NURS 6630 Assessing and Treating Patients With Bipolar Disorder

Walden University NURS 6630 Assessing and Treating Patients With Bipolar Disorder– Step-By-Step Guide

This guide will demonstrate how to complete the Walden University NURS 6630 Assessing and Treating Patients With Bipolar Disorder assignment based on general principles of academic writing. Here, we will show you the A, B, Cs of completing an academic paper, irrespective of the instructions. After guiding you through what to do, the guide will leave one or two sample essays at the end to highlight the various sections discussed below.

How to Research and Prepare for NURS 6630 Assessing and Treating Patients With Bipolar Disorder

Whether one passes or fails an academic assignment such as the Walden University NURS 6630 Assessing and Treating Patients With Bipolar Disorder depends on the preparation done beforehand. The first thing to do once you receive an assignment is to quickly skim through the requirements. Once that is done, start going through the instructions one by one to clearly understand what the instructor wants. The most important thing here is to understand the required format—whether it is APA, MLA, Chicago, etc.

After understanding the requirements of the paper, the next phase is to gather relevant materials. The first place to start the research process is the weekly resources. Go through the resources provided in the instructions to determine which ones fit the assignment. After reviewing the provided resources, use the university library to search for additional resources. After gathering sufficient and necessary resources, you are now ready to start drafting your paper.

How to Write the Introduction for NURS 6630 Assessing and Treating Patients With Bipolar Disorder

The introduction for the Walden University NURS 6630 Assessing and Treating Patients With Bipolar Disorder is where you tell the instructor what your paper will encompass. In three to four statements, highlight the important points that will form the basis of your paper. Here, you can include statistics to show the importance of the topic you will be discussing. At the end of the introduction, write a clear purpose statement outlining what exactly will be contained in the paper. This statement will start with “The purpose of this paper…” and then proceed to outline the various sections of the instructions.

How to Write the Body for NURS 6630 Assessing and Treating Patients With Bipolar Disorder

After the introduction, move into the main part of the NURS 6630 Assessing and Treating Patients With Bipolar Disorder assignment, which is the body. Given that the paper you will be writing is not experimental, the way you organize the headings and subheadings of your paper is critically important. In some cases, you might have to use more subheadings to properly organize the assignment. The organization will depend on the rubric provided. Carefully examine the rubric, as it will contain all the detailed requirements of the assignment. Sometimes, the rubric will have information that the normal instructions lack.

Another important factor to consider at this point is how to do citations. In-text citations are fundamental as they support the arguments and points you make in the paper. At this point, the resources gathered at the beginning will come in handy. Integrating the ideas of the authors with your own will ensure that you produce a comprehensive paper. Also, follow the given citation format. In most cases, APA 7 is the preferred format for nursing assignments.

How to Write the Conclusion for NURS 6630 Assessing and Treating Patients With Bipolar Disorder

After completing the main sections, write the conclusion of your paper. The conclusion is a summary of the main points you made in your paper. However, you need to rewrite the points and not simply copy and paste them. By restating the points from each subheading, you will provide a nuanced overview of the assignment to the reader.

How to Format the References List for NURS 6630 Assessing and Treating Patients With Bipolar Disorder

The very last part of your paper involves listing the sources used in your paper. These sources should be listed in alphabetical order and double-spaced. Additionally, use a hanging indent for each source that appears in this list. Lastly, only the sources cited within the body of the paper should appear here.

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Sample Answer for NURS 6630 Assessing and Treating Patients With Bipolar Disorder

Bipolar disorder (BD) is one of the leading causes of disability across the world. BD is characterized by alterations in an individual’s mood, between hypomania and mania, or between mixed status and depression as demonstrated by the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, text revision (DSM-5-TR). There are three main types of bipolar disorder, Bipolar 1, Bipolar II, and Mixed Episodes. This discussion illustrated the prevalence, neurobiology, diagnosis, and management of Bipolar I Disorder.  

Prevalence and Neurobiology of Bipolar I Disorder 

Studies show that bipolar disorder normally starts around the age of 25 years, but individuals can even be diagnosed during their childhood. In the United States, epidemiological studies report that the prevalence of bipolar I disorder is around 1% (Van Meter et al., 2019). However, due to differences in environmental, sociocultural, and racial/ethnic factors, the prevalence of this mental disorder varies across state lines. Genetic factors such as a family history of bipolar disorder are confirmed risk factors in addition to lifestyle habits like cannabis abuse. Consequently, bipolar has been reported to be more prevalent in depressed countries and communities. 

Patients diagnosed with bipolar I disorder usually present with a minimum of one manic episode throughout their life, undermining their qualify for life. Several biological factors have been associated with bipolar I disorder’s pathophysiology, utilizing a wide range of neuroendocrine and biochemical strategies (Harrison et al., 2018).  Signal transduction pathways have been reported to be an integral part of the development of the bipolar disorder, in addition to cellular resilience and neuroplasticity. In bipolar I disorder, changes in the above biological factors result in manic episodes, which are characterized by elevated mood, increased libido, disruptive behavior, increased energy, and grandiose beliefs and thoughts. 

DSM 5 TR Criteria 

Bipolar I disorder is a manic depressive mental disorder as described in the DSM-V. The mental disorder can occur with psychotic episodes or not. Patients with Bipolar I disorder must present with at least one manic episode, disrupting their daily lives (McIntyre et al., 2020). On the other hand, Bipolar II Disorder is also characterized by alternating episodes of depression and manic episodes but does not disrupt the normal livelihood of the patient. For a patient to qualify for bipolar I disorder diagnosis, they must present with at least one episode of mania, alternating with major depression or hypomania. For the diagnosis of bipolar II disorder, the patient is only required to present with alternating episodes of hypomania and depression (Van Meter et al., 2019). The diagnostic criteria qualify mania episodes only when symptoms of elevated, irritable, and disruptive mood have persisted for at least one week whereas in hypomania the symptoms are only required to persist for at least 5 days. In both diagnoses, during the period of hypomania or mania, the patient must display three or more of the following symptoms, inflated self-esteem, easily distracted, racing thoughts, reduced sleep, risky habits, and psychomotor agitation. 

