Assignment: Assessing and Treating Patients With Bipolar Disorder

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Sample Answer for Assignment: Assessing and Treating Patients With Bipolar Disorder

Bipolar is a mental health disorder characterized by extreme mood changes that alter the behavior and normal function of a patient. The mood fluctuation is on extreme ends and may take days to weeks before change, accompanied by difficulties in performing daily tasks and social interactions. The mood changes are mania or hypomania; mania is a happy or irritable mood, and hypomania is a sad mood or depression (Ashok, et al, 2017). These symptoms usually occur alternatively after weeks associated with a period of the normal state. There are types of bipolar which include bipolar 1, bipolar 2, and cyclothymic bipolar. Bipolar 1 has alternating episodes of mania, hypomania, and neutral mood. Bipolar two is associated with a major depressive mood disorder and hypomania state. Cyclothymic has frequent mood swings.

Select a family to complete a family health assessment. (The family cannot be your own.)

Before interviewing the family, develop three open-ended, family-focused questions for each of the following health patterns:

1. Values, Health Perception
2. Nutrition
3. Sleep/Rest
4. Elimination
5. Activity/Exercise
6. Cognitive
7. Sensory-Perception
8. Self-Perception
9. Role Relationship
10. Sexuality
11. Coping

The signs and symptoms of the manic episode are diminished need for sleep, increased and faster speech, increased activity, increased risky behavior, distractibility, and uncontrollable racing thoughts. Hypomania presents with intense sadness or despair, loss of interest, fatigue, difficulties in concentration, frequent thoughts, and suicidal ideation. Common causes of bipolar are genetic predisposition, family history of bipolar, stressful environment, and substance abuse. The patient in the case study is a 26years old female with bipolar. According to the American psychiatric association, she meets the DSM-5 criteria through her symptoms of the diminished need to sleep, excessive talking, increased distractibility, she is in a happy mood, rapid or pressured speech, and increased energy. She scores 22 on the young scale mania. The interventions for bipolar are the use of antipsychotics and psychotherapy. Antipsychotics relieve the symptoms of the patient while psychotherapy enables the patient to change their thinking and behavior to improve cognitive functions and quality of life. The essay describes the three decisions made in treating the patient including the impact of ethical principles.

Decision One

Which decision did you select?

Begin Seroquel XR 300mg orally at HS

Why did you select this decision?

Seroquel is a second-generation antipsychotic with a high affinity for dopamine and serotonin receptors. Its mechanism of action is by antagonizing these receptors and binding them to the norepinephrine transporter (Hamed, et al, 2017). This helps in improving memory, mood, aggression, and the muscle movement that plays a vital role in the brain for pleasure. Seroquel is the best drug for the patient because it is FDA approved for acute manic episodes and bipolar. Moreover, the American psychiatric association proves it is efficient in treating bipolar in its studies.

 

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Why did you not select the other two options provided in the exercise?

Risperdal is a second-generation antipsychotic for treating schizophrenia and maintenance treatment in bipolar. Its mechanism of action is by decreasing the serotonin and dopamine activity in the brain thus reducing the mood symptoms, agitation, and symptoms of schizophrenia. it has 94% bioavailability and is protein-bound with an active metabolite (Schoretsanitis, et al, 2017). It has a plasma half-life of three to twenty hours. However, I did not select this drug for the patient because it has undesirable effects like drooling, nausea, weight gain, nausea, fatigue, and tiredness. Lithium is a commonly prescribed drug for prophylaxis and treatment of manic episodes. Its mechanism of action is by modulating the neurotransmitters and inhibiting the excitatory neurotransmitters like dopamine and glutamate. It has neuro-proliferative and neuroprotective effects on the brain that helps in regulating mood. It is FDA approved for mood disorders and bipolar. However, I did not select the drug because the patient has not been compliant due to its unpleasant effects.

What were you hoping to achieve by making this decision?

The expectations of starting the patient on Seroquel XR 300mg are to relieve the symptoms and reduce the score of the young scale mania. The expected side effects are dry mouth, drowsiness, constipation, and weight gain.

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Communication is the exchange of information from the sender to the recipient to understand and interpret and eventually respond. Communicating with a patient with bipolar can be hectic because they talk fast and have racing thoughts. Therefore, the nurse incorporates the principle of justice when assessing the patient. Justice is providing equal and quality services to all despite their underlying issues. Justice enables the nurse to communicate effectively with the patient.

