism) of risperidone will not take place effectively and the levels will rise dangerously within the blood. This is a pharmacokinetic (ADME) effect of the presence of this gene in the Korean woman. What this means therefore is that the client would have suffered serious adverse effects such as prolonged sedation and drowsiness were they given risperidone.

            According to Ketter et al. (2016), quetiapine and lithium are both useful in managing bipolar disorder. However, each is more effective at different phases of treatment. It quetiapine (Seroquel) was therefore not chosen at this juncture because at this phase lithium works better. The quetiapine would be considered at a later phase. Quetiapine was also overlooked in favor of lithium because of the same reasons of severe side effects. By giving the lithium, it was hoped that the symptoms would start reducing within the first four weeks after follow up with 100% compliance.

Decision Point 2

            At this decision point, the client has been home for four weeks and comes back for review and reassessment of the efficacy of treatment. Unfortunately, her symptoms appear to have remained the same after she is tested again using the YMRS. On further questioning, it is soon clear that she has not been taking the medications as prescribed. She states that she has only been taking them “when she feels like”. Due to this noncompliance, it is therefore very difficult to determine if the lithium is effective or not. Three options are provided at this point too. They are increasing lithium to 450 mg BID, changing to valproate (Depakote ER) 500 mg at bedtime, or finding out the rationale for the noncompliance and then giving health education to the client on the drugs.

            The decision was made at this point to find out why the client was not complying with the medication regime and then to give her health education. Among the three, this was the only evidence-based option given the situation of the client. It was chosen because there was as yet no proof that the lithium as inefficacious at treating her. This could only be determined if she took the medication as prescribed without missing. As such finding out the reason for the non-compliance was more important than changing medications (which was not going to help with the noncompliance).

            The decision not to choose an increase in lithium dose was due to the fact that the client had not yet shown compliance and so therapeutic effect could not be determined at the current dose. Likewise, valproic acid was not chosen because a change to another medication was not yet indicated. The client needed to first comply to the lithium treatment before a decision could be made that lithium was inefficacious. In the event that the other decision of changing to another medication was made, the client would have been subjected to the risk of side effects yet lithium had not yet been proved ineffective. The overriding ethical considerations here were beneficence and nonmaleficence (Haswell, 2019). By taking this decision, it was hoped that the client would begin being compliant and that the symptoms would begin to subside in the next four weeks now.

Decision Point 3

            After a further four weeks, the client returns but this time reports two side effects. She states that she was having diarrhea and feeling nauseated after taking the lithium (Eskalith) as prescribed. The positive thing is that she had now started to be compliant with medication and was taking the drug as prescribed without fail. At this third and last decision point, three other options are also provided. The first is to switch to valproate (Depakote ER) 500 mg at bedtime. The second option is to keep the lithium (Eskalith) 300 mg orally BID but change the preparation to sustained release. Lastly, the third option is to switch from lithium to oxcarbamazepine (Trileptal) 300 mg orally BID (Stahl, 2017). The decision taken here is to keep the current dose and frequency of the lithium but to introduce a sustained release preparation. According to Stahl (2017), changing to a sustained release preparation in the case of side effects has the outcome of stabilizing the client’s mood and reducing the severity of the adverse effects.

            Oxcarbamazepine (Trileptal) was not chosen in this case because it is not FDA-approved for the treatment of mania. It also happens to be just a second-line option with minimal efficacy in the event that the lithium does not work as expected (Stahl, 2017). However, according to Luu and Rodway (2018) the medication is a worthy alternative to lithium in terms of efficacy. In this instance it was therefore not considered because the lithium had not yet shown lack of therapeutic response. Changing to sodium valproate would only be needed were the lithium to be proved ineffective. The expectation on choosing this option of a sustained release preparation as that it would discourage the side effects and allow the therapeutic effect to reduce the symptoms to remission. At this point too, the overriding ethical considerations were beneficence (doing good) and nonmaleficence (avoiding causing harm to the client).

Conclusion

            In this case, lithium (Eskalith) proved to be the best choice based on evidence-based practice and sound clinical judgment. Laski et al. (2021) and Young et al. (2017) provide the peer-reviewed scholarly evidence that is needed to prove that lithium is indeed efficacious in treating the mania of bipolar disease. The two level I evidence randomized controlled trials are current and unequivocally support the choice that has been made to stick to lithium as the medication of choice for this female of Korean ancestry. Additionally, lithium is also FDA-approved to treat bipolar disorder. This says that this was the best choice to make. Avoidance of the other medications in the options was also directed by sound pharmacokinetic principles. For instance, risperidone could not be used because the client has a genetic defect preventing her liver from effectively metabolizing the risperidone. Overall, the decisions taken in the three steps were the correct ones because the patient started showing signs of improvement through better scores on the YMRS.     

 References

American Psychiatric Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Dean, L. (2017). Risperidone therapy and CYP2D6 genotype. https://www.ncbi.nlm.nih.gov/books/NBK425795/#:~:text=In%20contrast%2C%20the%20decreased%20function,and%20may%20vary%20among%20populations

Depression and Bipolar Support Alliance [DBSA] (2022). Bipolar disorder statistics. https://www.dbsalliance.org/education/bipolar-disorder/bipolar-disorder-statistics/

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179.  https://doi.org/10.12968/joan.2019.8.4.177

Ketter, T.A., Miller, S., Dell’Osso, B., & Wang, P.W. (2016). Treatment of bipolar disorder: Review of evidence regarding quetiapine and lithium. Journal of Affective Disorders, 191, 256–273. https://doi.org/10.1016/j.jad.2015.11.002  

Laski, M., Foreman, R., Hancock, H., & Tavakoli, H.R. (2021). LITHIUM: An underutilized element: Despite precautions, lithium should remain a first-line therapy for bipolar disorder. Current Psychiatry, 20(12). https://go.gale.com/ps/i.do?id=GALE%7CA689356771&sid=googleScholar&v=2.1&it=r&linkaccess=abs&issn=15378276&p=AONE&sw=w&userGroupName=anon%7E98865756 

Lu, J., Yang, Y., Lu, J., Wang, Z., He, Y., Yan, Y., … & Zhao, J. (2021). Effect of CYP2D6 polymorphisms on plasma concentration and therapeutic effect of risperidone. BMC Psychiatry, 21(1). https://doi.org/10.1186/s12888-020-03034-9 

Luu, B., & Rodway, G. (2018). Lithium therapy for bipolar disorder. The Journal for Nurse Practitioners, 14(2), 93–99. https://doi.org/10.1016/j.nurpra.2017.09.025

Mohammadi, Z., Pourshahbaz, A., Poshtmashhadi, M., Dolatshahi, B., Barati, F., Zarei, M. (2018). Psychometric properties of the Young Mania Rating Scale as a mania severity measure in patients with bipolar I disorder. Practice in Clinical Psychology, 6(3), 175-182. http://jpcp.uswr.ac.ir/browse.php?a_id=552&sid=1&slc_lang=en&ftxt=0 

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6^th ed. Cambridge University Press.

Young, R.C., Mulsant, B.H., Sajatovic, M., Gildengers, A.G., Gyulai, L., Al Jurdi, R.K., … & Greenberg, R. (2017). GERI-BD: A randomized double-blind controlled trial of lithium and divalproex in the treatment of mania in older patients with bipolar disorder. American Journal of Psychiatry, 174(11), 1086–1093. https://doi.org/10.1176/appi.ajp.2017.1505065