Special Populations and Considerations 

The diagnosis of several mental disorders including bipolar I disorder is usually very challenging among special populations like the pediatric population. Studies show that most mental conditions displayed in children share similar symptoms, making it hard for the practitioner to determine the primary diagnosis and rule out the differentials (Yatham et al., 2018). For instance, a child with severe mood dysregulation and irritability might be suffering from attention deficit hyperactivity disorder rather than bipolar 1 disorder. As such, additional screening tools must be utilized to avoid incidences of misdiagnosis. Women during pregnancy or postpartum also tend to display a shift in mood due to hormone imbalance which can be confused for severe depression or anxiety disorder. older adults on the other hand usually exhibit a decline in cognitive function that predisposes them to comorbid mental illness. In emergency care, most patients may present with confusion and anxiety, which might be temporarily triggered by the hospital environment. Collecting the patient previous psychiatric and family history is crucial to develop the diagnosis of bipolar I Disorder among this vulnerable population. 

Several legal, ethical, cultural, and social factor must be considered during the assessment and management of bipolar I disorder in special populations such as pediatric patients. For instance, patients who are minors shift their legal responsibility of deciding on the most appropriate treatment approach to take to the parents or legal guardians (Post et al., 2019). Consequently, the practitioner is required to ensure appropriate off-label use of mood stabilizers at the right dose and frequency to avoid toxicity that might result in malpractice lawsuits. Culturally sensitive care should be provided to mentally ill patients concerning their ethnic and cultural values and beliefs, Consequently, considering social determinants of health like socioeconomic status can be beneficial in determining which treatment approach to recommend for affordability and compliance purposes.  

FDA Approved Pharmacological Treatment of Bipolar I Disorder 

The FDA recommends the use of lithium as the first-line mood stabilizer for patients with bipolar 1 disorder (Citrome, 2020). Additional drugs approved for the management of manic episodes include atypical antipsychotics like aripiprazole, asenapine, ziprasidone, risperidone, and olanzapine and anticonvulsants like Divalproex sodium and Carbamazepine (Ho et al., 2020). A combination of olanzapine and fluoxetine has also been approved for the management of acute depression (Monahan et al., 2022). Other drugs approved for the management of depression among bipolar patients include quetiapine and lurasidone. For mixed episodes, the FDA has approved the use of carbamazepine, ziprasidone, risperidone, asenapine, olanzapine, and aripiprazole. Drugs approved for maintenance therapy among bipolar I patients include lamotrigine, olanzapine, lithium, lamotrigine, and aripiprazole. 

Side Effects, FDA Approvals, and Warnings 

The most commonly used bipolar I medication is lithium. Which is FDA approved for the management of mania and maintenance therapy as mentioned above. Some of the common side effects of lithium include frequent urination, arm stiffness, weight gain, breathing problems, excessive thirst, and reduced and irregular heartbeat (Monahan et al., 2022). However, due to the increased risks of lithium toxicity, patients are advised to look for warning signs including palpitations, tremors, muscle weakness and tension, and excessive diarrheas. It is thus important to observe the serum concentration level of lithium during the first two weeks of treatment therapy to determine the maintenance dose for optimal benefit. 

Some atypical antipsychotics as mentioned earlier have also been approved by the FDA for the management of mania, depression, and maintenance therapy in bipolar I patients. They are known for extrapyramidal side effects like akinesia, akathisia, and tardive dyskinesia among others (Citrome, 2020). Other adverse effects include cataracts, myocarditis, weight gain, and prolonged QTc. Individuals with comorbid cardiovascular conditions are advised to use medication from this class with caution given the increased risks of myocarditis. Monitoring several parameters is necessary to evaluate positive outcomes, including fasting lipid level, waist circumference, BMI, HbA1c, and fasting plasma glucose levels. 

Only two anticonvulsants have been approved for use among bipolar I patients, Divalproex sodium and Carbamazepine. Some of the common side effects of this drug include dizziness, fatigue, nausea, drowsiness, nausea, tremors, weight gain, and rashes among others (Ho et al., 2020). Carbamazepine has been reported to lower the patient’s level of biotin, folate, and Vit. B2, beta carotene, Vit. B6, Vit. B22, Vit. C, Vit. D and Vit. E. However, to avoid such complications, regular monitoring of the patient’s serum concentration of the drug is necessary for optimal therapeutic levels.  

Prescription Writing 

Prescribers are encouraged to adopt the most applicable strategy to promote the appropriate writing of prescriptions and avoid errors. First, the prescriber must identify and confirm the patient’s name and date of birth or age. The prescriber identifies the medication and its strength, in addition to the amount to be taken, route of administration, and frequency (Yatham et al., 2018). The prescriber must consider the amount that should be dispensed at the pharmacy and the number of refills for the patient. The prescription is then completed with the signature of the prescriber with another identifier such as DEA or NPI number. The prescription should be issued to the pharmacy for interpretation and dispensing to the patient. The use of a prescriber order entry platform on the electronic health record software is recommended to reduce the incidence of medication errors. Consequently, practitioners are required to adhere to the hospital’s prescription protocols and countercheck all the information included and make sure that there are no errors, to promote patient safety and well-being. 

