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Assessing and Treating Clients with Bipolar Disorder

Assessing and Treating Clients with Bipolar Disorder

Bipolar disorder is an extreme emotional unsteadiness with genuine results for everyday living of patients and their guardians. Mind as usual principally comprises of pharmacotherapy and reliable treatment. In any case, a substantial number of patients demonstrate a defective reaction to treatment and experience the ill effects of incessant scenes, steady inter-episodic side effects, and poor social working. Both psychiatric and physical comorbid issue are visited, particularly identity issue, substance mishandle, cardiovascular maladies and diabetes. The multidisciplinary coordinated effort of experts is expected to join all skill with a specific end goal to accomplish great-incorporated treatment (Fisher et al., 2017). A few reviews have demonstrated likely impacts of coordinated treatment programs for patients with bipolar disorder. In this paper, bipolar therapy is examined with considerations to making the right treatment choices amid ethical considerations.

Decision Point One

Selected Decision

Begin Risperdal 1 mg orally BID

Reason for the Selection

The drug, Risperdal (risperidone), is a second generation or atypical antipsychotic agent whose uses include management of bipolar disorder. Its main action is through rebalancing the dopamine and serotonin and thereby to improve mood, to think, and behavior. Given that the patient was diagnosed with bipolar disorder, Risperdal is the best choice considering the available medications. In the prior treatment, the patient defaulted in lithium, and so it may not be a moral idea to begin lithium 300 mg as the chances are that the patient may not comply (Hamlat, O’Garro-Moore, Alloy, & Nusslock, 2016). Seroquel XR may be a good choice, but its side effects may include weight gaining and constipation. This may not be well received by the patient who defaulted in using lithium which has a similar side effect of constipation.

Expected Results

The patient should be able to improve within the first four weeks. The symptoms should reduce significantly with an improvement in the patient’s mood. The patient should exhibit a good sleeping pattern. Risperdal is an effective medication for balancing mental activity and restore sanity in the way that the patient thinks (Wilson, Crowe, Scott, & Lacey, 2017). The suicidal thoughts should decrease as well as symptoms of anxiety.

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The patient visited the hospital after four weeks, and she was lethargic and sedated. Her mum had to accompany her into the office. It was stated that these symptoms appeared after one week of medication. This was contrary to the anticipated results of reduced the symptoms of bipolar. It was expected that the patient would have improved mood and appropriate thinking. The difference in the results is the side effects of the drug. The high amount of Risperdal in the blood leads to sedation. Given that the patient is of Korean ancestry and positive for CYP2D6*10 allele means that she may not have a swift clearance of Risperdal from the blood leading to accumulation (Demant, Vinberg, Kessing, & Miskowiak, 2015).

Decision Two

Selected Decision

Decrease Risperdal to 1 mg at HS

Reason for Selection

Risperdal 1 mg orally BID did not fail to work during the second visit; it only caused side effects. It is wise to alter the dosage to manage the side effects rather than cease the medication for another. Altering Risperdal to 2 mg at HS may still attest to be a lot, and the side effects may not be sufficiently managed. A choice to switch back to lithium is still not right as the patient still has an attitude towards it (Demant, Vinberg, Kessing, & Miskowiak, 2015). Furthermore, it might confuse the patient on drugs used. Helping her cope with different dosage of the same drug will increase her confidence in drugs and appreciate that it is all about the alteration of the dosage.

Expected Results

As mentioned previously, Risperdal is effective in balancing dopamine and serotonin in the brains and thus managing mood, behavior and thought problems. The adverse effects have been ascribed to the accumulation of Risperdal in the patient’s blood. Lowering the dosage to Risperdal 1 mg at HS will warrant no accumulation of the drug in the patient’s blood as the body will be able to excrete it quite quickly. By altering the dosage, the patient should begin being less sedated and less lethargic. The patient should also begin experiencing improvement in the mood, have proper behaviors as well as think well (Demant, Vinberg, Kessing, & Miskowiak, 2015). This is the effect of Risperdal when taken in the correct amount.

Difference between Expected Results and Actual Results

The patient visited after four weeks, and she was less lethargic and sedated. Furthermore, the Young Mania Rating Scale had reduced from 22 to 16. The patient reported that there were no other side effects. These outcomes are very similar to the anticipated results. The side effects diminished quite faster than it was assumed and this the only difference and luckily in a positive direction. The results are similar because just as stated earlier, Risperdal is a proper medication for bipolar disorder. The adverse effects could not be used as a reason for discarding the drug in this case.

