Introduction
The patient being treated is a 26-year-old female of Korean descent. She is receiving an appointment after a 21-day hospitalization where she was diagnosed with bipolar disorder. Bipolar disorder, sometimes known as manic depression, is a mental health disorder characterized by extreme mood swings, with the patient experiencing emotional highs to the point of mania, and then rapidly transitioning to lows with deep depression and feelings of hopelessness (Mayo Clinic, n.d.). At the time of the visit, the patient is demonstrating signs of mania but controlled to an extent with a YRMS of 22 which indicates mild mania. Some elements of the case that may impact decision-making are, the patient not taking prescribed lithium medication, insight of judgment being impaired, and genetic testing demonstrating the CYP2D6*10 allele. A cautious well-researched approach should be taken to the treatment of the patient in question.
Decision #1
For the first decision, three options are presented: Lithium, Risperdal (Risperidone), and Seroquel XR (Quetiapine). All medications are approved by guidelines to be used for the acute treatment of mania in bipolar disorders. All three have confirmed double-blind, well-researched studies confirming their efficacy in treatment (Hirschfeld, n.d.). Lithium is not an option for this patient, as they have already been prescribed the medication and have a problem remaining on it, choosing to stop taking it. The patient would prefer another medication as a lithium prescription would likely result in the same outcome of abandoning the treatment plan. Left with Risperidone and Quetiapine, a study by Moosavi et al. (2015) shows that there is no significant difference between the two medications controlling acute psychotic signs and symptoms. However, according to Hirschfeld (n.d.), Seroquel XR (Quetiapine) has significantly more side effects such as weight gain, dizziness, somnolence, and dry mouth, while Risperdal (Risperidone) has nausea, somnolence, and also potentially mild weight gain. Furthermore, quetiapine is more commonly used, and the only FDA drug approved for bipolar II disorder, for the treatment of acute depressive episodes. The decision is to begin Risperdal 1mg orally BID.
Risperdal, under its generic name Risperidone, is a medication used to treat mental and mood disorders, primarily bipolar disorder, and schizophrenia. It is a second-generation antipsychotic. Its pharmacological effects rebalance dopamine and serotonin, which leads to clearer thinking, better mood, and stable behavior. It is FDA approved for acute treatment of manic or mixed episodes of bipolar disorder, as well as for long-term treatment of the bipolar disorder (National Alliance of Mental Illness, n.d.). The patient in the case is experiencing a mild manic episode of bipolar disorder. This is evident in her behavior, lack of stability, and poor insight into judgment. It is also known that this is the first visit after hospitalization after which she refused to take the prescribed lithium. Therefore, acute treatment is needed with Risperdal. It is an effective choice to stabilize the patient. According to Geddes & Miklowitz (2013), treatment of bipolar disorder should emphasize acute stabilization, bringing the patient in mania or the opposite, depression, to a euthymic and stable state, at which point there can be a focus on maintenance and relapse prevention. Therefore, by prescribing the patient Risperdal, the goal is to stabilize them for further maintenance treatment.
Psychiatry is a specialty that involves moral and ethical questions. Conditions, such as bipolar disorder, ultimately threaten or can define the patients as autonomous individuals. The conditions are also associated with suffering, disability, and stigma. When diagnosing and treating bipolar disorder, one has to follow all guidelines as there are ethical consequences. A wrong diagnosis which can lead to wrong treatment can have very negative implications. In selecting medications, there are specific risks and benefits to the core drugs used in bipolar disorder, based on age, gender, and other factors, which complicates clinical decision-making (Ostacher, 2018).
Decision #2
As a result of Decision #1 to prescribe Risperdal 1mg orally BID, the patient returns for a follow-up visit in 4 weeks, being highly sedated and lethargic. The patient is accompanied by the mother who indicates that a week after the visit, the patient is experiencing such symptoms. The choice now stands to switch completely to Lithium sustained release orally BID, or to stick with Risperdal, either 1mg at HS or 2mg at HS. The decision is to decrease Risperdal to 1mg at HS and observe.
