Fluent Essays

Replies Reply Posts Instructions Critique the decision making of two of your peers in your response post. Do you agree/disagree with their medication choice? Why? Is there anything else you recommend including? Compare peers decision making to yours—what are the advantages and disadvantages of each? Your response should include evidence of review of the course material through proper citations using APA format. Reply separately to two of your classmates’ post (see attached classmates, post#1 and post#2) Your response should include evidence-based research to support your statements using proper citations and APA format. Please, send me the two documents separately, for example one is the reply to my peers Post#1, and the second one is the reply to my other peer Post#2. -Minimum of 300 words per peer reply. -Turnitin Assignment. Background: I live in South Florida; I am currently enrolled in the Psych Mental Health Practitioner Program. I am a Family Nurse Practitioner working in psychiatric area. Bipolar Case Study by Barbra Scheirer 1. What information, if any, would you like to know that was not included in the case? There is a lot of information not given in the scenario and what was given by the patient may or may not be reliable. I would like to know if he has any mediation allergies, any medical history, any psychiatric history, if he smokes, drinks, or does drugs. It would also be helpful to know if the patient is agreeable to be on medications. I would like to confirm any family history of any psychiatric illnesses. I would like to know if the patient had any prior episodes of mania or depression, and if the voices he hears are telling him to harm himself or others. I would like to know if he has had any recent stressors or if the patient knows what caused his symptoms to begin. I would also like to know how long his symptoms have been continuing. 2. Which psychiatric symptoms are a treatment priority for this case? His mania and associated symptoms including hallucinations, lack of sleep, psychosis, flight of thoughts, rapid speech, ideas of grandeur, and delusions (McIntyre et al., 2020). 3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)? The only non-pharmacologic issue in this case that I can identify is his relationship with his co-worker who makes fun of him. 4. List one medication that would be appropriate for this case. Include the name and starting dose. I would prescribe Lithium 300mg po BID and adjust per plasma levels of 0.8 mEq/L (Puzantian & Carlat, 2016). 5. Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on. I choose lithium because it is the gold standard for bipolar disorder and is more useful for euphoric mania than for mixed and rapid-cycling types of bipolar disorder (Puzantian & Carlat, 2016). It is also known for its anti-suicide effects in bipolar and unipolar mood disorders (Puzantian & Carlat, 2016). Lithium has been found to reduce manic symptoms substantially (Stahl, 2013). Mechanism of action is unknown and complex. Lithium alters the sodium transport across the cell membranes in nerve and muscle cells (Stahl, 2017). It inhibits inositol monophosphatase, may alter intracellular signaling through actions on secondary messaging systems, it reduces protein kinase C activity, and increases cytoprotective proteins (Stahl, 2017). 6. What laboratory testing/monitoring is needed for safely prescribing this medication? Baseline electrolytes including kidney function, urine specific gravity, lithium level every 1-2 weeks until desired serum level is achieved, then every 2-3 months for the first 6 months, then every 6-12 months, once stable (Stahl, 2017). I would also check TSH level on initiation (Puzantian & Carlat, 2016). Weight should also be monitored (Stahl, 2017). 7. Are there any contraindications or safety issues associated with this medication? Lithium is contraindicated in patients with renal failure, cardiovascular insufficiency, Addison’s disease, and untreated hypothyroidism (Chokawala et al., 2021). I would not use lithium if a patient has Brugada syndrome, severe dehydration, sodium depletion, or an allergy to lithium (Stahl, 2017). 8. What non-pharmacologic interventions do you recommend? Do you recommend, including, but not limited to psychotherapy, complimentary and holistic therapies? I would recommend CBT therapy, family-focused therapy, psychoeducation, exercise, and balanced diet. Psycho-education (PE) is educating a patient regarding the illness and treatment when applied to mental disorders (Naik, 2015). Family-focused therapy (FFT) focuses on reducing high levels of stress and conflict in families of bipolar patients, thereby improving the patient’s illness course (Naik, 2015). I would also try to get John on a sleep schedule. I would suggest John try to avoid over-stimulating activities. I would suggest stress-reduction techniques. 