Conclusion 

Bipolar disorder is a disabling mental condition that can greatly undermine the patient’s quality of life. Bipolar I disorder is the most common, given its severity of manic episodes. Bipolar II disorder is less common since most patient lives with it without seeking medical attention due to the mild symptoms. However, several medications have been approved by the FDA for the management of bipolar I  disorder including lithium, atypical antipsychotics, and anticonvulsants. Most of these medications have serious adverse reactions hence the need of monitoring serum levels for dose adjustment and attainment of optimal therapeutic level.  

Also Read:

Assessing and Treating Patients With Anxiety Disorders

Treatment for a Patient With a Common Condition

Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

WEEK 8 Short Answer Assessment

Assessing and Treating Patients With Sleep Wake Disorders

Assessing and Treating Patients With ADHD

Psychopharmacologic Approaches to Treatment of Psychopathology

Assessing and Treating Patients With Impulsivity, Compulsivity, and Addiction

References 

Citrome, L. (2020). Food and Drug Administration–Approved Treatments for Acute Bipolar Depression. Journal of Clinical Psychopharmacology, 40(4), 334–338. https://doi.org/10.1097/jcp.0000000000001227 

Harrison, P. J., Geddes, J. R., & Tunbridge, E. M. (2018). The Emerging Neurobiology of Bipolar Disorder. Trends in Neurosciences, 41(1), 18–30. https://doi.org/10.1016/j.tins.2017.10.006‌ 

Ho, A. M., Coombes, B. J., Nguyen, T. T. L., Liu, D., McElroy, S. L., Singh, B., Nassan, M., Colby, C. L., Larrabee, B. R., Weinshilboum, R. M., Frye, M. A., & Biernacka, J. M. (2020). Mood‐Stabilizing Antiepileptic Treatment Response in Bipolar Disorder: A Genome‐Wide Association Study. Clinical Pharmacology & Therapeutics, 108(6), 1233–1242. https://doi.org/10.1002/cpt.1982 

McIntyre, R. S., Berk, M., Brietzke, E., Goldstein, B. I., López-Jaramillo, C., Kessing, L. V., Malhi, G. S., Nierenberg, A. A., Rosenblat, J. D., Majeed, A., Vieta, E., Vinberg, M., Young, A. H., & Mansur, R. B. (2020). Bipolar disorders. The Lancet, 396(10265), 1841–1856. https://doi.org/10.1016/s0140-6736(20)31544-0 

Monahan, C., McCoy, L., Powell, J., & Gums, J. G. (2022). Olanzapine/Samidorphan: New Drug Approved for Treating Bipolar I Disorder and Schizophrenia. Annals of Pharmacotherapy, 106002802110703. https://doi.org/10.1177/10600280211070330 

Post, R. M., Yatham, L. N., Vieta, E., Berk, M., & Nierenberg, A. A. (2019). Beyond the evidence‐based treatment of bipolar disorder: Rational pragmatic approaches to management. Bipolar Disorders, 21(7), 650–659. https://doi.org/10.1111/bdi.12813 

Van Meter, A., Moreira, A. L. R., & Youngstrom, E. (2019). Updated Meta-Analysis of Epidemiologic Studies of Pediatric Bipolar Disorder. The Journal of Clinical Psychiatry, 80(3). https://doi.org/10.4088/jcp.18r12180 

Yatham, L. N., Kennedy, S. H., Parikh, S. V., Schaffer, A., Bond, D. J., Frey, B. N., Sharma, V., Goldstein, B. I., Rej, S., Beaulieu, S., Alda, M., MacQueen, G., Milev, R. V., Ravindran, A., O’Donovan, C., McIntosh, D., Lam, R. W., Vazquez, G., Kapczinski, F., & McIntyre, R. S. (2018). Canadian Network for Mood and Anxiety Treatments (CANMAT) and International Society for Bipolar Disorders (ISBD) 2018 guidelines for the management of patients with bipolar disorder. Bipolar Disorders, 20(2), 97–170. https://doi.org/10.1111/bdi.12609 

Sample Answer 2 for NURS 6630 Assessing and Treating Patients With Bipolar Disorder

Mental health disorders are a crucial public health concern because of its rising rates and impacts on the health of the population. Mental health problems such a bipolar disorder affect the patient’s quality of life and productivity. Mental health nurse practitioners explore effective, evidence-based interventions that will promote recovery and prevent relapse among the affected populations. Often, pharmacological and non-pharmacological interventions are effective in facilitating bipolar disorder management and prevention of symptom relapse. Therefore, the purpose of this paper is to explore bipolar I disorder. It examines topics that include prevalence and neurobiology of bipolar I disorder, differences with bipolar II disorder, treatment in a special population and consideration, and monitoring drug use in the population.  

Prevalence and Neurobiology 

The selected type of bipolar disorder for analysis in the project is bipolar I disorder. Bipolar I disorder is a mental disorder characterized by patients experiencing episodes of irritable or highly elevated mood. The mood is referred to as mania. The expansive mood may be accompanied by other symptoms such as grandiosity, decreased need for sleep, racing thoughts, talkativeness, and engaging in risk-taking behaviors. The mood swings may shift between irritability, depression, anger and mania, resulting in mixed features in the bipolar disorder (Jones et al., 2022). Bipolar I disorder affects the health, wellbeing, and functioning of the patients, hence, the need for responsive strategies to optimize outcomes.  