Switching medications in the treatment of bipolar disorder is possible to achieve the best pharmacological response. Some causes for switching may include individual differences and sensitivity to side effects. However, evidence for switching remains relatively moderate to low quality, indicating potential improvements in the recurrence of mood episodes when switching between some of the conventional medications (NeuRA, 2020). Switching to Lithium is concerning as it is a significant transition in medication. As a professional, one also wants to avoid drug-induced switching in patients with bipolar disorder, where they transition from mania to depression or the other way around due to pharmacological effects (Grande et al., 2014). Furthermore, there are concerns about lithium that there were original with this patient regarding adherence. Even if lithium improves the patient’s current lethargic condition, it is not guaranteed that she will continue taking it once she is once again more aware. As for the other option of increasing Risperdal to 2mg, that is medically unnecessary. If 1mg at HS is having this lethargic effect, then increasing the dose will by all indications only worsen the state of the patient.
Therefore, decreasing the dose to 1mg at HS is the most logical decision. Notably, the initial objective of decreasing mania was achieved, and the patient stabilized. Even though they are lethargic does not indicate that they are depressed. Simply, the side effects of the dosage played a role. According to Soreff (2019), it is common and important to adjust the dosage of medication in the treatment of the bipolar disorder. Re-evaluation of treatment response should occur 2-4 weeks after initiation. Adjustments can occur via therapeutic plasma concentrations or modifying the dose until symptomatic improvement or a level of patient intolerance is reached (Soreff, 2019). Adjusting the dose and observing is a good approach to this decision. The ethical implication of this decision is that the patient’s quality of life is being concretely and adversely affected. It is necessary to decide which medication will improve the quality of life and the ability for self-sustainability.
Decision #3
After the previous decision, the patient comes in after 4 weeks with much improved symptoms. She is less sedated and lethargic, as well as showing symptoms of stability improvement with decreased YMRS score of 16, a 25% improvement. All points that Risperdal 1mg HS was effective, at both, decreasing significantly the side effects of the original dosage and providing the treatment expected for bipolar disorder. At this point, there is the option of increasing Risperdal back to 1mg orally BID, maintaining the same dosage and reassessing, or changing to Latuda 40mg orally daily. The decision made is to remain with the same dose of Risperdal and reassess.
Other options are less sensible. Increasing the dose back to 1mg orally BID poses the risk of putting the patient back into a lethargic state. Neither is there medical reasoning to do so given that the current dose at 1mg HS is working effectively. Since the client is of Asian American descent and positive for the CYP2D6*10 allele, as indicated by Chen et al. (2015) the medication has a slower clearance rate from the human system. Therefore, phenotype prediction and dose adjustment may be necessary to compensate. As a result, the Risperdal in the patient’s system was higher than normal which caused the sedation. Increasing the dosage will lead to similar side effects. Meanwhile, Latuda (lurasidone HCl) is not an option as the drug is aimed at treating bipolar depression, which the patient is not experiencing.
The decision aims to continue the trajectory of stabilization currently seen in the patient and improvement of symptoms with a reduction of side effects. It is necessary to reassess in 4 weeks to determine the treatment’s effectiveness, at which point a transition to maintenance can be made. The ethical consideration of this decision is the patient’s long-term well-being. The medication and treatment decisions made at this point have concrete effects on the health and further management of bipolar disorder.
Conclusion
The recommendations in this scenario proposed relying on Risperdal as the primary form of treatment for this specific patient’s bipolar disorder. At every decision, Risperdal was the logical option for the patient, based on her previous interaction with lithium and the potential incompatibility with other medications. As would commonly occur in practice, the Risperdal dosage was adjusted and monitored, first to account for side effects and then to consider the patient’s unique genetic characteristics. It is an acceptable and ethical course of action as it helps to find the optimal dose for the medication while avoiding any drastic transitions. In the end, the patient seems to have reached the stabilization stage in the bipolar disorder treatment, and after some observation can proceed to maintenance which would benefit her well-being and improve her quality of life.
References
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