Assessing And Treating Clients With Bipolar Disease

Bipolar Disease Assessing and Treating Clients with Bipolar Disorder

Bipolar Disease Assessing and Treating Clients with Bipolar Disorder

Write an examination of a case involving an Asian American woman with bipolar disorder, focusing on three clinical decisions about her medication. Consider factors impacting her pharmacokinetic and pharmacodynamic responses and address ethical considerations in her treatment.

Paper For Above instruction

Introduction

Bipolar disorder (BD) is a complex and often debilitating mental health condition characterized by significant mood fluctuations, including episodes of mania or hypomania and depressive states. Its management requires careful consideration of pharmacologic treatment, patient adherence, and cultural factors that influence health outcomes. This paper examines a case involving a 26-year-old Korean woman diagnosed with bipolar disorder, with focus on three critical medication decisions. These decisions are analyzed within the context of pharmacokinetic and pharmacodynamic factors and ethical considerations impacting her treatment plan.

Background on Bipolar Disorder

According to the American Psychiatric Association (2013), bipolar disorder affects approximately 4.4% of the U.S. population over a lifetime, with individuals experiencing episodes of mania and depression that can impair functioning and increase the risk of hospitalization, suicide, and comorbidities (Daigneault et al., 2015; Vieira, Manji, & Zarate, 2010). Early and accurate diagnosis paired with appropriate pharmacotherapy is essential for improving outcomes. Cultural factors and individual differences often impact medication adherence, especially among Asian populations, where beliefs about mental illness and medication can influence compliance and perceptions of treatment efficacy (Fancher et al., 2014).

Case Summary

The patient is a Korean woman of 26 years presenting with manic symptoms, including disorganized behavior, rapid speech, diminished sleep, and elevated energy levels. She was recently discharged from a psychiatric hospital after a manic episode and has been prescribed lithium but exhibits non-compliance. Her cultural background and previous non-adherence underscore the importance of culturally sensitive and evidence-based decision-making formulating her treatment plan.

Decision One: Initiate Lithium 300 mg BID

Chosen decision: Begin treatment with lithium 300 mg twice daily.

Rationale: Lithium remains the gold standard mood stabilizer for bipolar disorder, especially effective in reducing manic episodes and preventing suicidal behavior (Stahl, 2013; Vieira, Manji, & Zarate, 2010). Despite being an older drug, lithium's efficacy in acute bipolar episodes and maintenance therapy is well established, with a risk-benefit profile supported by numerous clinical trials (Vieta & Moreno, 2008; Stahl, 2014b).

In this patient, lithium is the initial recommendation due to her recent hospitalization for mania, and her previous non-compliance emphasizes the need for establishing a clear therapeutic plan and patient education. Avoiding concomitant use of antipsychotics like risperdal or quetiapine initially allows for assessment of lithium's effectiveness alone and prevents polypharmacy complications. The target is to reach therapeutic serum levels range of 0.6-1.2 mEq/L, with an onset of action typically 1-3 weeks (Gitlin, 2016).

Goals: Achieve rapid mood stabilization and prevent further manic episodes, while monitoring adherence and side effects. Patient education on the importance of medication compliance is vital.

Expected outcomes: Improvement in symptoms within four weeks, with adherence being critical to reaching full remission.

Outcome After Four Weeks

The patient reports inconsistent medication intake, citing forgetfulness or feeling unwell when taking lithium. Her mood remains manic, with her non-compliance thus far hindering clinical response, confirming the importance of addressing adherence before evaluating lithium's efficacy fully.

Decision Two: Assess Reasons for Non-Compliance

Chosen decision: Conduct comprehensive assessment of her reasons for medication non-adherence.

Rationale: Non-compliance is common in bipolar patients, often influenced by side effects, cultural beliefs, stigma, and perceptions of chronic treatment (Peselow et al., 2016; Fancher et al., 2014). In Asian cultures, including Korean, beliefs about mental illness and medication may involve stigma or concerns about traditional health concepts like yin-yang balance, affecting attitudes towards pharmacotherapy (Chen et al., 2002).

Understanding her specific reasons—whether side effects like nausea and diarrhea, cultural stigma, or beliefs about medication—allows for tailored interventions, such as psychoeducation, involving family, or peer support resources. It is also essential to assess whether her symptoms, such as gastrointestinal complaints, result from side effects or the mania itself (Gitlin, 2016).