9. What are the safety concerns, if any, associated with this case? How will you address safety? I would address safety concerns such as suicide risk with a screening tool and have the patient contract for safety. I am also concerned with the patient not getting any sleep and him inadvertently get hurt at work or hurting himself or others by operating a car while not being able to focus on his activity. I would admit John to the hospital stabilize his mood, titrate his medication, and start psychotherapy. 10. When would you follow up with this patient? Once discharged, I would follow up with this patient 2 weeks after discharge to evaluate his symptoms and need for medication adjustments. Hanging indentations were not retained References Chokawala, K., Lee, S., & Saadabadi, A. (2021). Lithium. StatPearls. Retrieved October 12, 2021, from https://www.ncbi.nlm.nih.gov/books/NBK499992/ McIntyre, R., Goldstein, B., Lopez-Jaramillo, C., Malhi, G., Neirenberg, A., & Majeed, A. (2020). Bipolar disorders. The Lancet, 396(10265), 1841–1856. https://doi.org/10.1016/50140-6736(20)31544-0 Naik, S. (2015). Management of bipolar disorders in women by nonpharmacological methods. Indian Journal of Psychiatry, 57(6), 264. https://doi.org/10.4103/0019-5545.161490 Puzantian, T., & Carlat, D. (2016). Medication fact book for psychiatric practice (3rd ed.). Carlat Publishing. Stahl, S. (2013). Stahls essential psychopharmacology (4th ed.). Cambridge University Press. Stahl, S. (2017). Stahls essential psychopharmacology prescribers guide (6th ed.). Cambridge University Press. 2 2 BIPOLAR CASE STUDY Ivan Oliva Regis College Course Number: Course Name Instructor’s Name Nicole Walters Assignment Due Date 10-15-21 Week 7 Discussion 1: Bipolar Case Study Identification of target symptoms/problems 1. What information, if any, would you like to know that was not included in the case? The provider in the case study has explored most of the information, including the patient’s symptoms, past medication, family history, etc. However, one of the areas that I would explore that was not included in the case study is the environmental factors. It is crucial to examine whether the patient had experienced some disturbing events in his surrounding that could have resulted in the depressive and manic symptoms. Another critical thing that I would inquire about is the significant changes in the patients life, i.e., whether he has gone through a divorce. 2. Which psychiatric symptoms are a treatment priority for this case? Some psychiatry symptoms that are a priority in this case study include; manic symptoms such as high energy, reduced need for sleep, and the loss of touch with reality. According to the case study, the patient sent different letters to different individuals, including the Pope and Tony Blair. He also talks about having a reduced need for sleep over the last few days. The patient has also lost touch with reality; he believes that God is speaking to him. On the other side, I would prioritize the depressive symptoms, including loss of energy during the interview, hopelessness, and sadness. 3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)? Some of the non-pharmacologic issues in the case study that the medication cannot address are anger issues, change of emotion, and thoughts. The patient exhibits anger issues on several occasions. First, after being irritated by his mate, Dave, the patient becomes angry. He also becomes angry because the previous G.P. cannot address his problems. Besides, he is irritated when the provider tells him that he does not seem to be well. Medications cannot effectively address such issues; only psychotherapies such as CBT can address them best. Medication Choice 1 4. List one medication that would be appropriate for this case. Include the name and starting dose. The medication that would best help the patient manage his symptoms is the atypical antipsychotics, Quetiapine (Seroquel). Dosage; I.R. 50 mg 1 Tab PO BID; adjust the dose according to response, maximum 800 mg/day (Ketter et al., 2016). 5. Describe your clinical decision-making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice and the neurotransmitters and areas of the brain on which the medication is proposed to act. Quetiapine would best address the symptoms exhibited in the case study because it re-balances the dopamine and serotonin in an individual’s brain; thus, improving thinking, mood, and behavior. Quetiapine is a second-generation antipsychotic with a high affinity for D2, 5-HT2A, H1, alpha 1, and 5-HT1A receptors (Abdyrakhmanova et al., 2021). In its mechanism of action, this medication reduces dopaminergic neurotransmission in the mesolimbic pathways; thus, eliminating the manic and depressive symptoms in a patient. If the patient in the case study takes this medication, he is likely to manage the severity of his manic and depressive symptoms. 