Decision Three

Selected Decision

Continue the same dose of Risperdal and reassess in four weeks

Reason for Selection

The patient is responded quite well to the current medication. It is more sensible to persist with the dosage as the evaluation continues to note any need for altering the medication in any way. Also, Risperdal I mg orally BID already proved to be unbearable by the patient’s system. Going back to it may cause the side effects witnessed earlier. Shifting to Latuda, on the other hand, is not appropriate since FDA only qualifies it for treatment of bipolar type 1. The patient’s mental condition is not consistent with bipolar type 1. The drug is also very costly. Thus, it is wise to go on with the same dosage of Risperdal and only alter when necessary.

Expected Results

Given that the patient has appropriately responded to the treatment by Risperdal, it is anticipated that continual use of the drug will lead to even further reduction of the symptoms of bipolar. The first instant resulted in more than twenty-five percent reduction in symptoms; hence, the reduction should be close to fifty percent by the fourth week. The patient will have a good sleeping pattern, improved mood, rational behavior, and appropriate thinking (Fisher et al., 2017). The adverse effects experienced in the initial dosage are not expected to be seen again.

Difference between Expected Results and Actual Results

As per the advice given after the third decision, the expected results will be that the patient will have achieved a significant progressive reduction of the previous symptoms. It will result in managing the bipolar disorder if the Risperdal continues to be effective at this dosage. These are however similar results to those anticipated when the dosage was being used. Given consistency in the pharmacokinetics and pharmacodynamics, these should be the expected results and the goals of therapy will be achieved in a short time.

Impact of Ethical Considerations on Treatment Plan

In healthcare, ethical considerations play a huge role in the treatment plan. When handling patients having bipolar disorder, ethical considerations come centrally to the way the PMHNP approaches the treatment (Burdick, Ketter, Goldberg, & Calabrese 2015). The patient is mentally unstable, and therefore the PMHNP nurse has to know the appropriate way to present any info to them and the exact time to do that. Ethical contemplations affected the way the patient was counseled to go on using Risperdal in an altered dosage after the first one had caused sedation and lethargy side effects.

When choosing among the drugs to use, ethical considerations were at the core since some drugs are known for specific side effects to several descents of people. For example, Seroquel XL is known for constipation and dry mouth. The patient had complained of comparable side effects when she used lithium in her previous medication. Ethical considerations demand that the PMHNP considers the long-term effects this may bring about; like damage of the teeth (Goodwin et al., 2016). Hence, the medication had to be foregone for a better alternative with relatively fewer adverse effects.

Conclusion

Bipolar disorder is a complicated condition to diagnose because of the numerous symptoms that resemble symptoms for other mental disorders. In the treatment of this condition, due considerations ought to be made as to the side effects of the drugs used. Ethical contemplations are also vital to the treatment plan for bipolar disorder given the mental unsteadiness of the patient. There are drugs recognized for the treatment of bipolar disorder; nevertheless, the PMHNP need to be aware of which drug is suitable and the dosage for every specific bipolar disorder patient.

References

Fisher, A., Manicavasagar, V., Sharpe, L., Laidsaar-Powell, R., & Juraskova, I. (November 01, 2017). A Qualitative Exploration of Clinician Views and Experiences of Treatment Decision-Making in Bipolar II Disorder. Community Mental Health Journal, 53, 8, 958-971.

Hamlat, E. J., O’Garro-Moore, J. K., Alloy, L. B., & Nusslock, R. (January 01, 2016). Assessment and Treatment of Bipolar Spectrum Disorders in Emerging Adulthood: Applying the Behavioral Approach System Hypersensitivity Model. Cognitive and Behavioral Practice, 23, 3, 289-299.

Wilson, L., Crowe, M., Scott, A., & Lacey, C. (2017). Psychoeducation for bipolar disorder: A discourse analysis. International Journal of Mental Health Nursing.

Goodwin Gm, Et Al. (2016). Evidence-Based Guidelines for Treating Bipolar Disorder: Revised third edition recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology (Oxford, England). 30, 495-553.