Decision Two

Which decision did you select?

Discontinue Seroquel and begin Geodon 40mg

Why did you select this decision?

Geodon is a second-generation antipsychotic that inhibits the reuptake of norepinephrine and serotonin, blocking the alpha and antihistaminic activities. These decrease hallucinations, improve clear and positive thinking, reduces agitation, and improve activities of daily living (Findling et al, 2022). It has 60% bioavailability and is 99% protein bound. The drug is initiated at a low dose and increased gradually within two weeks to reduce the side effects. I chose this drug because it is effective in treating bipolar and has no side effects on the patient.

Why did you not select the other two options provided in the exercise?

Increasing the dose of Seroquel to 400mg to improve the patient’s symptoms is not a good option because she previously complained of weight gain and constipation. Increasing the dose worsens the drug’s side effects. The use of dietary measures to control weight gain and obesity is ineffective because the drug has the effect of muscarinic cholinergic antagonism that induces gastrointestinal hypomotility and hence constipation and weight gain. Decreasing the dosage will not have positive effects on the patient’s symptoms and will still exhibit unpleasant side effects.

What were you hoping to achieve by making this decision?

The expectation of switching the patient’s treatment to Geodon is to improve the symptoms, decrease the young scale mania, and relieve constipation and weight gain.

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

The nurse considers the principle of autonomy in this decision point. Autonomy is respect for a person’s decisions and preferences (Asl, et al, 2022). The patient is uncomfortable with Seroquel because it causes constipation despite the improvement of the symptoms. The nurse, therefore, changes the treatment to ensure patient satisfaction.

Decision Three

Which decision did you select?

Increase Geodon to 60 mg orally BID with a 500-calorie meal

Why did you select this decision?

Geodon was effective during the initial stage of treatment. Increasing from 40mg to 60mg is effective in improving the symptoms. Additionally, the recommended dose is 60mg to 80mg with a gradual increment every two weeks. I selected this choice because it will hasten the improvement of the symptoms.

Why did you not select the other two options provided in the exercise?

I did not continue with the same drug dosage because the American psychiatric association recommends 60mg to 80mg to relieve the symptoms. I did not augment with lithium because it has unpleasant side effects. Additionally, augmentation is recommendable in the incidence of depression and hypomania. There is a contraindication for lithium augmentation with antipsychotics like olanzapine, haloperidol, and Geodon.

What were you hoping to achieve by making this decision?

The expectation for increasing the dosage is to hasten the improvement of the symptoms.

Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

The nurse uses the principle of beneficence and non-maleficence. Beneficence is doing what is right and non-maleficence is protecting the patient from harm. The nurse carefully analyzes the best treatment for the patient to improve the symptoms and prevent adverse effects.

Conclusion

Bipolar is a mood fluctuation disorder on the extreme ends and may take days to weeks before change, accompanied by difficulties in performing daily tasks and social interactions. The signs and symptoms of the manic episode are diminished need for sleep, increased and faster speech, increased activity, increased risky behavior, distractibility, and uncontrollable racing thoughts. Hypomania presents with intense sadness or despair, loss of interest, fatigue, difficulties in concentration, frequent thoughts, and suicidal ideation. Seroquel is a second-generation antipsychotic that antagonizes these receptors to improve memory, mood, aggression, and muscle movement that plays a vital role in the brain for pleasure. However, it causes weight gain and constipation. Geodon is an effective drug for treating bipolar because it is well tolerated. Ethical principles in nursing improve assessment and communication techniques. They are beneficence, autonomy, consent, justice, and non-maleficence.

References

Ashok, A., Marques, T., Jauhar, S. et al. The dopamine hypothesis of bipolar affective disorder: the state of the art and implications for treatment. Mol Psychiatry 22, 666–679 (2017). https://doi.org/10.1038/mp.2017.16

Asl, R. G., Taghinejad, R., Parizad, N., & Jasemi, M. (2022). The relationship between professional autonomy and job stress among intensive care unit nurses: A descriptive correlational study. Iranian Journal of Nursing and Midwifery Research, 27(2), 119. https://doi.org/10.4103%2Fijnmr.ijnmr_375_20

