Week 7 Assignment Walden University 6630N

 

 

           

Week 7: Assessing and Treating Patients with Psychosis and Schizophrenia

 

 

 

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Week 7: Assessing and Treating Patients with Psychosis and Schizophrenia

Schizophrenia is a chronic psychological disorder characterized by an abnormal interpretation of the reality by the affected individual. According to the DSM-V, individuals diagnosed with schizophrenia normally present with some combination of delusion, hallucination, and extremely disordered behavior and thinking which impairs their normal daily function (Ganguly et al., 2018). However, clinical practice guidelines provide several treatment options for such patients. Schizophrenia requires lifelong treatment hence keen measures must be taken when deciding on which treatment to assign to a given patient.

The patient in the case study provided is 34 years old Pakistani female with a 21-day history of hospitalization following a brief psychotic disorder. The patient presents with symptoms such as both auditory and visual hallucination, delusion, hostility, paranoia, and poor perception of reality. Her husband reports calling the police on her once when she was out of control. She has been taking Risperdal ever since she was hospitalized but stopped about a week ago after being discharged. Upon conducting a mini-mental status exam, the patient was diagnosed with schizophrenia, a paranoid type.

Selecting the most effective treatment plan for the patient requires consideration of several pharmacokinetic and pharmacodynamic factors. For instance, the patient’s Pakistani race will affect the choice of antipsychotic agent to use. Her BMI of 23.3 which indicates overweight will also affect her drug choice. Other additional factors include her female gender, previous use of Risperdal, current symptoms, and diagnosis among others (Maroney, 2020). The purpose of this paper is to demonstrate the selection of the most effective treatment plan for the patient based on pharmacokinetic and pharmacodynamic factors.

 

Decision #1

Selected Decision and Rationale

            From the available options, the most appropriate initial intervention for the patient is to initiate Invega Sustenna 234 mg IM X1 followed by 156 mg IM on the 4^th day and every month afterward. Current clinical guidelines recommend the use of Invega Sustenna, for the management of schizoaffective disorder among adult patients as either monotherapy or an adjunct to another psychotropic (Barnes et al., 2020).

Invega Sustenna is a long-acting atypical antipsychotic agent approved by the FDA for the management of schizoaffective disorders. The mode of action of the drug in the management of schizophrenia is through antagonizing the D2 and 5HT_2A receptors centrally (Maroney, 2020). The drug has a long duration of action with very low water solubility which promotes slow absorption into the body system when administered intramuscularly, hence displaying a favorable safety profile.

Zyprexa was not an excellent choice at this point as a result of its short duration of action which requires daily dosing (DeBattista, 2018). The patient had already displayed non-compliance with taking Risperdal, it was thus necessary to give a drug that is less frequently administered to promote her compliance and treatment outcome.

Abilify on the other hand is associated with poor effectiveness and low tolerance among patients of Pakistani descent with increased risks of weight gain (Barnes et al., 2020). The patient is already overweight, hence the risks of taking this drug will outweigh the benefits.

Expected Outcome

            Within the following four weeks of using Invega Sustenna, the patient is expected to display at least 50% remission of schizoaffective symptoms. She should be able to display minimal episodes of hallucination and delusion or abnormal interpretation of reality (DeBattista, 2018). Her PANSS score is also expected to reduce to 2 or 3.

Ethical Implications

            Patients diagnosed with schizophrenia disorder normally display poor interpretation of reality. As such, the PMHNP is normally faced with the ethical challenge of disclosing the information to other individuals who might be affected by the patient’s condition (Barnes et al., 2020). For the current patient, it is necessary to involve the patient’s husband in the available treatment option, and the best alternative to promote the patient’s mental health and quality of life.

Decision #2

Selected Decision and Rationale

            Based on the outcome from the previous intervention, it was necessary to continue the patient on the same drug, but change the injection site to the deltoid muscles. This was necessary to help manage the pain on the injection site as reported by the patient (Krogmann et al., 2019).