6. What laboratory testing/monitoring is needed for safely prescribing this medication? Various laboratory tests needed before administering this medication are as follows. One of the tests is fasting blood lipid testing; this is monitored at the start and periodically during the treatment to examine the amount of cholesterol in the patient’s blood (Vatsalya et al., 2016). Another test required is the Body Mass Index (BMI); this measures the patients weight and whether it is suitable for the medication. And the last lab test is a complete blood count (CBC) to evaluate the cells circulating in the patient’s blood. 7. Are there any contraindications or safety issues associated with this medication? Quetiapine has various contraindications or safety issues. One of them is that individuals with low thyroid hormone levels should not take the medication because it might lower metabolism in an individual; thus, causing weight gain or feeling tired. Another safety concern is that the medication should not be administered to individuals with low magnesium and potassium levels in the blood (Kim et al., 2016). Quetiapines administration on individuals with low magnesium or potassium levels in the blood might lead to sedation, weight gain, or postural hypotension. And the last contraindication is that the medication should not be administered to individuals with high blood pressure because it might further complicate the situation, leading to death. Non pharmacologic Interventions 8. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complementary and holistic therapies? One of the non-pharmacological interventions that I would recommend to the patient is Cognitive Behavioral Therapy (CBT). CBT works by changing the patient’s patterns of thoughts, thus, addressing the manic and the depressive symptoms (Ellard et al., 2018). CBT helps the patient recognize the warning signs of a mood change, thus, helping them change the unhealthy patterns. Another strategy that can be used in the case study to manage the symptoms is reflexology. This technique focuses on applying pressure to the foot, which eventually brings relaxation and a healing effect on the mind. As a result, the patient efficiently manages the depressive and manic symptoms. And the last strategy is meditation; this helps individuals disengage from the stressful and anxious thoughts; thus, better controlling their moods. Safety Risk Assessment 9. What are the safety concerns, if any, associated with this case? How will you address safety? The safety concern associated with this case is getting rid of the drugs. The patient in the case study does not believe that he is suffering from any mental issues; therefore, he is likely to get rid of any medication prescribed to him by the provider. Such a safety concern can be addressed by connecting the patient to family and close relatives to minimize the severity of the symptoms. 10. When would you follow up with this patient? The first follow-up will take place in 7 days, then in two weeks as per the patient’s progress. References Abdyrakhmanova, A. K., Shnayder, N. A., Neznanov, N. G., & Nasyrova, R. F. (2021). Pharmacogenetics of quetiapine. Personalized Psychiatry and Neurology, 1(1), 73-83. Ellard, K. K., Gosai, A. G., Bernstein, E. E., Kaur, N., Sylvia, L. G., Camprodon, J. A., ... & Deckersbach, T. (2018). Intrinsic functional neurocircuitry associated with treatment response to transdiagnostic CBT in bipolar disorder with anxiety. Journal of affective disorders, 238, 383-391. Ketter, T. A., Miller, S., Dell’Osso, B., & Wang, P. W. (2016). Treatment of bipolar disorder: Review of evidence regarding quetiapine and lithium. Journal of affective disorders, 191, 256-273. Kim, A., Lim, K. S., Lee, H., Chung, H., Yoon, S. H., Yu, K. S., ... & Chung, J. Y. (2016). A thorough Q.T. study to evaluate the QTc prolongation potential of two neuropsychiatric drugs, quetiapine, and escitalopram, in healthy volunteers. International clinical psychopharmacology, 31(4), 210-217. Vatsalya, V., Pandey, A., Schwandt, M. L., Cave, M. C., Barve, S. S., Ramchandani, V. A., & McClain, C. J. (2016). Safety assessment of liver injury with quetiapine fumarate X.R. management in very heavy drinking alcohol-dependent patients. Clinical drug investigation, 36(11), 935-944. 