Bipolar Descendants And Ancestry Background Information

Bipolar Therdescentancestrybackground Informationthe Client Is A 26 Y

Bipolar Therdescentancestrybackground Informationthe Client Is A 26 Y

Bipolar TherDescent/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 weighs 110 lbs. and is 5’5”.

Subjective: The patient reports experiencing a “fantastic” mood. She states she sleeps about 5 hours per night, adding “I hate sleep, it’s no fun.” Review of her hospital records shows she has been medically evaluated and reported to be in overall good health, with lab studies within normal limits. She underwent genetic testing (GeneSight), which revealed a positive CYP2D6*10 allele. She confesses that she stopped taking her lithium (prescribed in the hospital) two weeks ago.

Mental Status Exam: The patient is alert and oriented to person, place, time, and event. She is dressed oddly, wearing what appears to be an evening gown. Speech is rapid, pressured, tangential. Self-reported mood is euthymic. Her affect is broad. She denies visual or auditory hallucinations, and no overt delusions or paranoia are observable. Judgment appears grossly intact, but insight is impaired. She denies suicidal or homicidal ideation. Her 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).

Paper For Above instruction

The case of this 26-year-old Korean woman presenting with bipolar I disorder illustrates the complexities involved in managing bipolar symptoms, especially considering genetic factors affecting medication metabolism and her cultural background. As a psychiatric nurse practitioner (PMHNP), the primary goal is to stabilize her mood while considering her individual pharmacogenetics, medication adherence challenges, and cultural context. The multi-phased decision-making process detailed herein reflects evidence-based interventions aimed at optimizing her treatment plan, promoting adherence, and minimizing adverse effects.

Decision Point One: Pharmacological Initiation

For her first intervention, I chose to initiate lithium 300 mg orally twice daily. This decision was based on lithium’s status as a gold-standard mood stabilizer with proven efficacy in managing acute manic episodes and reducing suicidality (Geddes & Burgess, 2013). Given her recent hospital stay for mania, lithium’s rapid mood-stabilizing effect was deemed appropriate. Moreover, her genetic testing revealed she is positive for the CYP2D6*10 allele, which influences drug metabolism (Chen et al., 2015). Although lithium is not extensively impacted by CYP2D6, understanding her pharmacokinetic profile aids in tailoring dosage and monitoring.

This initiation aims to rapidly control manic symptoms, prevent relapse, and improve her insight and judgment. Starting with 300 mg BID allows cautious titration, considering her weight, age, and genetic makeup, and helps minimize side effects (Suppes & Frye, 2010). Evidence suggests early initiation of lithium in bipolar disorder effectively reduces manic episodes and shortens hospital stay (Young et al., 2015). My expectation was to see a reduction in manic symptoms within four weeks, with improved medication adherence over time.

Outcome vs. Expectations: Her return after four weeks indicated persistent manic symptoms, with YMRS remaining elevated. The medication’s efficacy was limited by her non-adherence, which highlights the importance of addressing adherence and potential side effects early. The decision to initiate lithium was appropriate, but her non-compliance underscores the need for psychoeducation and considering alternative strategies to enhance adherence.

Decision Point Two: Addressing Non-Compliance

When she returned reporting only episodic use of medication and ongoing manic symptoms, my decision was to adjust her lithium to a sustained-release formulation, changing to lithium 450 mg BID. The rationale was to improve tolerability—specifically gastrointestinal side effects like nausea and diarrhea—that she reported at the previous dose. Extended-release formulations often better accommodate compliance and reduce side effects (McKnight et al., 2012).

The intention was to maintain therapeutic lithium levels while alleviating discomfort to foster sustained adherence. I hoped this increase would stabilize her mood further, reduce manic episodes, and support consistent medication-taking behavior. Additionally, I plan to discuss her views on medication, explore barriers to adherence, and provide psychoeducation regarding her diagnosis and the importance of compliance (Sajatovic et al., 2016).

Outcomes vs. expectations: Upon her subsequent visit, she reported side effects with nausea and diarrhea recurring, leading to poor adherence. This illustrates the dynamic nature of pharmacokinetics—individual genetic profiles and side effects directly impact drug tolerability and compliance. These findings highlighted the importance of ongoing assessment and individualized treatment adjustments.

