Assessing and Treating Patients With Bipolar Disorder

Bipolar Therapy Client of Korean Descent/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 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. Assessing and Treating Patients With Bipolar Disorder

Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient confesses that she stopped taking her lithium (which was prescribed in the hospital) since she was discharged two weeks ago.

 

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:

 

PART#1Decision Point One

Begin Lithium 300 mg orally BID

RES Client informs Today’s presentation is similar to the first day you met her

Decision Point Two

 

Increase Lithium to 450 mg orally BID

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client returns reports that she is still taking the medication when she feels that she needs it

·  She remains quite manic and reports that her family is getting really upset because she likes to play her new guitar at night

Decision Point Three

 

Assess for rationale for non-compliance and educate client

 

Guidance to Student The PMHNP should further assess for dangerousness to self or others. The client should be assessed for self-care, to including hygiene, eating, sleeping, etc. Hospitalization may be indicated if the client remains non-compliant and is a danger to self. If the client is not a danger to self, and hospitalization is not indicated, the PMHNP needs to assess for rationale for non-compliance. Many clients enjoy mania as it is a nice feeling to be consistently happy. When clients are successfully treated for mania, they often describe themselves as feeling ‘down’ or ‘flat.’ The PMHNP needs to assess for depression at this point as opposed to normalization of mood. Abilify is also FDA approved as monotherapy for mania and mixed presentations, but at a dose of 15 mg. day., so although you may be tempted to begin Abilify- be certain to use correct dose. Also, because it can be “activating” you need to dose this drug in the morning. However, the client is non-compliant and therefore, eliciting reasons for non-compliance is essential to the care of this client.

Decision Point One

 

Begin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”

·  Today’s presentation is similar to the first day you met her

egin Lithium 300 mg orally BID

Decision Point Two

 

 Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology

RESULTS OF DECISION POINT TWO.

 Client returns to clinic in four weeks

·  Client states that the drug makes her nauseated and gives her diarrhea

·  Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again

 

Decision Point Three

Change to Depakote ER 500 mg at HS

 

Guidance to Student In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents. Assessing and Treating Patients With Bipolar Disorder

RESULTS OF DECISION POINT TWORESULTS OF DECISION POINT T

Decision Point One

 

 Begin Lithium 300 mg orally BIDBegin Lithium 300 mg orally BID RESULTS OF DECISION POINT ONE

 

·  Client returns to clinic in four weeks

·  Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”

·  Today’s presentation is similar to the first day you met her

 

RESULTS OF DECISION POINT TWO

 Assess rationale for non-compliance to elicit reason for non-compliance and educate client re: drug effects, and pharmacology

 Client returns to clinic in four weeks

·  Client states that the drug makes her nauseated and gives her diarrhea

·  Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again

egin Risperdal 1 mg orally BID

Guidance to Student In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents. Assessing and Treating Patients With Bipolar Disorder

 

Decision Point One

 

Begin Lithium 300 mg orally BIDBegin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”

·  Today’s presentation is similar to the first day you met her

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client states that the drug makes her nauseated and gives her diarrhea

·  Client states that she stops taking it until these symptoms abate, at which point she re-starts only to experience the symptoms again

Begin Seroquel XR 100 mg orally at HS

 

Decision Point Three

 

Change to trileptal 300 mg orally BID

 

Guidance to Student In this case, the client is having nausea and diarrhea, classic side effects of lithium therapy. Changing the client to an extended release formulation can often prevent these symptoms while at the same time affording the client the benefit of lithium’s mood stabilizing properties. Also, lithium is a good choice for control of mania and has also been shown to decrease risk of suicide, which adds to its overall benefits. Depakote may be an option if changing to sustained release lithium does not alleviate the side effects. Oxcarbazpine (Trileptal) is an option, but is a second line therapy and is not appropriate at this stage as the client has not had an adequate trial of first line agents. Assessing and Treating Patients With Bipolar Disorder

Decision Point One

 