7 Bipolar Case Study Name: Course Name: Course Number: Instructor’ Name: Institution: Date of Submission: Bipolar Case Study Identification of target symptoms/problems 1. What information, if any, would you like to know that was not included in the case? For this patient, I would inquire about the status of his relationships if any. I would inquire whether he is or has been in an intimate relationship in the past. Based on his presenting symptoms and behaviors, there is likelihood that he has trouble forming relationships or maintaining them. Thus, a response indicating a past relationship that has recently had troubles would affirm a significantly compromised social life (Jarvis, 2019). It would also be important to inquire whether the patient lives alone or lives with his family members. The inquiry would seek to know whether the patient can identify any recent instances where he has had trouble with the family members and the cause of the trouble. Further, I would inquire about the patient’s spending behaviors in the recent past. Patients with manic symptoms usually demonstrate excessive and uncontrolled spending while also having regrets about those behaviors later. Inquiring about the patient’s sexual life would also be important. Patients with manic symptoms demonstrate an excessive urge for sex. The inquiry on intimacy and sex would also identify whether the patient has been practicing safe sex and whether he felt any sense of shame or guilt following any said sexual escapades. It would also be important to inquire from the patient on their feeding patterns as well as whether they have had any signs of weight loss. Considering the patient’s notable behaviors of disorganized behavior and hyperactivity, there is a chance they cannot sustain a consistent feeding pattern. Weight loss would be an indication of poor nutritional patterns probably influenced by poor feeding habits (Jarvis, 2019).  2. Which psychiatric symptoms are treatment priorities for this case? The priority symptom for treatment in John’s case is sleep. The patient admits to not having had sufficient sleep because apparently, he “does not need it” and has “enthusiasm from God”. Sleep deprivation tends to elevate manic symptoms and would allow relaxation of the patient to enable better decision-making. The second priority is delusion and confusion. The patient cannot sustain a coherent and logical conversation thus making it difficult to communicate their needs from a subjective position (Rathee, 2019). Resolving these delusions will gradually help in minimizing the feelings of grandiosity and create a sense of reality for the patient. With reality dawning on the patient, it will be possible to collaboratively manage their condition including identification of the trigger factors and methods for resolving them (AHRQ, 2014). 3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)? A major problem for John is medication adherence and nutritional issues. Based on his disorganized thoughts, it is highly likely that John cannot sustain a regular pattern including on medication. The disorganized behaviors will also affect his nutritional patterns especially in keeping a regular pattern. A third issue is John’s workplace issues. There is a risk that the patient has not been delivering well at work and has had run-ins with colleagues which explains why Dave –his mate – once told him he was “bonkers’. These issues may require a support person to help John manage his medications, maintain a regular feeding pattern, and communicate at his workplace on his current health issues (Sani et al., 2017). Medication Choice 1 4. List one medication that would be appropriate for this case. Include the name and starting dose. Lithium extended release 900mg twice daily (morning and nighttime) (Malhi et al., 2013) 5. Describe your clinical decision-making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain on which the medication is proposed to act on. Typically, a Lithium dosage of 300mg twice daily immediate release would be considered appropriate for a patient with bipolar disorder (Malhi et al., 2013). However, in this case, the patient manifests manic symptoms that tend to occur throughout the day and also disrupting his sleeping patterns. In such circumstances, an extended-release dosage would be more important. The extended release has prolonged effects and will help resolve the possible issues with medication adherence that would occur with 300mg thrice daily (Malhi et al., 2013). Lithium acts by regulating the excitatory factors dopamine and glutamate. In patients with bipolar disorder, the GABA levels and their neurotransmission are usually diminished (Malhi et al., 2013). GABA is the inhibitory factor responsible for regulating glutamate and dopamine. Lithium, therefore, causes elevations in GABA levels while also activating the GABA receptor. These outcomes cause a decrease in glutamate and dopamine levels while also causing down-regulation of the NMDA receptors further enhancing neurotransmission inhibition. The levels of dopamine and glutamate are therefore sustained at desired low levels to inhibit excitatory outcomes (Malhi et al., 2013). 6. What laboratory testing/monitoring is needed for safely prescribing this medication? Serum level testing should be conducted at regular intervals. The recommendation is to test the serum levels just before the next dosage is taken. The serum levels determine the need for dosage modification (Malhi et al., 2013).  