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This case study describes a 26-year-old woman of Korean descent who was diagnosed with bipolar I disorder. Generally, bipolar disorder is a rather severe medical condition that is characterized by unusual shifts in concentration, activity levels, energy, and mood, as well as reduced ability to carry out everyday tasks (Carvalho et al., 2020). Particularly bipolar I disorder is “defined by manic episodes that last at least seven days, or by manic symptoms that are so severe that the person needs immediate hospital care” (National Institute of Mental Health [NIMH], 2020, para. 3). Depressive episodes that may last more than two weeks can also be present (Carvalho et al., 2020).
This mental disorder is typically treated with medications that may help manage symptoms. For example, treatment plans can include mood stabilizers (such as Lithobid), antipsychotics (namely, Zyprexa), and antidepressants (NIMH, 2020). To prevent triggering a manic episode, antidepressants and mood stabilizers should be combined.
There was a twenty-one-day hospitalization for the onset of acute mania. The patient’s physician reported her to be in overall good health, and lab studies were all within normal limits. During her hospitalization, there was genetic testing that revealed the woman being positive for the CYP2D6*10 allele, which negatively affects the metabolism of a number of drugs, namely mood stabilizers, antipsychotics, and antidepressants.
According to Tirona and Kim (2017), in Asians, CYP2D6∗10 that is characterized by nonsynonymous polymorphism and decreased activity is found in up to 50%. The woman confessed that she stopped taking her lithium that was prescribed in the hospital. The patient denies having auditory or visual hallucinations, and there are no signs of delusional or paranoid thought processes. What is more, the woman denies suicidal or homicidal ideation as well, though her Young Mania Rating Scale (YMRS) score is 22, which is mild mania.
The first decision step was to begin Risperdal 1mg orally twice a day. Researchers note that it is “indicated for the treatment of acute manic or mixed episodes associated with bipolar I disorder” (“Risperdal,” 2020, para. 4). Even though it is metabolized by CYP2D6, it was decided to avoid prescribing other medications and monitor the effectiveness and side effects of this drug (“Risperdal,” 2020). What is more, since it was impossible to rely on the patient and trust her about taking medicine properly after the lithium incident, prescribing only one drug and explaining the necessity of taking it was important.
The second decision point came after the patient returned to the office after four weeks. She was accompanied by her mother, who had to help her enter the office. The client looked very sedated and lethargic, and it was reported by the mother that the patient had been in this state since approximately a week after the last office visit. It was decided to decrease Risperdal to 1mg at HS. This decision was based on the necessity to avoid toxicity because it was evident that there was a problem with this drug metabolism.
In four weeks, the client returns to the office with several improvements. It becomes evident that she was compliant with the prescription, and now she appears to be less sedated and lethargic, which is the result of lowering the levels of Risperdal in her blood. What is more, her Young Mania Rating Scale has decreased from 22 to 16, which is a bit more than a 25% decrease in symptoms. Therefore, the third decision step is to continue at the same dose of Risperdal (1mg at bedtime) and reassess in four weeks. During this period, the patient is expected to get used to taking drugs and show an improvement in her mental state. After that, it may become possible to prescribe other medications and be sure that the woman will not avoid taking them.
References
Carvalho, A. F., Firth, J., & Vieta, E. (2020). Bipolar disorder. New England Journal of Medicine, 383(1), 58-66.
National Institute of Mental Health [NIMH]. (2020). Bipolar disorder. NIMH. Web.
Risperdal. (2020). RxList. Web.
Tirona, R. G., & Kim, R. B. (2017). Introduction to clinical pharmacology. In D. Robertson & G. H. Williams (Eds.), Clinical and translational science (2nd ed, pp. 365-388). Elsevier.
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