Bipolar I disorder has a lifetime prevalence of 0.6%. The prevalence is distributed equally between males and females. However, males tend to experience more manic episodes with the disorder while female experience more of depressive cycling episodes. The rates of bipolar I disorder is high in the developed countries (1.4%) as compared to the low-income countries (0.7%). Separated, widowed, or divorced individuals have the highest rate of bipolar I disorder. The cumulative prevalence of the three types of bipolar disorders is 1.8%. The onset of bipolar I disorder in the USA is at the age of 20 years while it is 29 years in the European countries (Psychdb.com, 2022). The prevalence rate among adults aged 18 years and above is 2.8%, with 4.4% of this population expected to develop it at some point in their lives. Adolescents have a lifetime prevalence of 2.9% of developing bipolar I disorder, with 2.6% of them suffering from severe impairment (Psychom.net, 2021). The risk factors for developing bipolar I disorder include genetics and environment risks such as traumatic experiences, substance abuse, and maternal vital infections during the prenatal period.  

Bipolar I disorder has neurobiological basis. First, most studies have shown that individuals with bipolar disorder, including bipolar I experience death of neurons and glial cells. Persistent exposure to stress or traumatic events affects the functioning of glial cells and neurons, precipitating the onset of symptoms. There is also the role of neurotransmitters in the development of bipolar disorder. Accordingly, patients with bipolar disorder demonstrate changes in the regulation of dopamine, serotonin, and acetylcholine neurotransmitters (Young & Juruena, 2021). Alterations in the balance as well as their receptor systems affect functions such as behavior, endocrine regulation, and sleep-wakefulness.  

Patients with bipolar I disorder also have problems with intracellular signaling in their brains. Studies have found the existence of macroscopic changes in brain regions and circuits, which are accompanied by chemical and histopathological brain changes. Stressors promote oxidative processes, which destroy brain cells, neurons, and cause imbalance in chemicals causing symptoms of bipolar I disorder (Scaini et al., 2020). For instance, there is an increase in the activity of chemical superoxide dismutase, which can depression and manic episodes in the affected patients.  

Differences 

A comparison is made between bipolar I and bipolar II disorder. The both types of bipolar have periods of depressive symptoms and elevated mood. The disorders also share similar symptoms during manic episode such as euphoria, insomnia, excessive talking, racing thoughts, and inflated self-esteem.  They also have the same symptoms of depression such as low energy, sadness, decreased appetite, feelings of guilt, and isolation (Jones et al., 2022). However, they have some differences. The first one is that patients experience full manic episodes in bipolar I disorder. They experience extreme shifts in energy and mood. The symptoms are severe to affect the functioning of the patients in the social and occupational roles. The symptoms of mania and depression are less severe in bipolar II disorder. For example, hypomanic symptoms in this disorder such as elevated mood are not intense to affect the individual’s functioning. The depressive symptoms in bipolar I disorder lasts at least two weeks while in bipolar II they last at least two weeks but longer than bipolar I. Patients experiencing bipolar I disorder also have at least an episode of mania while there is no mania in bipolar II disorder (Coda, 2022). There is also the experiences of delusions and hallucinations in bipolar I disorder, which are not evident in bipolar II disorder.  

Special Population and Considerations 

Treatment of bipolar I disorder in special populations present unique challenges to mental health practitioners. The special populations include children, adolescents, pregnant mothers, post-operative adults, and the elderly. Each of this populations have unique needs that influence the selection of treatment in bipolar disorders. Children and adolescents have immature organs such as the liver and kidneys. These vital organs are involved in the metabolism and excretion of the different drugs used in treating bipolar disorders. Psychiatric mental health nurse practitioners must weigh the benefits and risks of the different options for treatment before prescribing them. Most of the treatments utilized for children and adolescents are also off-label. This places them at an increased risk of harm due to the use of drugs with unknown safety and efficacy index. The elderly patients also experience considerable functional declines that affect the options of treatment for bipolar disorders (Healthcare, 2023; Skidmore-Roth, 2022). For example, the decline in renal and hepatic functions affect the dosing of different medications for use in treating bipolar I disorder. Psychiatric mental health nurse practitioners must also assess the efficacy of the different drugs to prenatal mothers to eliminate risks of teratogenicity.  

One of the legal consideration when treating bipolar I disorder is the psychiatric mental health nurse practitioner providing care within her scope. This includes ensuring the prescription of drugs for bipolar I disorder within her prescriptive authority. Practicing within the scope eliminates potential issues that may arise due to harm from the provided care. PMHNP should also make decisions based on ethical considerations. This includes seeking informed consent, and promoting privacy and confidentiality of the patients’ data. The nurse must also ensure safety in the care process. The prescribed treatments should not predispose the special populations to any harm. The decisions made should also aim at safeguarding the rights and needs of the patients, hence, non-maleficence and benevolence. PMHNP should also adopt patient-centered interventions in bipolar I disorder management. This includes utilizing interventions that align with the values, beliefs, practices, and expectations of the patients and their families (Healthcare, 2023; Williams, 2021). The consideration of patient factors in the treatment process promotes outcomes such as enhanced adherence to the prescribed interventions.  

FDA and or Clinical Practice Guidelines 

The Food and Drug Administration (FDA) is mandated with the responsibility of recommending drugs for use in treating conditions in different populations. The FDA has approved olanzapine-fluoxetine combination for treatment of bipolar disorder with depressive symptoms. The other approved drugs for acute treatment of bipolar depression include quetiapine and lurasidone. The FDA has also approved Risperdal, quetiapine, and aripiprazole for use in children and adolescents experiencing any stage of bipolar disorder. Lithium is approved for use in adolescents aged 12 and above years (Skidmore-Roth, 2022). Olanzapine recommendations is used for adolescents aged 13 years and above. The FDA also recommends lithium and aripiprazole use in children and adolescents to prevent symptom relapse. The FDA has also approved caplyta for treating bipolar disorder in the elderly population. The FDA approved treatment for mixed bipolar disorder entails the use of quetiapine and combination of fluoxetine and olanzapine (Citrome, 2020; Wang & Osser, 2020). Healthcare providers may also consider antipsychotics such as aripiprazole, asenapine, risperidone, and ziprasidone for maintenance treatment, as they are FDA approved.  