7. Are there any contraindications or safety issues associated with this medication? Lithium demonstrates significant contraindications with antihypertensive medications such as hydrochlorothiazide. The medication also contraindicates with non-steroidal anti-inflammatory drugs (NSAIDs) drugs such as naproxen and ibuprofen. Equally, Lithium should not be administered in patients with hypertension, renal failure, unmanaged hyperthyroidism, as well as those diagnosed with Addison’s disease (Sani et al., 2017). Non pharmacologic Interventions 8. What non-pharmacologic interventions do you recommend? Including but not limited to psychotherapy, complementary and holistic therapies? For John, cognitive-behavioral therapy (CBT) and interpersonal therapy will be a priority. For CBT, the intention is to help John change his thought process that depicts grandiosity, delusion, and disorganization. CBT will gradually help John to develop a sense of reality, logic, and rationality in his decision-making (AHRQ, 2014). The significance of interpersonal therapy is to enhance John’s social skills and ability to form and sustain relationships. The feelings of grandiosity seem to be compromising John’s social life especially by causing rifts with his social circles most of whom he considers less clever. More importantly, it would be useful to integrate a support person for John especially a family member (AHRQ, 2014). John’s delusions and current manic symptoms may be enhanced by a probably isolated life. He is experiencing a state of continued destruction of his social circles occasioned by the feelings of grandiosity which do not seem to augur well with friends or people in his circle. With a support person, John can find someone to open up to and collaboratively identify the impact of his delusion on his social and occupational functioning. The support person will allow John to communicate without feeling judged or shameful. This instance of opening up is significant in the design of viable interventions including identification of the trigger factors (AHRQ, 2014). Safety Risk Assessment 9. What are the safety concerns, if any, associated with this case? How will you address safety? Agitation/irritability: The patient demonstrates signs of irritability and aggression especially when involved in an inquiry-like conversation. These feelings are exacerbated by situations that he perceives to be challenging his grandiosity. These behaviors are likely to trigger conflicts with people around him whether at work or in the workplace. Such conflicts could likely lead to physical confrontations that would lead to injuries or other adverse outcomes. The best strategy to assure his safety is to involve the support person to communicate to people at home or in the workplace about his current health issue (Rathee, 2019).  Risk for self-harm: John demonstrates significant racing thoughts that are usually accompanied by irrational decision-making. For an individual who demonstrates irritability at the smallest confrontation or challenge, he could easily experience overwhelming frustrations that can trigger negative thoughts such as suicide and other self-harm behaviors. The strategy is to limit John’s movements including a possible bed rest for at least one week. In a controlled indoor environment, John is less likely to experience triggers for possible frustrations that can elicit self-harm thoughts (AHRQ, 2014). 10. When would you follow up with this patient? John’s follow-up will be in four weeks. In the first two weeks of Lithium use, the patient usually demonstrates reasonable changes in behavior towards the desired direction. However, optimal benefits are attained in week three and even further towards week four. Importantly, the outcomes/benefits are dependent on the patient’s ability to demonstrate medication adherence through the period of medication (Baldessarini et al., 2019).  References AHRQ. (2014). Treatment for bipolar disorder. Effective Health Care Program. https://effectivehealthcare.ahrq.gov/products/bipolar-disorder-treatment/research-protocol Baldessarini, R. J., Tondo, L., & Vázquez, G. H. (2019). Pharmacological treatment of adult bipolar disorder. Molecular psychiatry, 24(2), 198-217. Jarvis, C. (2019). Physical examination & health assessment (8th ed.). St. Louis, MO: Elsevier. Malhi, G. S., Tanious, M., Das, P., Coulston, C. M., & Berk, M. (2013). Potential mechanisms of action of lithium in bipolar disorder. CNS drugs, 27(2), 135-153. Rathee, S. (2019). Psychosocial management of bipolar affective disorder. Int J Indian Psychol, 7, 404-12. Sani, G., Perugi, G., & Tondo, L. (2017). Treatment of bipolar disorder in a lifetime perspective: is lithium still the best choice? Clinical drug investigation, 37(8), 713-727.