Be Begin Lithium 300 mg orally BIDgin Lithium 300 mg orally BID

·  Client returns to clinic in four weeks

·  Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”

·  Today’s presentation is similar to the first day you met her

Decision Point Two

 

Switch to Depakote ER 500 mg orally at HS

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client reports that she has been compliant and you notice a marked reduction in manic symptoms. Young Mania Rating Scale was 11 (50% reduction from first office visit)

·  Client reports that she has gained 6 pounds over the last 4 weeks and wants to stop the medication because of this

Decision Point Three

Select what the PMHNP should do next:

 

Educate client regarding diet/weight loss and continue client on the same drug/dose

Guidance to Student The PMHNP should begin by educating the client regarding weight loss/and importance of diet/exercise while taking Depakote which can cause weight gain. Decreasing the dose of Depakote would not be appropriate as she still has symptoms and decreasing dose of Depakote may result in some weight loss, it may result in a return of manic symptoms. The PMHNP can switch to Zyprexa but if weight gain is the issue, then this will be compounded by Zyprexa which is associated with significant weight gain (up to 20 kg over a 24 month period). Assessing and Treating Patients With Bipolar Disorder

 

 

Decision Point One

Begin Lithium 300 mg orally BID

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client informs the PMHNP that she has been taking her drug “off and on” only when she “feels like she needs it”

·  Today’s presentation is similar to the first day you met her

 

Decision Point Two

 

Switch to Depakote ER 500 mg orally at HS

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client reports that she has been compliant and you notice a marked reduction in manic symptoms. Young Mania Rating Scale was 11 (50% reduction from first office visit)

·  Client reports that she has gained 6 pounds over the last 4 weeks and wants to stop the medication because of this

 

 

 Decrease Depakote ER to 250 mg orally at HS

Guidance to Student The PMHNP should begin by educating the client regarding weight loss/and importance of diet/exercise while taking Depakote which can cause weight gain. Decreasing the dose of Depakote would not be appropriate as she still has symptoms and decreasing dose of Depakote may result in some weight loss, it may result in a return of manic symptoms. The PMHNP can switch to Zyprexa but if weight gain is the issue, then this will be compounded by Zyprexa which is associated with significant weight gain (up to 20 kg over a 24 month period). Assessing and Treating Patients With Bipolar Disorder

Switch medication to Zyprexa 15 mg orally daily at HS

 

 

PART#2 Decision Point One

 

Begin Risperdal 1 mg orally BIDBegin 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

 

Discontinue Risperdal and start Lithium sustained release 300 mg orally BID

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client no longer lethargic after the end of the first week

·  Client has a slight decrease in her Young Mania Rating Scale (from 22 to 19)

·  Client reports that her sleep is again decreasing, but that overall, she is happy

Decision Point Three

Increase Lithium SR to 450 mg orally BID

 

Guidance to Student Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may be demonstrating slower clearance of Risperdal from her system, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The client responded well to the discontinuation of Risperdal and after about a week of drug cessation, she was no longer lethargic/sedate. However, in the following 3 weeks, she had experienced increased symptoms, although a slight improvement in YMSR score was noted. The PMHNP could make no changes at this time and allow the lithium to remain at its current dose for an additional 4 weeks and reassess. Conversely, the PMHNP can increase the lithium to 450 mg orally BID and then reassess in 4. The additional milligrams may hasten mood stabilization. Risperdal 0.5 mg orally BID may be appropriate if the clients’ symptoms are worsening, however, the PMHNP would need to have the client return to the office sooner than 4 weeks for an interim visit to assess effects of drug and presence of somnolence/lethargy. Assessing and Treating Patients With Bipolar Disorder

 

 Decrease Risperdal to 1 mg at HS

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

 

Continue at same dose of Risperdal and reassess in 4 weeks

 