Goals: Enhance adherence through patient-centered education and cultural sensitivity, aiming for at least a 40% reduction in symptoms or full remission in four weeks.

Outcome and Reflection

The patient reports attempting medication but experiencing nausea and diarrhea, prompting her to stop treatment temporarily. These side effects are common with lithium, especially at higher serum levels (>0.8 mEq/L), and often resolve with dose adjustments or formulation changes (Gitlin, 2016). Addressing her concerns through education about side effects and gradual dose escalation could improve compliance.

Decision Three: Switch to Sustained-Release Lithium

Chosen decision: Transition from immediate-release lithium to sustained-release (SR) formulation while maintaining the same dosage and frequency.

Rationale: Gastrointestinal side effects like nausea and diarrhea are frequently associated with lithium absorption issues and can be mitigated by using sustained-release formulations (Gitlin, 2016). Switching to SR can reduce peak serum levels and minimize side effects, potentially improving adherence.

This approach also aligns with the goal of maintaining mood stability while addressing tolerability issues. If side effects persist, considering a switch to alternative mood stabilizers like valproate (Depakote) could be contemplated after successful trial of the SR lithium. Both depot formulations and alternative agents require management plans considering pharmacokinetics and individual responses.

Given her history, it’s prudent to optimize lithium therapy before considering augmentation strategies like adding anticonvulsants or antipsychotics (Stahl & Ball, 2009b). Incorporating routine monitoring of serum lithium levels, kidney function, and thyroid function remains essential.

Outcome and Reflection

The patient reports reduced gastrointestinal discomfort after switching to SR lithium, and her manic symptoms show slight improvement. Continued education and close monitoring are planned to ensure therapeutic levels and adherence.

Ethical Considerations in Treatment Planning

Informed consent is imperative when initiating psychotropic medications, with thorough discussions about potential benefits, side effects, and the importance of adherence (Vitiello, 2013). Recognizing cultural beliefs about health and medication is vital, especially considering her Asian background, where traditional views may influence perceptions of mental illness and pharmacotherapy (Chen et al., 2002).

Healthcare providers must foster culturally sensitive communication, ensuring the patient feels respected and empowered in decision-making. Avoiding discrimination and bias enhances therapeutic rapport and supports adherence. The ethical obligation extends to confidentiality and shared decision-making, respecting her autonomy and cultural identity.

Conclusion

Bipolar disorder management requires a comprehensive, culturally sensitive approach that addresses pharmacologic, psychosocial, and ethical factors. Initiating lithium therapy, evaluating adherence, addressing side effects with formulation changes, and engaging the patient in her treatment decisions are essential steps. Recognizing cultural influences and fostering open communication improves adherence and outcomes, ultimately enhancing her quality of life. Continued monitoring and support are vital to long-term stability and recovery.

References

  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.).
  • Chen, J., Barron, C., Lin, K., & Chung, H. (2002). Prescribing medication for Asians with mental disorders. The Western Journal of Medicine, 176(4).
  • Daigneault, A., Duclos, C., Saury, S., Paquet, J., Dumont, D., & Beaulieu, S. (2015). Research report: Diagnosis of bipolar disorder in primary and secondary care: What have we learned over a 10-year period? Journal of Affective Disorders. https://doi.org/10.1016/j.jad.2014.10.057
  • Gitlin, M. (2016). Lithium side effects and toxicity: Prevalence and management strategies. International Journal of Bipolar Disorders, 4(1), 1.
  • Peselow, D. E., Long, R., Steiner, J. A., Pizano, R. D., Naghdechi, L., Akladios, N., & IsHak, W. W. (2016). Factors Affecting Long-term Lithium Compliance in Bipolar Patients. International Neuropsychiatric Disease Journal, 7(4), 1–8. https://doi.org/10.9734/INDJ/2016/26987
  • Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.).
  • Stahl, S. M., & Ball, S. (2009b). Stahl’s illustrated mood stabilizers. Cambridge University Press.
  • Vieta, E., & Moreno, D. (2008). Pharmacological treatment of bipolar disorder. World Psychiatry, 7(2), 108–115.
  • Vieira, M. R., Manji, K. H., & Zarate, A. C. (2010). The role of lithium in the treatment of bipolar disorder: convergent evidence for neurotrophic effects as a unifying hypothesis. Neuropsychopharmacology, 35(2), 189–206. https://doi.org/10.1038/npp.2009.70

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