Burdick Ke, Ketter Ta, Goldberg Jf, & Calabrese Jr. (2015). Assessing cognitive function in bipolar disorder: challenges and recommendations for clinical trial design. The Journal of Clinical Psychiatry. 76, 342-50.

Demant, K. M., Vinberg, M., Kessing, L. V., & Miskowiak, K. W. (2015). Assessment of subjective and objective cognitive function in bipolar disorder: Correlations, predictors and the relation to psychosocial function. Psychiatry Research. 229, 565-571.

 

Individuals suffering from bipolar disorder face unexpected and sometimes perplexing symptoms daily. The disorder’s cause is still a mystery despite ongoing research. An imbalance in brain chemistry that affects mood regulation, specific brain characteristics, very stressful experiences, a history of abuse or trauma, and a family history of the disease or other mental disorders are some of the factors associated with bipolar disorder (Baldessarini et al., 2018). There are four basic types of bipolar disorder, each with specific features. The purpose of this paper is to assess the prevalence and neurobiology of bipolar I disorder, differentiate between bipolar I and bipolar II disorders, address specific groups, discuss FDA-approved treatment, and study medicines for the treatment of bipolar I disorder.

Prevalence and Neurobiology

A psychiatric disease known as bipolar disorder, often called manic-depressive disorder, is characterized by rapid changes between depressive and manic episodes. According to the National Institute on Mental Illness, bipolar illness often manifests in adolescence or the early stages of adulthood and affects 5.7 million persons in the United States (2.6% of the adult population) (Carvalho et al., 2020). The bulk of BD heritability is due to common, inconsequential polymorphisms. Many risk genes and genetic networks have been uncovered. Calcium signaling is important among inherited risk pathways and appears to have the most potential as a therapy. Digital technologies, as well as complicated mathematical and statistical studies, are being used to assess and interpret BD. These innovative methods of BD support and reflect a reframing of the disorder as one characterized by continuous instability in mood and neural circuitry.

 

Differences in Bipolar I and Bipolar II Disorder

The most prevalent bipolar types are 1 and 2. They also have a lot in common, particularly given that both can result in spells of hypomania and despair. There is, however, one significant distinction: mania is not a feature of bipolar disorder type 2; it is only a feature of bipolar disorder type 1 (Kato, 2019). This is significant since manic episodes can significantly impair your life and perhaps need hospitalization.

The DSM-5 and the ICD-11 kept the difference between BD-1 and BD-2. Both systems believe that BD-2 consists of recurrent major depressive episodes with mood and activity increases that are seldom more severe than hypomania and infrequently entail psychosis, especially during [hypo]manic stages (McIntyre et al., 2020). The DSM-5 does not, however, recognize the criteria for BD-2 that were provided for BD-1, including the polarity associated with the most recent events, the severity of events, the presence of mixed/psychotic features, or the extent of remission. Furthermore, it has been demonstrated that mood-stabilizing treatments can be effective in both BD-1 and BD-2. Although antidepressants commonly prove to be less effective and potentially destabilizing, antipsychotics and certain other antimanic treatments are generally not necessary for hypomania in BD-2.

Special Population and Considerations

Age and other physical characteristics may have an impact on how depression and bipolar illnesses manifest and are treated. The severity of mood symptoms in young children is less clear-cut than in adults, thus pharmaceutical treatment should be provided at modest dosages with thorough monitoring for adverse effects (Rhee et al., 2020). The diagnosis of depression in the perinatal population depends more on emotional than on physical symptoms because the latter may be a side effect of the gravid condition. In this demographic, treating mood disorders requires striking a fine balance between promptly alleviating negative symptoms and guarding against adverse drug reactions in children. For senior patients who mostly appear with chronic diseases or recent loss, it’s crucial to be sensitive to the possibility of depression. Due to age-retarded drug metabolism, mood problems may mimic physical complaints, and drugs should be taken carefully.

Clinicians may face particular legal and ethical issues while treating people with bipolar illnesses. For instance, due to their impulsivity, lack of understanding, and poor judgment, individuals with manic and mixed-mood states may be unable to offer informed consent or make wise decisions on their treatment (McIntyre et al., 2020). Moreover, some clinical manifestations, such as impatience, grandiosity, and delusional thinking, might endanger the therapeutic relationship. Moreover, due to the relapsing-remitting nature of the illness, patients may occasionally feel better and doubt the necessity of continuing therapy, thus putting the clinician’s treatment objectives at odds with the patient’s autonomy in decision-making.