Findling, R. L., Atkinson, S., Bachinsky, M., Raiter, Y., Abreu, P., Ianos, C., & Chappell, P. (2022). Efficacy, Safety, and Tolerability of Flexibly Dosed Ziprasidone in Children and Adolescents with Mania in Bipolar I Disorder: A Randomized Placebo-Controlled Replication Study. Journal of Child and Adolescent Psychopharmacology, 32(3), 143-152. https://doi.org/10.1089/cap.2021.0121

Hamed, R., AlJanabi, R., Sunoqrot, S., & Abbas, A. (2017). The effect of pH, buffer capacity and ionic strength on quetiapine fumarate release from matrix tablets prepared using two different polymeric blends. Drug Development and Industrial Pharmacy, 43(8), 1330-1342. https://doi.org/10.1080/03639045.2017.1318897

Schoretsanitis, G., Spina, E., Hiemke, C., & de Leon, J. (2017). A systematic review and combined analysis of therapeutic drug monitoring studies for long-acting risperidone. Expert review of clinical pharmacology, 10(9), 965-981.

https://doi.org/10.1080/17512433.2017.1345623

Sample Answer 2 for Assignment: Assessing and Treating Patients With Bipolar Disorder

In the provided case study, the 8-year-old Caucasian female patient came to the clinic accompanied by her parents for psychiatric evaluation. The patient’s teacher suggested that the patient might be having attention deficit hyperactivity disorder (ADHD). Their family physician also suggested that the patient should see a psychiatrist for further evaluation of her mental disorder. The patient parents came with a completed Conner’s Teacher Rating Scale-Revised screening tool, which revealed that the patient is easily distracted at school, and with a short attention span. The patient also displayed poor arithmetic, spelling, and reading skills in addition to being inattentive and forgetful most of the time. Her teacher claims that the patient even failing to complete her homework will lack interest in school activities. She also fails to follow instructions at times. Despite the patient’s parents being in denial that their daughter has ADHD, mental status examination results proved otherwise together with the Conner’s Teacher Rating Scale-Revised screening tool completed by the teacher, supporting the diagnosis of attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.

Developing a treatment plan for pediatric patients with mental disorders is quite challenging given the safety issues associated with this age group. However, appropriate prescriptive practice will involve considering patient-specific factors that might affect the pharmacokinetic and pharmacodynamic processes. Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. The purpose of this discussion is thus to demonstrate the appropriate decision-making process in the selection of the most appropriate intervention in the treatment of the 8-year-old attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.

Decision Point One

Selected Decision and Rationale

From the listed options, initiating Ritalin (methylphenidate) 10mg chewable tablets taken every morning was decided on as the initial intervention. Ritalin is recommended by most clinical guidelines as the first-line medication for the management of ADHD among both children and adults (Rodrigues et al., 2021). Despite the psychostimulant not being approved by the FDA, it has displayed great effectiveness in the management of ADHD with a desirable safety profile in most children from ages 6 to 15 years (American Psychiatric Association, 2013; Castells et al., 2021)). It has demonstrated a substantial impact in managing ADHD symptoms such as inattention, forgetfulness, impulsivity, diminished interest, and hyperactivity among children (Hodgkins et al., 2012). The chewable formulation is considered the best option for children with sweeteners to mask the bitter taste of the drug (Breaux et al., 2022). Consequently, the drug has a short onset of action of between 1 to 2 hours with a long duration of action of between 7.5 to 10.5 hours after oral administration (Mechler et al., 2021). This helps in the management of the patient’s symptoms all day long (Coghill et al., 2021).

Bupropion is associated with increased risks of seizures among children below the age of 10 years, hence not an appropriate decision (Coghill et al., 2021). Intuniv on the other hand is associated with cardiovascular side effects, hence should only be considered in case there is no other safer and more effective drug for use in the pediatric population (Rodrigues et al., 2021).

Expected Outcome

The patient will experience improved symptoms of ADHD in the next four weeks (Coghill et al., 2021). She should be able to improve her spelling, arithmetic, and language skills, in addition to being more attentive and able to concentrate on school work (Hodgkins et al., 2012). Her school performance will improve significantly within this period.

Ethical Considerations

The patient is 8 years of age, which gives the parents legal responsibility of making decisions concerning the health of their child (American Psychiatric Association, 2013). As such, the PMHNP must educate them adequately regarding the patient’s diagnosis and potential treatment options, to promote sound decision-making in promoting the health of their child (Rodrigues et al., 2021).

