Assessing and Treating Patients With Psychosis and Schizophrenia

Assessing and Treating Patients With Psychosis and Schizophrenia

Psychosis and schizophrenia greatly impact the brain’s normal processes, which interfere with the ability to think clearly. When symptoms of these disorders are uncontrolled, patients may struggle to function in daily life. However, patients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the patient case study in this week’s Learning Resources, consider how you might assess and treat patients presenting with psychosis and schizophrenia.

To prepare for this Assignment:

· Review this week’s Learning Resources, including the Medication Resources indicated for this week.

· Reflect on the psychopharmacologic treatments you might recommend for the assessment and treatment of patients with schizophrenia-related psychoses.

The Assignment: 5 pages

Examine Case Study: Pakistani Woman With Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this patient. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

· Briefly explain and summarize the case for this Assignment. Be sure to include the specific patient factors that may impact your decision making when prescribing medication for this patient.

Decision #1 (1 page)

· Which decision did you select?

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.

· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).

· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #2 (1 page)

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Decision #3 (1 page)

· Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
· Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
· What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
· Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.

Conclusion (1 page)

· Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.

Note:

 Support your rationale with a minimum 5 academic resources. While you may use the course text to support your rationale, it will not count toward the resource requirement. You should be utilizing the primary and secondary literature.

Delusional Disorders
Pakistani Female With Delusional Thought Processes

Pakistani Female With Delusional Thought Processes

BACKGROUND

The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her when she was 9 years old). She presents following a 21-day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.

Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control,” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.

During today’s assessment, she appears quite calm and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She says she knows this because the television is telling her so.

She currently weighs 140 lbs., and she is 5’ 5.

SUBJECTIVE

Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.

A review of her hospital records shows that she received a medical workup from physician, who reported her to be in overall good health. Lab studies were all within normal limits.

Client admits that she stopped taking her Risperdal about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.

MENTAL STATUS EXAM

The client is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and, at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect is constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.

You administer the PANSS which reveals the following scores:

-40 for the positive symptoms scale

-20 for the negative symptom scale

-60 for general psychopathology scale

Diagnosis: Schizophrenia, paranoid type

RESOURCES

PANSS Scale. Available at: 

http://egret.psychol.cam.ac.uk/medicine/scales/PANSS

§ Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. doi:10.1093/schbul/13.2.261

https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers

§ Clozapine REMS Program. (n.d.). Clozapine REMS: A guide for healthcare providers. Retrieved September 7, 2016, from 
https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers

http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149

§ Paz, Z., Nalls, M., and Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal, 13(10), 625–629. Retrieved from 
http://www.ima.org.il/FilesUpload/IMAJ/0/40/20149

Decision Point One

Select what you should do:

Start Zyprexa (olanzapine) 10 mg orally at BEDTIME

Start Invega Sustenna 234

mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

Start Abilify (aripiprazole) 10 mg orally at BEDTIME

Delusional Disorders
Pakistani Female With Delusional Thought Processes

 
Decision Point One
mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

· Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter

· RESULTS OF DECISION POINT ONE

RESULTS OF DECISION POINT ONE

·  Client returns to clinic in four weeks

·  A decrease in the PANSS score of 25% (in positive symtpoms) is noted at this visit

·  Client seems to be tolerating medication

·  Her husband has made sure she makes her appointments for injections (one thus far)

·  She has noted a 2-pound weight gain, but it does not seem to be an important point for her

·  She does, however, complain of injection-site pain, telling you that she has trouble sitting for a few hours after the injections and doesn’t like having to walk around for such a long period of time

Decision Point Two

Continue same made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward

RESULTS OF DECISION POINT TWO

·  Client returns to clinic in four weeks

·  Her PANNS has been reduced by a total of 50% (in positive symptoms) from the initiation of Invega Sustenna

·  When questioned about injection-site pain, she states it is much better in the arm

·  Her weight has increased by an additional 2.5 pounds (total of 4.5 pounds in a 2-month period). She is somewhat bothered by the weight gain and is afraid that her husband does not like it. He is not present at this visit as she brought herself

·  She likes how she feels on the Invega Sustenna but is wondering if there is another drug like it that would not cause the weight gain

Decision Point Three

sel client on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can
Continue with the Invega Sustenna. Counsel client on the fact that weight gain from Invega Sustenna is not as much as what other drugs with similar efficacy can cause. Make appointment with a dietician and an exercise physiologist. Follow up in one monthcause. Make appointment with a dietician and an exercise physiologist. Follow up in one month

Guidance to Student

Weight gain can occur with Invega Sustenna. It is modest in nature and can be controlled with proper nutrition and exercise. It is always a good idea to try and control a client’s weight through consultation with a dietician and exercise physiologist (life coach) before switching to another agent when a product is showing efficacy for at least 6 months.

Abilify Maintena is a good option for someone who has good response to Abilify oral. Remember that Abilify does not bind to the D2 receptor for a great period of time (such as Invega) and can be less effective in certain individuals. Also, remember that akathisia can be a possible side effect. Once an IM long-acting medication is given, the effects of the drug (both efficacious and untoward effects) can be maintained for a long duration (up to a month or longer). Tolerability and efficacy should be established with oral medication before administering the first injection. Also a disadvantage to Abilify Maintena is that a 2-week overlap of oral therapy is required due to effective blood levels lagging behind the induction dose.

Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).

Learning Resources

Required Readings 

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier.

American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline

Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers

Funk, M. C., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018). Resource document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/

McClellan, J. & Stock. S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976–990. https://www.jaacap.org/article/S0890-8567(09)62600-9/pdf

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649–659. https://doi.org/10.2165/00023210-200923080-00002

IBM Corporation. (2020). IBM Micromedex. https://www.micromedexsolutions.com/micromedex2/librarian/deeplinkaccess?source=deepLink&institution=SZMC%5ESZMC%5ET43537

Note: To access the following medications, use the IBM Micromedex resource. Type the name of each medication in the keyword search bar. Be sure to read all sections on the left navigation bar related to each medication’s result page, as this information will be helpful for your review in preparation for your Assignments.