According to statistics, those who have mental diseases experience worse social determinants of health. Some patients might not have jobs, have inadequate jobs, or have insecure jobs (Carvalho et al., 2020). The absence of employment usually results in a lack of money and, consequently, a lack of means to support oneself. Those with lesser incomes than those with higher wages have also been found to have poorer mental health. This might signal that the patient lacks access to running water, electricity, or money to buy food. Worse effects on mental health follow from this.

Pharmacological Treatment

Mood stabilizers and antipsychotics are a few of the drugs the FDA has approved for use in the treatment of the bipolar disorder (Baldessarini et al., 2018). One medicine should be begun at a time, with additional ones added as necessary, just like with any novel pharmacologic therapy. Use the smallest quantity possible if the patient reacts to one medication (Yalin & Young, 2020). It is also simple to determine which medications work the best or have the worst side effects. Risperidone 3 mg orally daily, Lamotrigine 200 mg orally daily, or Lithium 0.8 mg daily would be given as monotherapy, depending on the patient’s presentation (Rhee et al., 2020). Manic and mixed episodes are treated with risperidone. Lamotrigine or lithium is suggested for maintenance. The patient may also think about starting psychotherapy, particularly family-centered counseling.

The medicine used to treat bipolar illness, among other medications, can have dangerous side effects (Yalin & Young, 2020). Sleepiness, increased appetite, fatigue, coughing, urine incontinence, excessive saliva, diarrhea, ataxia, nausea, dizziness, tremor, acne, and dyspepsia are among the most prevalent side effects of risperidone (Baldessarini et al., 2018). Those with diabetes should take risperidone cautiously as it may result in hyperglycemia. Regular blood glucose checks are necessary. A month after the initial dosage and then every six months thereafter, CBC testing should be performed since risperidone has the potential to induce leukopenia, neutropenia, and agranulocytosis. Risperidone use may result in seizures, orthopnea, and a higher incidence of suicidal thoughts.

Lithium may cause tremors, seizures, lightheadedness, somnolence, agitation, arrhythmias, tachycardia, nausea, and many other serious adverse effects (Carvalho et al., 2020). Lithium toxicity can occur, thus it’s important to monitor levels often. Even extremely close to therapeutic levels, toxicity can still develop. Lithium use should be avoided by patients who are pregnant since it might affect the unborn child. Insufficient renal and cardiac performance is also a warning against using lithium (McIntyre et al., 2020). For patients, these labs ought to be additionally examined. A CBC and kidney function test should be examined after one month of therapy and then every 6 months after that

Proper Prescriptions

Conclusion

Although many individuals have a preponderance of one or the other, bipolar illnesses are characterized by bouts of mania and depression that may alternate. Sociocultural factors, alterations in brain neurotransmitter levels, and heredity may all be involved, even though the exact cause is unknown. A diagnosis is made by looking at the past. Treatment consists of psychotherapy and mood-stabilizing drugs. 

References

Baldessarini, R. J., Tondo, L., & Vázquez, G. H. (2018). Pharmacological treatment of adult bipolar disorder. Molecular Psychiatry24(2), 198–217. https://doi.org/10.1038/s41380-018-0044-2

Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar Disorder. New England Journal of Medicine383(1), 58–66. https://doi.org/10.1056/nejmra1906193

Kato, T. (2019). Current understanding of bipolar disorder: Toward integration of biological basis and treatment strategies. Psychiatry and Clinical Neurosciences73(9), 526–540. https://doi.org/10.1111/pcn.12852

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. The Lancet396(10265), 1841–1856. https://doi.org/10.1016/s0140-6736(20)31544-0

Rhee, T. G., Olfson, M., Nierenberg, A. A., & Wilkinson, S. T. (2020). 20-Year Trends in the Pharmacologic Treatment of Bipolar Disorder by Psychiatrists in Outpatient Care Settings. American Journal of Psychiatry, appi.ajp.2020.1. https://doi.org/10.1176/appi.ajp.2020.19091000

Yalin, N., & Young, A. H. (2020). Pharmacological Treatment of Bipolar Depression: What are the Current and Emerging Options? Neuropsychiatric Disease and TreatmentVolume 16, 1459–1472. https://doi.org/10.2147/ndt.s245166