Decision Point Two

Selected Decision and Rationale

The second decision was to change the treatment regimen to long-acting Ritalin 20mg administered orally in the morning. Based on the treatment outcome, Ritalin displayed potential effectiveness given that the patient’s ADHD symptoms improved evidenced by her improved school performance (Breaux et al., 2022). However, since the medication was not able to manage the patient’s symptoms throughout the entire day, it was necessary to introduce a long-acting formulation to prolong the duration of action of the drug (American Psychiatric Association, 2013). Studies show that long-acting Ritalin lasts for between 8 to 12 hours hence, helps in managing the patient’s symptoms throughout the day (Castells et al., 2021). It is also administered once daily which is more convenient and much easier. The patient also reported a side effect of elevated pulse, which is a common self-limiting side effect of Ritalin that is expected to diminish with time (Coghill et al., 2021).

Continuing with the same drug at the same dosage was inappropriate as the patient would still exhibit ADHD symptoms later in the day, once the drug wears off from the body system (Mechler et al., 2021). Replacing Ritalin with Adderall is also inappropriate as Adderall is associated with increased incidences of suicidal events when used among children (Hodgkins et al., 2012).

Expected Outcome

 The long-acting formulation is expected to manage the patient’s symptoms all day long within the following four weeks (Breaux et al., 2022). The patient’s school performance will improve even further. The side effect of elevated heart rate will resolve completely within this time (Coghill et al., 2021).

Ethical Considerations

In making this decision, the PMHNP had to consider several ethical principles including justice, beneficence, nonmaleficence, and respect for the patient’s autonomy (Breaux et al., 2022). The patient was quite comfortable with how the drug was working, but only concerned with the side effect, and effectiveness of the medication later in the day (Rodrigues et al., 2021). As such, it was necessary to respect the patient and display clinical judgment in making decisions that will promote the patient’s mental health.

Decision Point Three

Selected Decision and Rationale

Maintaining the patient on the current medication and reevaluating after four weeks, seemed to be the most appropriate decision for the third intervention. The patient reported great effectiveness and tolerance to the medication, with resolved side effects of an elevated pulse (Mechler et al., 2021). Previous evidence shows that once the optimal dose of Ritalin has been attained, it can take between 8 to 12 weeks to completely manage the patient’s symptoms of ADHD (American Psychiatric Association, 2013; Castells et al., 2021). Consequently, at safe doses, long-term use of the drug has been associated with limited possibilities of side effects, hence the need to reevaluate the patient within 4 weeks (Hodgkins et al., 2012). Studies also show that long-term use of Ritalin normally reduces the risks of side effects as the patient will display further tolerance to the drug, enhancing its safety profile (Breaux et al., 2022).

Increasing the dose of Ritalin to 30mg was not necessary at this point, as studies suggest that low effective doses are safer to use to promote positive outcomes, with reduced risks of side effects (Mechler et al., 2021). Consequently, obtaining EKG at this point was not necessary given that the patient’s pulse had already resolved back to normal for her age, with a recording of 92 during the current visit (Rodrigues et al., 2021).

Expected Outcome

With great compliance to the treatment regimen, the patient will report even further management of the ADHD symptoms over the following two weeks (Breaux et al., 2022). Her academic performance is also expected to improve (American Psychiatric Association, 2013). No side effects are expected.

Ethical Considerations

The nurse’s main objective is to promote the health of the patient and not harm. At this point, the patient was satisfied with the treatment outcome (Hodgkins et al., 2012). It was thus necessary to respect the patient’s autonomy and maintain the dose for further evaluation of the treatment outcome (Mechler et al., 2021).

Conclusion

The 8-year-old patient in the case study presented with symptoms of ADHD. Formulating a treatment plan for the patient involved consideration of certain patient-specific factors which affect her pharmacokinetic and pharmacodynamic processes (American Psychiatric Association, 2013). Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. Based on these factors, the first decision was to initiate a 10mg Ritalin chewable table once daily as recommended by most clinical guidelines given its effectiveness in the management of ADHD and safety for pediatric use (Coghill et al., 2021). Intuniv and bupropion were neglected because of their increased risks of side effects among children as reported by most studies (Mechler et al., 2021). After 4 weeks, the patient came back to the clinic reporting improved symptoms but with side effects of increased pulse rate. The second decision was thus to change the treatment regimen to long-acting Ritalin 20mg once daily in the morning, to prolong the duration of action of the medication throughout the day (Castells et al., 2021). Maintaining the dose would still lead to ineffectiveness, while Adderall display increased risks of suicidality hence neglected (Breaux et al., 2022).

