Bipolar Therapy

Bipolar Therapy


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The client is a 26-year-old woman of Korean descent who presents to her first appointment following a 21-day hospitalization for onset of acute mania. She was diagnosed with bipolar I disorder.

Upon arrival in your office, she is quite “busy,” playing with things on your desk and shifting from side to side in her chair. She informs you that “they said I was bipolar, I don’t believe that, do you? I just like to talk, and dance, and sing. Did I tell you that I liked to cook?”

She weighs 110 lbs. and is 5’ 5”


Patient reports “fantastic” mood. Reports that she sleeps about 5 hours/night to which she adds “I hate sleep, it’s no fun.”

You reviewed her hospital records and find that she has been medically worked up by a physician who reported her to be in overall good health. Lab studies were all within normal limits. You find that the patient had genetic testing in the hospital (specifically GeneSight testing) as none of the medications that they were treating her with seemed to work.

Genetic testing reveals that she is positive for CYP2D6*10 allele.

Patient did well enough on Lithium to be discharged from the hospital but admits she has not been taking it as prescribed. When further questioned on the subject, she provides no additional details.


The patient is alert, oriented to person, place, time, and event. She is dressed quite oddly- wearing what appears to be an evening gown to her appointment. Speech is rapid, pressured, and tangential. Self-reported mood is euthymic. Affect broad. Patient denies visual or auditory hallucinations, no overt delusional or paranoid thought processes readily apparent. Judgment is grossly intact, but insight is clearly impaired. She is currently denying suicidal or homicidal ideation.

The Young Mania Rating Scale (YMRS) score is 22


§ Chen, R., Wang, H., Shi, J., Shen, K., & Hu, P. (2015). Cytochrome P450 2D6 genotype affects the pharmacokinetics of controlled-release paroxetine in healthy Chinese subjects: comparison of traditional phenotype and activity score systems. European Journal of Clinical Pharmacology, 71(7), 835-841. doi:10.1007/s00228-015-1855-6



Decision Point One

Select what the PMHNP should do: Lithium 300 mg orally BID Risperdal 1 mg orally BID Begin Seroquel XR 300 mg orally at HS


Decision Point One Begin Seroquel XR 300 mg orally at HS


Client returns to clinic in four weeks

Client is reporting that she sleeps a bit more at bedtime

Client states that she has gained about 2 or 3 pounds, which she does not like

Client also reports that she has been constipated since starting this medication

Client is also complaining of dry mouth which she does not like.

Client’s score on the Young Mania Rating Scale has decreased from a 22 to an 18

Client is reporting really good mood, but is asking for a different medication because of the weight gain


Decision Point Two

Select what the PMHNP should do: Seroquel XR to 400 mg orally at HS Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal same dose of Seroquel and counsel client regarding ways to prevent constipation


Decision Point Two Seroquel and start Geodon 40 mg orally BID. Administer with 500 calorie meal



Client returns to clinic in four weeks

Client demonstrates a 50% decrease in score on the Young Mania Rating Scale (from 22 to 11)

Client denies any additional weight gain and denies any additional side effects


Decision Point Three

Select what the PMHNP should do: same dose and reassess in 4 weeks Geodon to 60 mg orally BID with a 500 calorie meal with Lithium sustained release 300 mg orally BID


Decision Point Three same dose and reassess in 4 weeks

Guidance to Student


The PMHNP should provide counseling to the client about this side effect and encourage increased fluids and fiber in the diet to combat constipation. Hard candies or gum can be used to prevent dry mouth. This is another issue as the drug can cause dental problems as a result of dry mouth.

Changing to Geodon clearly helped with symptoms and arrested weight gain in this client. The PMHNP could wait 4 weeks and see if any changes in Young Mania Rating Scale are noted, or increasing to 60 mg orally BID in an attempt to hasten symptom improvement. Increasing dose may be associated with side effects.

Augmentation with Lithium may be appropriate if the goal of therapy is to discontinue antipsychotic therapy and treat with Lithium monotherapy. Lithium was problematic for this client but changing formulation to the extended release may overcome the difficulties she was experiencing with side effects. The PMHNP would need to educate client regarding side effects of medication and need to maintain compliance


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