Side Effects, FDA Warnings and Monitoring 

Safety and quality should be upheld when treating patients with bipolar disorder. As a result, patients should be monitored closely for side effects and adverse reactions to the above treatments. The healthcare providers should monitor patients prescribed Risperdal, quetiapine, and aripiprazole for side effects that include weight gain, dizziness, akathisia, tiredness, nausea, night tremors, and decreased libido. They should also assess for increased appetite, drowsiness, and heartburn. Rare side effects that must be reported include seizures, parkinsonian side effects such as tremors and muscle stiffness, changes in ECG, and neuroleptic malignant syndrome (Healthcare, 2023; Williams, 2021). The signs to monitor related to neuroleptic malignant syndrome include fainting spells, racing heart rate, fever, and muscle stiffness.  

Patients prescribed lithium should be monitored for side effects that include drowsiness, bradycardia, fainting, confusion, and weight gain. The additional side effects include diarrhea, seizures, blurred vision, tinnitus, and vomiting. Patients prescribed fluoxetine should be monitored for side effects such as weight gain, decreased libido, and insomnia. The use of antidepressants such as fluoxetine carriers the risk of suicidal thoughts, attempts, or plans. Patients and family members should be educated about the importance of monitoring mood and sudden surge in the patient’s energy. Such observations are clues to potential intent of self-harm by the patient. Weight gain in already obese or overweight patients should also be considered an issue of concern (Skidmore-Roth, 2022). Patients should be referred to a nutritionist for dietary recommendations and be educated about the importance of healthy lifestyles and behaviors such as engaging in active physical activity.  

Proper Prescription 

Name: Mr. V 

Age: 35 

Diagnosis: Bipolar I disorder 

Treatment: po risperidone 2 mg od 1/12 

Refills: none 

Signature:  

Name: AA 

Age: 15 

Diagnosis: Bipolar I disorder 

Treatment: po Lithium 300mg od 1/12 

Refills: none 

Signature:  

Name: Mrs. W 

Age: 25 

Diagnosis: Bipolar I disorder 

Treatment: po risperidone 3mg od 1/12 

Refills: none 

Signature:  

Conclusion 

In summary, bipolar I disorder is a type of a mental health disorder associated with severe mania and hypomania. It affects negatively patient’s health, wellbeing, and functioning. Bipolar I disorder is severe than bipolar II. The FDA has approved several drugs for use in bipolar disorder. Psychiatric mental health nurse practitioners should monitor patients for side and adverse reactions to the prescribed treatments. 

References 

Citrome, L. (2020). Food and Drug Administration–Approved Treatments for Acute Bipolar Depression: What We Have and What We Need. Journal of Clinical Psychopharmacology, 40(4), 334. https://doi.org/10.1097/JCP.0000000000001227 

Coda, F. (2022). 2023 Foundations of Psychiatric-Mental Health Nursing. Amazon Digital Services LLC – Kdp. 

Healthcare, S. (2023). Pharmacology, Nutrition, Paediatric Nursing—2023. Svastham Healthcare. 

Jones, D. J. S., Jones, J. S., & Beauvais, D. A. M. (2022). Psychiatric Mental Health Nursing: An Interpersonal Approach. Jones & Bartlett Learning. 

Psychdb.com. (2022, January 16). Bipolar I Disorder. PsychDB. https://www.psychdb.com/bipolar/bipolar-i 

Psychom.net. (2021, July 14). Prevalence of Bipolar 1 Disorder. https://pro.psycom.net/assessment-diagnosis-adherence/bipolar-disorder/bipolar-disorder-prevalence-and-risks 

Scaini, G., Valvassori, S. S., Diaz, A. P., Lima, C. N., Benevenuto, D., Fries, G. R., & Quevedo, J. (2020). Neurobiology of bipolar disorders: A review of genetic components, signaling pathways, biochemical changes, and neuroimaging findings. Brazilian Journal of Psychiatry, 42, 536–551. https://doi.org/10.1590/1516-4446-2019-0732 

Skidmore-Roth, L. (2022). Mosby’s 2023 Nursing Drug Reference—E-Book. Elsevier Health Sciences. 

Wang, D., & Osser, D. N. (2020). The Psychopharmacology Algorithm Project at the Harvard South Shore Program: An update on bipolar depression. Bipolar Disorders, 22(5), 472–489. https://doi.org/10.1111/bdi.12860 

Williams, L. (2021). Nursing 2022: Drug Handbook. Independently Published. 

Young, A. H., & Juruena, M. F. (2021). The Neurobiology of Bipolar Disorder. Current Topics in Behavioral Neurosciences, 48, 1–20. https://doi.org/10.1007/7854_2020_179 

Sample Answer 3 for NURS 6630 Assessing and Treating Patients With Bipolar Disorder

In the provided case study, the 8-year-old Caucasian female patient came to the clinic accompanied by her parents for psychiatric evaluation. The patient’s teacher suggested that the patient might be having attention deficit hyperactivity disorder (ADHD). Their family physician also suggested that the patient should see a psychiatrist for further evaluation of her mental disorder. The patient parents came with a completed Conner’s Teacher Rating Scale-Revised screening tool, which revealed that the patient is easily distracted at school, and with a short attention span. The patient also displayed poor arithmetic, spelling, and reading skills in addition to being inattentive and forgetful most of the time. Her teacher claims that the patient even failing to complete her homework will lack interest in school activities. She also fails to follow instructions at times. Despite the patient’s parents being in denial that their daughter has ADHD, mental status examination results proved otherwise together with the Conner’s Teacher Rating Scale-Revised screening tool completed by the teacher, supporting the diagnosis of attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.

