Introduction
Bipolar disorder is characterized by mood swings from low depressive moments to manic highs with increased energy (Perlis and Ostacher, 2016a). Unfortunately, the condition has no direct causes that can be pinpointed, which makes its treatment challenging. Moreover, laboratory testing using various diagnostic parameters may not be useful in the diagnosis of the disorder as these parameters may be normal in the patients. Additionally, symptoms of bipolar disorder overlap with those of other conditions such as cyclothymia (Perlis and Ostacher, 2016a). Therefore, a proper understanding of the pathophysiology of bipolar disorder is critical in the diagnosis and treatment of the disorder. However, few symptoms are more evident in bipolar disorder and can be used to differentiate the disorder from other conditions with similar symptoms. Patients with bipolar disorder show symptoms of high energy, reduced sleep, depressive and high states and a reduced interest in daily activities.
From the case, the patient shows symptoms of bipolar disorder. She has reduced sleep and attention. Her euthymic mood is evident in bipolar disorder as this type of mood is easily differentiable from that of healthy people. Her dressing is also inappropriate, considering that she has worn a nightdress during an appointment. Together with the initial diagnosis, these symptoms confirm that the patient has bipolar disorder. From her score on the YMR scale, her condition is in a mild state. This could be the reason she does not experience hallucinations that are evident in severe states.
The patient has a low BMI value of 18.3, which shows that she is underweight. Dose reduction may therefore be necessary, based on her body weight. In addition to that, she has the CYP2D6*10 mutation that is responsible for reduced enzyme activity and response to antipsychotic and antidepressant drugs (Lu et al., 2021). The mutation is due to a cytosine-to-thymine substitution at nucleotide 100, causing serine to be converted to proline at codon 34. As a result, the choice of drugs for her treatment should not be substrates for CYP2D6. Alternatively, the activity score of CYP2D6 in patients will be used to determine a personalized dose requirement for her.
Decision #1
Seroquel XR 300mg orally at hours of sleep was begun as the initial treatment for the patient. This was the drug of choice because it helps relieve the symptoms of bipolar I disorder, mania and other symptoms of psychotic disorders (Ostacher and Hsin, 2016). Even though bipolar I disorder is not completely treatable, managing the symptoms helps the patients lead a normal life. The age of the patient does not fall under the contraindicated pediatric age. Therefore, the drug was an appropriate choice. Also, results from clinical pharmacokinetic studies reveal that Seroquel is not entirely metabolized by CYP2D6 (Suttajit et al., 2014). Instead, CYP 3A4 has been determined to be the main enzyme that metabolizes Seroquel (by 89%). CYP2D6 only plays a minor role in the metabolism of the drug. Considering that the patient has the CYP2D6*10 mutant allele, a choice of drug not affected by the allele was necessary.
The remaining drugs options were forgone because they are substrates for CYP2D6 (Suttajit et al., 2014). The patient’s genetic test has revealed a mutation in the enzyme; hence these drugs would not be metabolized adequately. The result would be the buildup of the concentrations of the drugs to toxic levels that would harm the patient. By selecting Seroquel, I hoped to achieve optimum relief from the symptoms without exposing the patient to complications of drug toxicity. Similarly, I wanted to achieve optimum relief without having to use several drug combinations as Seroquel can be used as a single treatment. Clinical studies have declared Seroquel to be efficacious in treating all symptoms that the patient in the case has.
Ethical considerations are likely to affect patient compliance to the treatment and my communication with them (Traeger et al., 2016). For example, withholding the patient from viewing the psychiatric chart may not be acceptable to them. As a result, psychiatrist-patient communication may change henceforth, or the patient may be angry. However, if the need to disclose the information arises, the standard criteria may be used to exclude some information and only show the client what is necessary.