Guidance to Student At this point, the PMHNP may be wise to allow the client to remain at the same dose and reassess in 4 weeks. Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may have slower clearance of Risperdal from her system, which may have resulted in higher than normal levels of Risperdal in the blood, which in turn resulted in sedation. Therefore, if we were to increase back to 1 mg orally BID, she may have the same side effects. Latuda is FDA approved for bipolar I depression, which is not the presentation we are attempting to treat. Additionally, it is quite expensive and many insurance companies will not pay for it until other agents have been attempted and failed.

idance to Student At this point, the PMHNP may be wise to allow the client to remain at the same dose and reassess in 4 weeks. Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may have slower clearance of Risperdal from her system, which may have resulted in higher than normal levels of Risperdal in the blood, which in turn resulted in sedation. Therefore, if we were to increase back to 1 mg orally BID, she may have the same side effects. Latuda is FDA approved for bipolar I depression, which is not the presentation we are attempting to treat. Additionally, it is quite expensive and many insurance companies will not pay for it until other agents have been attempted and failed. Assessing and Treating Patients With Bipolar Disorder

 

Decision Point One

 

Be Begin Risperdal 1 mg orally BIDgin 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

Change Risperdal to 2 mg at HS

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client’s mother accompanies client again to today’s appointment and states “I think she’s getting worse, that medication is no good- look at her!”

·  Client remains quite sedate and lethargic

Decision Point Three

Select what the PMHNP should do next:

 

Decrease Risperdal to 1 mg orally at HS

Guidance to Student Recall that the client is of Korean descent and is positive for CYP2D6*10 allele. As a result, she may have slower clearance of Risperdal from her system, resulting in higher than normal levels of Risperdal in the blood, resulting in sedation. The change of administration time may help with sedation, somewhat, but if she is not clearing the drug from her system, she is accumulating the medication and this is resulting in sedation. The PMHNP should consider decreasing the drug to 1 mg orally daily at HS secondary to decreased clearance of the drug. The PMHNP could discontinue Risperdal and begin Seroquel XR, but the dose is quite high and BID administration would likely result in sedation as well. Seroquel XR is also dosed only once a day. Discontinuation of Risperdal in favor of Geodon may also be an appropriate choice as Geodon is cleared by approximately one third through the CYP-3A4,1A2 alleles and the remaining two-thirds of the drug are cleared through aldehyde oxidase, which means that it should not cause the same sedation of the client is currently experiencing with Risperdal. Geodon must be administered with a 500 calorie meal in order to assure adequate absorption. Assessing and Treating Patients With Bipolar Disorder

Discontinue Risperdal and begin Seroquel XR 400 mg orally BID

Guidance to Student The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth. Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects. Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended release may overcome the difficulties she was experiencing with side effects. The PMHNP would need to educate client regarding side effects of medication and need to maintain compliance. Assessing and Treating Patients With Bipolar Disorder

 

Decision Point One

Begin Seroquel XR 100 mg orally at HS

Begin Seroquel XR 100 mg orally at HS

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client is reporting that she sleeps a bit more at bedtime

·  Client states that she has gained about 2 or 3 pounds, which she does not like

·  Client also reports that she has been constipated since starting this medication

·  Client is also complaining of dry mouth which she does not like.

·  Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18

·  Client is reporting really good mood, but is asking for a different medication because of the weight gain

Decision Point Two

 

Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client demonstrates a 50% decrease in score on the Young Mania Rating Scale (from 22 to 11)

·  Client denies any additional weight gain and denies any additional side effects

Decision Point Three

 

Augment with Lithium sustained release 300 mg orally BID

 

Guidance to Student The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth. Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects. Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended release may overcome the difficulties she was experiencing with side effects. The PMHNP would need to educate client regarding side effects of medication and need to maintain compliance. Assessing and Treating Patients With Bipolar Disorder

PART#3Decision Point One

 

PART#3B Begin Seroquel XR 100 mg orally at HSegin Seroquel XR 100 mg orally at HS

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client is reporting that she sleeps a bit more at bedtime

·  Client states that she has gained about 2 or 3 pounds, which she does not like

·  Client also reports that she has been constipated since starting this medication

·  Client is also complaining of dry mouth which she does not like.