Developing a treatment plan for pediatric patients with mental disorders is quite challenging given the safety issues associated with this age group. However, appropriate prescriptive practice will involve considering patient-specific factors that might affect the pharmacokinetic and pharmacodynamic processes. Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. The purpose of this discussion is thus to demonstrate the appropriate decision-making process in the selection of the most appropriate intervention in the treatment of the 8-year-old attention deficit hyperactivity disorder (ADHD), predominantly inattentive presentation.

Decision Point One

Selected Decision and Rationale

From the listed options, initiating Ritalin (methylphenidate) 10mg chewable tablets taken every morning was decided on as the initial intervention. Ritalin is recommended by most clinical guidelines as the first-line medication for the management of ADHD among both children and adults (Rodrigues et al., 2021). Despite the psychostimulant not being approved by the FDA, it has displayed great effectiveness in the management of ADHD with a desirable safety profile in most children from ages 6 to 15 years (American Psychiatric Association, 2013; Castells et al., 2021)). It has demonstrated a substantial impact in managing ADHD symptoms such as inattention, forgetfulness, impulsivity, diminished interest, and hyperactivity among children (Hodgkins et al., 2012). The chewable formulation is considered the best option for children with sweeteners to mask the bitter taste of the drug (Breaux et al., 2022). Consequently, the drug has a short onset of action of between 1 to 2 hours with a long duration of action of between 7.5 to 10.5 hours after oral administration (Mechler et al., 2021). This helps in the management of the patient’s symptoms all day long (Coghill et al., 2021).

Bupropion is associated with increased risks of seizures among children below the age of 10 years, hence not an appropriate decision (Coghill et al., 2021). Intuniv on the other hand is associated with cardiovascular side effects, hence should only be considered in case there is no other safer and more effective drug for use in the pediatric population (Rodrigues et al., 2021).

Expected Outcome

The patient will experience improved symptoms of ADHD in the next four weeks (Coghill et al., 2021). She should be able to improve her spelling, arithmetic, and language skills, in addition to being more attentive and able to concentrate on school work (Hodgkins et al., 2012). Her school performance will improve significantly within this period.

Ethical Considerations

The patient is 8 years of age, which gives the parents legal responsibility of making decisions concerning the health of their child (American Psychiatric Association, 2013). As such, the PMHNP must educate them adequately regarding the patient’s diagnosis and potential treatment options, to promote sound decision-making in promoting the health of their child (Rodrigues et al., 2021).

Decision Point Two

Selected Decision and Rationale

The second decision was to change the treatment regimen to long-acting Ritalin 20mg administered orally in the morning. Based on the treatment outcome, Ritalin displayed potential effectiveness given that the patient’s ADHD symptoms improved evidenced by her improved school performance (Breaux et al., 2022). However, since the medication was not able to manage the patient’s symptoms throughout the entire day, it was necessary to introduce a long-acting formulation to prolong the duration of action of the drug (American Psychiatric Association, 2013). Studies show that long-acting Ritalin lasts for between 8 to 12 hours hence, helps in managing the patient’s symptoms throughout the day (Castells et al., 2021). It is also administered once daily which is more convenient and much easier. The patient also reported a side effect of elevated pulse, which is a common self-limiting side effect of Ritalin that is expected to diminish with time (Coghill et al., 2021).

Continuing with the same drug at the same dosage was inappropriate as the patient would still exhibit ADHD symptoms later in the day, once the drug wears off from the body system (Mechler et al., 2021). Replacing Ritalin with Adderall is also inappropriate as Adderall is associated with increased incidences of suicidal events when used among children (Hodgkins et al., 2012).

Expected Outcome

The long-acting formulation is expected to manage the patient’s symptoms all day long within the following four weeks (Breaux et al., 2022). The patient’s school performance will improve even further. The side effect of elevated heart rate will resolve completely within this time (Coghill et al., 2021).

Ethical Considerations

In making this decision, the PMHNP had to consider several ethical principles including justice, beneficence, nonmaleficence, and respect for the patient’s autonomy (Breaux et al., 2022). The patient was quite comfortable with how the drug was working, but only concerned with the side effect, and effectiveness of the medication later in the day (Rodrigues et al., 2021). As such, it was necessary to respect the patient and display clinical judgment in making decisions that will promote the patient’s mental health.

Decision Point Three

Selected Decision and Rationale

Maintaining the patient on the current medication and reevaluating after four weeks, seemed to be the most appropriate decision for the third intervention. The patient reported great effectiveness and tolerance to the medication, with resolved side effects of an elevated pulse (Mechler et al., 2021). Previous evidence shows that once the optimal dose of Ritalin has been attained, it can take between 8 to 12 weeks to completely manage the patient’s symptoms of ADHD (American Psychiatric Association, 2013; Castells et al., 2021). Consequently, at safe doses, long-term use of the drug has been associated with limited possibilities of side effects, hence the need to reevaluate the patient within 4 weeks (Hodgkins et al., 2012). Studies also show that long-term use of Ritalin normally reduces the risks of side effects as the patient will display further tolerance to the drug, enhancing its safety profile (Breaux et al., 2022).

Increasing the dose of Ritalin to 30mg was not necessary at this point, as studies suggest that low effective doses are safer to use to promote positive outcomes, with reduced risks of side effects (Mechler et al., 2021). Consequently, obtaining EKG at this point was not necessary given that the patient’s pulse had already resolved back to normal for her age, with a recording of 92 during the current visit (Rodrigues et al., 2021).