The patient reported further improvement in ADHD symptoms all day long, with resolved side effects of elevated pulse, which led to the final decision of maintaining the treatment regimen and reevaluating the patient after 4 weeks. Obtaining EKG and increasing the dose of Ritalin was not necessarily due to safety issues (Hodgkins et al., 2012). Finally, the PMHNP encountered several ethical considerations in each decision process with the observation of ethical principles such as justice, respect for patient autonomy, not harm, and beneficence (Rodrigues et al., 2021).

 

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Breaux, R., Dunn, N. C., Swanson, C. S., Larkin, E., Waxmonsky, J., & Baweja, M. D. (2022). A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD. Frontiers in Psychiatry, 151. https://doi.org/10.3389/fpsyt.2022.794044

Castells, X., Ramon, M., Cunill, R., Olivé, C., & Serrano, D. (2021). Relationship between treatment duration and efficacy of pharmacological treatment for ADHD: a meta-analysis and meta-regression of 87 randomized controlled clinical trials. Journal of attention disorders, 25(10), 1352-1361. https://doi.org/10.1177/1087054720903372

Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., … & Simonoff, E. (2021). The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). European Child & Adolescent Psychiatry, 1-25. https://doi.org/10.1007/s00787-021-01871-x

Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. https://doi.org/10.2165/11599630-000000000-00000

Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2021). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940

Rodrigues, R., Lai, M. C., Beswick, A., Gorman, D. A., Anagnostou, E., Szatmari, P., … & Ameis, S. H. (2021). Practitioner Review: Pharmacological treatment of attention‐deficit/hyperactivity disorder symptoms in children and youth with autism spectrum disorder: a systematic review and meta‐analysis. Journal of Child Psychology and Psychiatry, 62(6), 680-700. https://doi.org/10.1111/jcpp.13305

Sample Answer 3 for Assignment: Assessing and Treating Patients With Bipolar Disorder

Bipolar disorder is one of the mental health problems with considerable impacts on the global population. Bipolar disorder patients experience distressing symptoms that affect their health, well-being, and functioning. Healthcare providers must adopt treatment interventions that address the prioritized health needs of their patients and promote safety, quality, and efficiency outcomes. Evidence-based data inform the care interventions for patients with bipolar disorder. Therefore, this essay examines the prevalence and neurobiology of bipolar I disorder, its differences from bipolar II disorder, special considerations, clinical practice guidelines, side effects, and monitoring patients prescribed different treatments.

Prevalence and Neurobiology of Bipolar I Disorder

Bipolar I disorder is the selected disorder for analysis in this paper. Bipolar I disorder is one of the subtypes of bipolar disorder. Patients who are affected by bipolar I disorder experience episodes of neuropsychological deficits, severe mood disturbances, functioning impairment, and physiological changes. Data obtained from epidemiological studies reveal that the lifetime prevalence of bipolar I disorder is about 1% in the entire population. The overall lifetime prevalence of an individual being affected by bipolar I disorder is 0.6% and 2.4% for bipolar spectrum disorders. When compared to other bipolar spectrum disorders, bipolar I disorder has the lowest prevalence of all (McIntyre et al., 2020). However, the United States of America has a 1% higher prevalence rate of bipolar disorder when compared to other developed countries.

Bipolar I disorder has a neurobiological basis. Studies agree that an interaction between genetic factors and environmental factors precipitate bipolar I disorder. Environmental factors such as traumatic events and stress trigger the development of bipolar I disorder in individuals with a genetic predisposition. Besides the interaction, dysfunction in different intracellular cascades in the brain also contributes to bipolar disorder. This includes an imbalance in the different neurotransmitters that regulate emotions in the brain (Scaini et al., 2020). Mitochondrial dysfunction and oxidative stress also increase the risk of bipolar I disorder. The dysfunction and stress cause considerable impairment in neuronal plasticity, hence, the damage and loss of brain tissue. Studies have also revealed that patients with bipolar disorders have altered peripheral biomarkers related to inflammation, neurotrophins, hormones, and oxidative stress (Young & Juruena, 2021). The alteration explains the physiological, emotional, immunological, and functional impairments seen in patients with bipolar disorders.