Decision Point Three: Managing Side Effects and Long-Term Treatment

Given her ongoing side effects, my third intervention was to switch her medication from lithium to Depakote ER 500 mg at bedtime. This decision recognizes Depakote’s effectiveness in controlling manic episodes, especially in patients intolerant to lithium (Ghaemi et al., 2003). Additionally, using the extended-release formulation reduces gastrointestinal side effects, which aligns with her reported nausea and diarrhea.

This switch aims to achieve mood stabilization and improve adherence by minimizing adverse effects. I also plan to educate her on weight management and lifestyle modifications since Depakote is associated with weight gain, which she noted as a concern later. Continuously, I will monitor liver function, serum ammonia, and platelet counts due to Depakote’s side effect profile (Rosenbaum et al., 2013).

The expectation was that Depakote ER would provide symptomatic relief with better tolerability, leading to sustained adherence and mood stabilization. However, her report of weight gain later demonstrated the need to balance medication efficacy and side effects and to incorporate psychoeducation about lifestyle choices.

Ethical Considerations and Cultural Competence

Throughout this process, respecting her autonomy, cultural background, and understanding her beliefs about medication management were crucial. Her Korean descent, which may include cultural perspectives on mental health and medication stigma, informed the need for culturally sensitive communication. Ethical principles such as beneficence, non-maleficence, and respect for autonomy guided the decisions. Ensuring she understands her treatment options, potential side effects, and the importance of adherence aligns with ethical standards to promote informed consent and shared decision-making (Kirmayer et al., 2012). Addressing her concerns about medication effects, including weight gain and side effects, within her cultural context supports trust and compliance. Maintaining open, nonjudgmental communication enhances therapeutic rapport, essential for long-term management of bipolar disorder.

Conclusion

Management of bipolar disorder in this case exemplifies the importance of individualized, evidence-based interventions considering pharmacogenetic factors, side effects, and cultural influences. Initial pharmacotherapy should aim for rapid mood stabilization while fostering adherence through psychoeducation and patient engagement. Treatment adjustments must address side effects actively and incorporate patient preferences and cultural values. Ethical principles underpin all decisions, ensuring client-centered, respectful care. Ongoing assessment and flexibility are key to optimizing outcomes in bipolar disorder management, emphasizing the dynamic and personalized nature of psychiatric nursing practice.

References

• Ghaemi, S. N., Morrissette, D. A., & Goodwin, F. K. (2003). Are mood stabilizers antimania or prophylactic? A review. Journal of Clinical Psychiatry, 64(Suppl 4), 10–16.
• Kirmayer, L. J., Groleau, D., Looper, K. J., & Dao, M. D. (2012). Culture and mental health: beyond mind and body. Transcultural Psychiatry, 49(3-4), 377-389.
• McKnight, R. F., MacEwan, J. P., Britt, W., & Geddes, J. R. (2012). Lithium therapy for depression: systematic review and meta-analysis. The British Journal of Psychiatry, 201(2), 118–124.
• Rosenbaum, J. F., Fava, M., & Saji, S. (2013). Pharmacological treatment of bipolar disorder. In M. H. Pollack & J. M. Katner (Eds.), Mood Stabilizers: Pharmacology and Treatment (pp. 147–164). Springer.
• Sajatovic, M., Miles, K. M., & Kasper, S. (2016). Treatment adherence with mood stabilizers: The clinical perspective. Journal of Clinical Psychiatry, 77(2), e227–e232.
• Suppes, T., & Frye, M. A. (2010). Pharmacotherapy of bipolar disorder. In S. J. Gibbs (Ed.), Textbook of Psychopharmacology (pp. 508–530). Humana Press.
• Young, A. H., Martin, A., & Jewell, K. (2015). Lithium in the treatment of bipolar disorder. In D. J. Nierenberg & H. M. Thase (Eds.), Bipolar Disorder: A Guide for Patients and Families (pp. 45–53). Johns Hopkins University Press.
• 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), 869–876. https://doi.org/10.1007/s00228-015-1792-5
• Geddes, J. R., & Burgess, S. (2013). Lithium: Neurobiological mechanisms of action. Biological Psychiatry, 73(2), 73–74.
• Young, A. H., Bschor, T., & Bauer, M. (2015). Lithium in bipolar disorder management: Recent advances and future directions. World Psychiatry, 14(2), 193–197.