·  Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18

·  Client is reporting really good mood, but is asking for a different medication because of the weight gain

Decision Point Two

 

Continue same dose of Seroquel and counsel client regarding ways to prevent constipation

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client continues to experience constipation and has gained an additional 5 pounds

·  Client feels that her PMHNP is not sympathetic to her concerns and states “I want to stop medication altogether, this is no way to live!”

Decision Point Three

Select what the PMHNP should do next:

 

Discontinue Seroquel and go back to Lithium, but this time, using an extended release preparation

Guidance to Student In this case, the Seroquel is causing side effects through the muscarinic 1 receptors. The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth. When this approach fails, changing drug therapy should be considered. Discontinuation of the Seroquel in favor of extended release lithium may be appropriate to overcome initial side effects that resulted in discontinuation of lithium, but Lithium takes several weeks to bring about control of manic symptoms. An atypical antipsychotic will need to be used until lithium’s effects can be realized. Similarly, discontinuation of Seroquel and initiation of Lamictal is not appropriate as the dose of 100 mg is too high. Lamictal must be slowly and cautiously titrated from a starting dose of 25 mg orally daily- otherwise, an increased risk of Steven Johnson Syndrome can occur. Secondly, the Lamictal is not indicated for bipolar mania. Assessing and Treating Patients With Bipolar Disorder

 

Decision Point One

 

Begin Seroquel XR 100 mg orally at HSBegin Seroquel XR 100 mg orally at HS

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client is reporting that she sleeps a bit more at bedtime

·  Client states that she has gained about 2 or 3 pounds, which she does not like

·  Client also reports that she has been constipated since starting this medication

·  Client is also complaining of dry mouth which she does not like.

·  Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18

·  Client is reporting really good mood, but is asking for a different medication because of the weight gain

Decision Point Two

 

Discontinue Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client demonstrates a 50% decrease in score on the Young Mania Rating Scale (from 22 to 11)

·  Client denies any additional weight gain and denies any additional side effects

 

Continue same dose and reassess in 4 weeks

 

Guidance to Student The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth. Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects. Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended release may overcome the difficulties she was experiencing with side effects. The PMHNP would need to educate client regarding side effects of medication and need to maintain compliance.

Decision Point One

 

Begin Seroquel XR 100 mg orally at HSBegin Seroquel XR 100 mg orally at HS

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  Client is reporting that she sleeps a bit more at bedtime

·  Client states that she has gained about 2 or 3 pounds, which she does not like

·  Client also reports that she has been constipated since starting this medication

·  Client is also complaining of dry mouth which she does not like.

·  Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18

·  Client is reporting really good mood, but is asking for a different medication because of the weight gain

Decision Point Two

 

Continue same dose of Seroquel and counsel client regarding ways to prevent constipation

 

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Client continues to experience constipation and has gained an additional 5 pounds

·  Client feels that her PMHNP is not sympathetic to her concerns and states “I want to stop medication altogether, this is no way to live!”

 

 

Decision Point Three

 

Discontinue Seroquel and begin Lamictal 100 mg orally daily

 

Guidance to Student In this case, the Seroquel is causing side effects through the muscarinic 1 receptors. The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth. When this approach fails, changing drug therapy should be considered. Discontinuation of the Seroquel in favor of extended release lithium may be appropriate to overcome initial side effects that resulted in discontinuation of lithium, but Lithium takes several weeks to bring about control of manic symptoms. An atypical antipsychotic will need to be used until lithium’s effects can be realized. Similarly, discontinuation of Seroquel and initiation of Lamictal is not appropriate as the dose of 100 mg is too high. Lamictal must be slowly and cautiously titrated from a starting dose of 25 mg orally daily- otherwise, an increased risk of Steven Johnson Syndrome can occur. Secondly, the Lamictal is not indicated for bipolar mania.