Differences Between Bipolar I and Bipolar II Disorders

Bipolar I disorder differs from bipolar II disorder. According to DSM-5, a diagnosis of bipolar I disorder is reached if a patient presents to the hospital with symptoms of a manic episode. The symptoms include abnormally and persistently elevated irritable or expansive mood and abnormal engagement in goal-directed activity with high energy levels lasting at least a week. The symptoms persist most days almost every day (McIntyre et al., 2020). Patients have symptoms such as inflated self-esteem, insomnia, talkativeness, flight of ideas, easy distractibility, and increased involvement in harmful activities during this period.

Patients with bipolar II disorder present to the hospital with symptoms that meet at least a major depressive and hypomanic episode. They also do not have a history of manic episodes. Hypomania and depressive episodes cannot be attributed to other causes such as schizophrenia, schizoaffective disorder, or delusional disorder among other mental health problems. The symptoms of hypomania episodes are similar to those of mania in bipolar I disorder. However, a difference lies in their duration. In bipolar II disorder, the hypomania symptoms should last at least four consecutive days, most of the days, and almost every day (Angst et al., 2019). In both disorders, the symptoms should not be attributed to other causes such as substance abuse, medication use, or other mental health problems.

Special Populations and Special Considerations

Children, adolescents, pregnant and post-partum mothers, and older adults are special populations that must be treated with care when diagnosed with bipolar I disorder. Diagnosis of bipolar I disorder in children and adolescents is difficult because of the existence of comorbidities. Often, they present to the hospital with mixed or atypical features of bipolar spectrum disorders such as irritability, rapid cycling of symptoms, and labile mood. They might also have other coexisting problems such as substance abuse, which makes it challenging to diagnose bipolar affective spectrum disorders. Adolescents might also present with symptoms such as paranoia, bizarre behaviors, and incongruent mood, which makes diagnosis difficult. Therefore, practitioners should emphasize the context of symptom occurrence during screening and use the DSM-5 diagnostic tool to develop accurate diagnoses (Gautam et al., 2019). In addition, tools such as the Kiddie Schedule for Affective Disorders and Schizophrenia should be used to overcome difficulties in diagnosis.

The typical onset of bipolar spectrum disorders is in the early twenties. This means that its occurrence overlaps with pregnancy and childbirth periods. The risk of bipolar I disorder relapse among pregnant and post-partum women is high because of hormonal factors, medication discontinuation, and distressing experiences such as sleep deprivation during these periods. Treatment of bipolar spectrum disorders during pregnancy and the post-partum period is also associated with considerable ethical and clinical issues (Singh & Deep, 2022). Healthcare providers must weigh the risks and benefits of bipolar treatments to the unborn fetus and relapse of bipolar I disorder.

A diagnosis of bipolar I disorder among older adults is challenging for most practitioners. This is because of the underestimated incidence of bipolar I disorder in this population and the limited applicability of DSM5 and ICD10 to this population. Practitioners might also misjudge older adults for other conditions since physical illnesses produce symptoms seen in most mental health problems. There is also an increased risk of harm from pharmacological treatments due to polypharmacy among the elderly population (Ljubic et al., 2021). Physiological changes with aging such as decreased drug absorption, metabolism, and elimination also affect bipolar I disorder treatment in older adults. For instance, older adults have diminished drug-binding ability to plasma due to low albumin, which increases the risk of adverse drug reactions among them. Therefore, practitioners must weigh the benefits and risks of the different treatments to ensure safety and quality outcomes in the treatment process.

Some of the ethical considerations that inform nurse practitioners’ decisions in treating bipolar I disorder in the above vulnerable populations include the promotion of patient autonomy, beneficence, non-maleficence, and data integrity. For example, weighing the risks of pharmacological treatments for bipolar I disorder on the developing fetus in pregnant women aims at ensuring safety, hence, non-maleficence. Practitioners must also provide care within their areas of specialization and by state laws to avoid legal issues such as malpractice in the care of patients with bipolar I disorder. Cultural practices affect the uptake and utilization of different treatments for bipolar I disorder. For example, practices during pregnancy rooted in culture might result in poor treatment adherence among mothers with bipolar I disorder (Singh & Deep, 2022). Practitioners should strive to address social determinants of health such as costs, access, and availability of mental health services to improve health outcomes for vulnerable populations.