Expected Outcome

With great compliance to the treatment regimen, the patient will report even further management of the ADHD symptoms over the following two weeks (Breaux et al., 2022). Her academic performance is also expected to improve (American Psychiatric Association, 2013). No side effects are expected.

Ethical Considerations

The nurse’s main objective is to promote the health of the patient and not harm. At this point, the patient was satisfied with the treatment outcome (Hodgkins et al., 2012). It was thus necessary to respect the patient’s autonomy and maintain the dose for further evaluation of the treatment outcome (Mechler et al., 2021).

Conclusion

The 8-year-old patient in the case study presented with symptoms of ADHD. Formulating a treatment plan for the patient involved consideration of certain patient-specific factors which affect her pharmacokinetic and pharmacodynamic processes (American Psychiatric Association, 2013). Such factors which will affect the decision on which drugs to prescribe include the patient young age, Caucasian race, female gender, ADHD diagnosis, and presenting symptoms. Based on these factors, the first decision was to initiate a 10mg Ritalin chewable table once daily as recommended by most clinical guidelines given its effectiveness in the management of ADHD and safety for pediatric use (Coghill et al., 2021). Intuniv and bupropion were neglected because of their increased risks of side effects among children as reported by most studies (Mechler et al., 2021). After 4 weeks, the patient came back to the clinic reporting improved symptoms but with side effects of increased pulse rate. The second decision was thus to change the treatment regimen to long-acting Ritalin 20mg once daily in the morning, to prolong the duration of action of the medication throughout the day (Castells et al., 2021). Maintaining the dose would still lead to ineffectiveness, while Adderall display increased risks of suicidality hence neglected (Breaux et al., 2022).

The patient reported further improvement in ADHD symptoms all day long, with resolved side effects of elevated pulse, which led to the final decision of maintaining the treatment regimen and reevaluating the patient after 4 weeks. Obtaining EKG and increasing the dose of Ritalin was not necessarily due to safety issues (Hodgkins et al., 2012). Finally, the PMHNP encountered several ethical considerations in each decision process with the observation of ethical principles such as justice, respect for patient autonomy, not harm, and beneficence (Rodrigues et al., 2021).

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Breaux, R., Dunn, N. C., Swanson, C. S., Larkin, E., Waxmonsky, J., & Baweja, M. D. (2022). A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD. Frontiers in Psychiatry, 151. https://doi.org/10.3389/fpsyt.2022.794044

Castells, X., Ramon, M., Cunill, R., Olivé, C., & Serrano, D. (2021). Relationship between treatment duration and efficacy of pharmacological treatment for ADHD: a meta-analysis and meta-regression of 87 randomized controlled clinical trials. Journal of attention disorders, 25(10), 1352-1361. https://doi.org/10.1177/1087054720903372

Coghill, D., Banaschewski, T., Cortese, S., Asherson, P., Brandeis, D., Buitelaar, J., … & Simonoff, E. (2021). The management of ADHD in children and adolescents: bringing evidence to the clinic: perspective from the European ADHD Guidelines Group (EAGG). European Child & Adolescent Psychiatry, 1-25. https://doi.org/10.1007/s00787-021-01871-x

Hodgkins, P., Shaw, M., McCarthy, S., & Sallee, F. R. (2012). The pharmacology and clinical outcomes of amphetamines to treat ADHD: Does composition matter? CNS Drugs, 26(3), 245–268. https://doi.org/10.2165/11599630-000000000-00000

Mechler, K., Banaschewski, T., Hohmann, S., & Häge, A. (2021). Evidence-based pharmacological treatment options for ADHD in children and adolescents. Pharmacology & Therapeutics, 107940. https://doi.org/10.1016/j.pharmthera.2021.107940

Rodrigues, R., Lai, M. C., Beswick, A., Gorman, D. A., Anagnostou, E., Szatmari, P., … & Ameis, S. H. (2021). Practitioner Review: Pharmacological treatment of attention‐deficit/hyperactivity disorder symptoms in children and youth with autism spectrum disorder: a systematic review and meta‐analysis. Journal of Child Psychology and Psychiatry, 62(6), 680-700. https://doi.org/10.1111/jcpp.13305

NURS 6630 Week 6 Patient Case Scenario Debate Discussion Sample

Introduction 

     For many patients, both depression and attention deficit hyperactivity disorder (ADHD) are chronic conditions. This co-occurrence presents significant challenges for clinicians when crafting treatment plans. Major depression can often worsen ADHD symptoms and dysfunctions. In fact, patients with ADHD who have depression might experience more severe impairments compared to those with depression alone. This can further complicate achieving positive treatment outcomes. Finding the right medication to address both conditions simultaneously can be a significant hurdle for clinicians. This discussion will explore the potential cons of using methylphenidate medications like Ritalin and other common formulations in combination with paroxetine to treat comorbid ADHD and depression. 

Mechanism of Action and Appropriateness for Patient 

     Methylphenidate works by influencing the way certain brain chemicals communicate. It acts by blocking the reuptake of two important messengers, dopamine and norepinephrine, in brain cells. Normally, these messengers are released and then reabsorbed by the cells that sent them. Methylphenidate disrupts this process, allowing dopamine and norepinephrine to remain for a longer time in the space between brain cells, called the synaptic cleft (Verghese & Abdijadid, 2023). While this medication is effective in treating ADHD due to the actions that take place in the prefrontal cortex of the brain, the medication combined with Paroxetine can have adverse effects and must be monitored very carefully if prescribed. For this reason, I am arguing the cons of using these medications with Paroxetine to treat this patient’s depression. 