Decision #2
The second decision was to continue the same dose of Seroquel XR 300mg orally at sleep hours and counsel the client regarding ways to prevent constipation. The reason for the continuation of the medication was its effectiveness in managing the symptoms. Based on the initial treatment choice, there have been improvements in sleep. Client score on the Young Mania Rating Scale has also improved significantly. Mood swings have also reduced. All these show a positive response towards treatment, and therefore the continuation of the drug would be appropriate (Ostacher and Hsin, 2016). Constipation and dry mouth are some of the side effects of the drug and can be minimized by frequent hydration and taking a high-fiber diet. Weight gain is caused by stimulation of appetite by the drug Seroquel and can be minimized by controlled eating.
The alternative drugs were not selected in the second option due to the success of the first option. The drug selected did not show signs of failure, and therefore its discontinuation would not be appropriate. Discontinuation of the first choice would cause recurrence of the symptoms. By making this second decision to use Seroquel, I anticipated the complete alleviation of the symptoms. Treatment of mental disorders takes longer to achieve the initial healthy state of the patient (Suttajit et al., 2014). Accordingly, using the same drug for the second time would finally treat all the symptoms.
Ethical considerations made in this second decision would affect the treatment plan (Ventura et al., 2021). The patient is experiencing side effects of the drug and is requesting an alternative medication. However, it would not be considered ethical to withdraw an effective drug at the expense of treatable side effects. This ethical dilemma was solved by allowing the continuation of the initial dose. Consequently, the patient may not comply much, considering that her request for the change of the drug has not been honored.
Decision #3
The third decision was to discontinue Seroquel XR 300mg orally at sleep hours and begin Geodon 40mg orally twice a day with a 500-calorie meal. From the results in decision 2, it was clear that the patient would not continue using Seroquel if it was to be continued. Therefore, addressing her need without compromising the treatment plan was necessary. The antipsychotic drug Geodon differs from other antipsychotics in that it does not cause weight gain (Ostacher and Hsin, 2016). Research has shown that this drug can be an effective treatment option for overweight patients. This was confirmed by Enric et al. in 2012, who contrasted the effects of Geodon from those of Olanzapine. At the same time, it treats the symptoms of bipolar I disorder. Accordingly, it was a suitable alternative for Seroquel.
Seroquel and other options were not considered in the third option due to their ability to cause weight gain (Suttajit et al., 2014). Geodon causes appetite loss with subsequent weight loss and therefore was preferred. This was the patient’s need, and alternative options would discourage the patient from taking the medication, translating to the treatment plan’s failure. In this decision, I was hoping to achieve weight loss and continue the treatment of bipolar I at the same time. Other options to control weight gain had failed in option two, and thus decision 3 was necessary.
One of the ethical obligations of the PMHNP is to respect the values and preferences of the patient (Ventura et al., 2021). Failure to respect patient preferences could raise ethical issues. Even though the PMNHP aims at making decisions that benefit the patient, consideration of patient preference is important. This is why an alternative medication that meets the patient’s demand without compromising treatment was begun.
Conclusion
The patient’s initial treatment was by the use of Lithium. This improved her recovery and allowed for her release from the hospital. Seroquel is, however, more efficacious in when used to treat symptoms of bipolar I disorder compared to Lithium. A combination of the two drugs in the treatment of mania has shown to be more effective than using a single drug at a time (Perlis and Ostacher, 2016b). This increased efficacy is not evident in Bipolar I disorder, and thus the combination was not necessary.
Initial use of Seroquel was due to its efficacy over Lithium (Perlis and Ostacher, 2016b). It significantly reduces the severity of the symptoms and promotes healing. Its continuation later was due to an alternative method of dealing with the adverse effects, including hydration and a fibre-rich diet to control constipation. Failure of the recommended methods to control the adverse effects necessitated a change of the treatment option. Use of the initial treatment option of Lithium would be useful, but the drug has a slower onset of action (Perlis and Ostacher, 2016b). This would mean that the patient would revert to the symptoms experienced before the treatment was begun. On the other hand, the use of Lamictal would require high doses that could not be administered in outpatient services. Geodon would cause neither of these effects, which left it to be the most suitable option. It produces a quicker onset of action than Lithium and does not require high doses like Lamictal. These decisions were made based on ethical considerations to benefit the patient and bring satisfaction during treatment.
References
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