FDA and/or Clinical Practice Guidelines

A range of drug options is available for treating bipolar I disorder. They include mood stabilizers, antidepressants, antipsychotics, and somatic treatments. Mood stabilizers include lithium, divalproex, lamotrigine, topiramate, and gabapentin. Antidepressants include tricyclic antidepressants, serotonin and norepinephrine reuptake inhibitors, selective serotonin reuptake inhibitors, mirtazapine, and bupropion. Antipsychotics include first and second generation antipsychotics (Rhee et al., 2020). Clinical practice guidelines recommend the use of monotherapy or a combination of lithium, lamotrigine, quetiapine, olanzapine-fluoxetine combination, valproate+lithium, valpropate+antidepressant in the acute stage. It also recommends combination therapy comprising a mood stabilizer/antipsychotics+antidepressants for acute bipolar I disorder. Maintenance therapy is achievable with olanzapine, risperidone, and valproate or lithium, lamotrigine, and antipsychotics with a focus on dose optimization (Fountoulakis et al., 2020). The FDA has approved olanzapine plus fluoxetine combination, quetiapine, cariprazine, lurasidone, and lumateperone for treating bipolar spectrum disorders.

Side Effects, FDA Warnings, and Monitoring

Patients prescribed the above treatments should be monitored for side and adverse effects. Antidepressants are associated with side effects that include insomnia, decreased libido, and weight gain. Patients should be monitored for adverse effects such as suicidal thoughts and serotonin syndrome. Antipsychotics are associated with side effects such as dizziness, dry mouth, dyskinesia, and sedation. Patients should be monitored for adverse reactions such as heart rhythm changes through scheduled electrocardiography tests. Patients who have been prescribed lithium should be monitored for nausea, diarrhea, excessive urination, and vomiting since they predispose patients to lithium toxicity (Hedya et al., 2023).

Examples of Proper Prescription

Name:

Age: 55 years

Diagnosis: Bipolar I disorder

Treatment

Oral fluoxetine 20 mg once daily 1/12

Refills: None

Date:

Name and signature

Name:

Age: 25 years

Diagnosis: Bipolar I disorder

Treatment

Oral lithium 600 mg twice daily 2/52

Refills: None

Date:

Name and signature

Name:

Age: 34 years

Diagnosis: Bipolar I disorder

Treatment

Oral lamotrigine 200 mg once daily 1/52

Refills: None

Date:

Name and signature

Conclusion

In summary, this paper has examined the prevalence and neurobiology of bipolar I disorder. It is evident from the analysis that bipolar I disorder differs from bipolar II disorder. Practitioners should be aware of the special considerations for vulnerable populations. Different medications can be used in acute and maintenance treatment for bipolar I disorder. Patients should be monitored for side and adverse effects of the different treatments.

 

 

References

Angst, J., Rössler, W., Ajdacic-Gross, V., Angst, F., Wittchen, H. U., Lieb, R., Beesdo-Baum, K., Asselmann, E., Merikangas, K. R., Cui, L., Andrade, L. H., Viana, M. C., Lamers, F., Penninx, B. W., de Azevedo Cardoso, T., Jansen, K., Dias de Mattos Souza, L., Azevedo da Silva, R., Kapczinski, F., … Vandeleur, C. L. (2019). Differences between unipolar mania and bipolar-I disorder: Evidence from nine epidemiological studies. Bipolar Disorders, 21(5), 437–448. https://doi.org/10.1111/bdi.12732

Fountoulakis, K. N., Yatham, L. N., Grunze, H., Vieta, E., Young, A. H., Blier, P., Tohen, M., Kasper, S., & Moeller, H. J. (2020). The CINP Guidelines on the Definition and Evidence-Based Interventions for Treatment-Resistant Bipolar Disorder. International Journal of Neuropsychopharmacology, 23(4), 230–256. https://doi.org/10.1093/ijnp/pyz064

Gautam, S., Jain, A., Gautam, M., Gautam, A., & Jagawat, T. (2019). Clinical Practice Guidelines for Bipolar Affective Disorder (BPAD) in Children and Adolescents. Indian Journal of Psychiatry, 61(Suppl 2), 294–305. https://doi.org/10.4103/psychiatry.IndianJPsychiatry_570_18

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