Disadvantages of using Methylphenidate 

     Serotonin syndrome (SS) is a potentially life-threatening condition caused by excessive serotonin levels in the brain. This can occur when medications that elevate serotonin, like SSRIs, are combined with others that influence serotonin indirectly. While research by Poilan & Chiavegatto suggests methylphenidate lacks direct affinity for serotonin receptors, it appears to increase 5-HT release and postsynaptic 5-HT1A receptor sensitivity when combined with SSRI medications (2023). This potential, particularly when combined with SSRIs, raises the concern for serotonin syndrome. 

Disadvantages or Advantages of Other Medications 

      Amphetamines like methylphenidate combined with Paroxetine increase the patient’s risk of of SS. According to Poilan & Chiavegatto, Amphetamines like methylphenidates can lead to SS due to an increase in 5-HT release and postsynaptic 5-HT1 A receptor sensitivity(2023). Therefore this medication has the same disadvantage 

     The interaction between some Alpha adrenergic antagonists and paroxetine can increase the toxicity of the other medications, as in the combination of clonidine and Paxil (Drug interaction checker,n.d.). Although they can be used together, they must be monitored closely. While Strattera, a non-stimulant medication for ADHD, can be used with Paroxetine, it can notably elevate atomoxetine levels in the bloodstream, leading to a greater occurrence of side effects like dizziness, dry mouth, sleep issues, and heart palpitations (Paroxetine and Strattera Interactions n.d.). Paroxetine potentiates the effects of atomoxetine by inhibiting the CYP2D6 enzyme responsible for its metabolism in the liver. While this combination can be explored cautiously, it necessitates a reduced initial dose of atomoxetine to minimize potential side effects (Drug interaction checker n.d.). Of the four types of drug classes, I would prescribe a non-stimulant for the patient in this case study. 

Side Effects to be Evaluated 

     Close monitoring is crucial when prescribing methylphenidate and paroxetine concurrently due to the potential for serotonin syndrome. This serious condition arises from excessive serotonin levels in the brain. Be alert for changes in vital signs, including elevated temperatures exceeding 104°F, tachycardia, hypertension, and breathing tachypnea (Poilan & Chiavegatto, 2023). Additionally, monitor for alterations in mental status such as delirium, agitation, and even coma. Other signs suggestive of serotonin syndrome include tremors, diaphoresis, and hyperactive bowel sounds. 

Legal, Ethical, and Social Implications for Prescribing Methylphenidate with Paroxetine 

     As a future PMHNP, the decision to prescribe medication involves a careful risk-benefit analysis. While psychotropic medications can offer significant improvements, they also carry the potential for side effects, as Methylphenidate and Paroxetine carry the risk of SS. I must consider common and potentially serious side effects associated with the medication being considered, as well as other medical conditions that increase their risk of experiencing side effects. Prescribing medication is a cornerstone of treatment, but it carries a crucial responsibility: ensuring patient safety. Failing to consider potential drug interactions can have severe consequences. Patients could experience serious side effects, some potentially life-threatening. Beyond the immediate harm to patients, neglecting this aspect of care also exposes myself to legal ramifications. Medical malpractice lawsuits could arise if a medication interaction leads to adverse outcomes. In extreme cases of negligence, this could even result in license suspension or, in rare instances, criminal charges. 

      The ethical issue with prescribing Methylphenidate for me is the patient’s age. Individuals in this age group are known to use Methylphenidate such as Ritalin and Adderall and, to some extent, abuse them. Aikins reports that the use of cognitive-enhancing drugs (CEDs) represents a recent phenomenon at the crossroads of modern medicine and the intense academic pressure within meritocratic societies(2019). Particularly prevalent among college students in the United States, CEDs have become a growing concern. College health resources and popular media extensively document this trend, highlighting the increasing reliance on these study aids by achievement-oriented students (Aikins, 2019). 

     Lastly, research suggests significant disparities in the use of cognitive-enhancing drugs (CEDs) across various demographics. Studies reveal that non-medical use of prescription stimulants (NMUPS) is nearly three times more prevalent among white students compared to Black and Latino students (Aikins, 2019). Additionally, men are reported to be twice as likely to use NMUPS than women. These disparities are likely connected to the complex interplay between socioeconomic status, racial background, and access to mental healthcare (Aikins, 2019). 

Conclusion 

     As a future PMHNP address, this discussion has helped me to realize the importance of understanding how medications work in your body. Through careful analysis of the four types of medications, I was able to decide to argue against prescribing of Methylphenidate due to the risk of SS when combined with Paroxetine. Furthermore, due to the legal, ethical, and social issues of using medications such as Ritalin and Adderall, I believe my decision was best for the patient. 

References 

Aikins, R. (2019). “The White Version of Cheating?” Ethical and Social Equity Concerns of Cognitive Enhancing Drug Users in Higher Education. Journal of Academic Ethics, 17(2), 111. https://doi.org/10.1007/s10805-018-9320-7 

Drug interaction checker. Drug Interactions Checker – Medscape Drug Reference Database. (n.d.). https://reference.medscape.com/drug-interactionchecker 

Paroxetine and Strattera Interactions. Drugs.com. (n.d.). https://www.drugs.com/drug-interactions/paroxetine-with-strattera-1800-0-275-1683.html#:~:text=PARoxetine%20may%20significantly%20increase%20the,have%20any%20questions%20or%20concerns. 

Poian, L. R., & Chiavegatto, S. (2023). Serotonin Syndrome: The Role of Pharmacology in Understanding Its Occurrence. Cureus, 15(5), e38897. https://doi.org/10.7759/cureus.38897 

Verghese C, Abdijadid S. Methylphenidate. [Updated 2023 Jan 2]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482451/