The patient displayed great tolerance and adherence to the medication as no substantial side effects were reported, with a 25% remission of schizoaffective symptoms. Studies show that Invega Sustenna might take up to 6 to 8 weeks to completely manage symptoms of patients with schizophrenia disorder (Cerveri et al., 2019). However, with slight management of symptoms with no side effects within the first month, the patient should continue taking the drug to realize optimal effectiveness (DeBattista, 2018). The most common side effect of the IM route of administration is usually pain on the injection site, which is managed by altering the site of injection, and not discontinuing the medication.

Stopping Invega Sustenna and replacing it with Haldol Decanoate was not necessary as the patient had already displayed great tolerance and adherence to the initial medication. Consequently, the patient already reported issues with compliance based on previous management, as such, changing to another drug will lead to new side effects which might discourage the patient from going on with the treatment (Krogmann et al., 2019).

Adding Abilify to the current treatment regime is also not necessary as a 25% reduction of symptoms shows great effectiveness with the use of Invega Sustenna alone (Maroney, 2020). Abilify is also associated with weight gain, which might complicate the patient overweight status.

Expected Outcome

            In the next visit, the patient is expected to report even further remission of symptoms, with resolved pain at the injection site. Her PANSS score is also expected to reduce to less than 2 as initially expected. The patient should be able to interpret reality normally within this time (Ganguly et al., 2018).

Ethical Implications

The PMHNP has a legal obligation of preventing harm and promoting the health and well-being of the patient as demonstrated by the ethical principle of beneficence and nonmaleficence (DeBattista, 2018). As such, the clinician needed to explain to the patient why she was experiencing pain at the site of injection, and the best cause of action to manage the pain while still benefiting from the initially administered drug.

 

 

 

Decision #3

Selected Decision and Rationale

            The last intervention was to continue administering Invega Sustenna and advise the patient to see a dietitian and exercise physiologist to help with her weight gain. Weight gain due to prolonged use of Invega Sustenna is quite limited as compared to other antipsychotic agents, hence the need for the patient to use lifestyle modification approaches to reduce the impact of this side effect as she continues enjoying the benefits of the medication in managing her schizophrenia (Cerveri et al., 2019).

Based on the reported outcome from the previous intervention, the patient has displayed great tolerance and compliance to the medication with great effectiveness in the management of her symptoms. The only problem the patient is experiencing is her weight gain of 2.5 pounds. Studies show that prolonged use of Invega Sustenna can lead to weight gain (Ganguly et al., 2018). However, if the benefits outweigh this side effect, then the patient must adopt nonpharmacological approaches to reduce the impact of this side effect.

Replacing Invega Sustenna with Abilify at this point was not necessary as this would interfere with the patient’s compliance as a result of new side effects as mentioned earlier (DeBattista, 2018). Consequently, the drug displays minimal effectiveness in the management of schizoaffective symptoms, with increased risks of weight gain as compared to Invega Sustenna.

Qsymia is a weight loss medication normally recommended for the management of obesity (Krogmann et al., 2019). However, the drug is also associated with additional side effects such as confusion, insomnia, and dizziness which would otherwise complicate the patient’s condition, undermining the impact of Invega Sustenna in the management of the patient’s symptoms.

Expected Outcome

            At this point, the patient has already displayed great effectiveness with the use of Invega Sustenna in the management of her schizophrenia symptoms. She is expected to display complete remission of symptoms with continuous use of this medication. With the adoption of an appropriate dietary and exercise plan, the patient will be able to manage her body weight (Ganguly et al., 2018).

Ethical Implications

The PMHNP has an ethical obligation of upholding the patient’s autonomy. As such, it is necessary to address the patient weight gain, as she finds it to be quite disturbing (Barnes et al., 2020). However, the PMHNP must educate the patient on the need of considering non-pharmacological interventions such as diet and exercise, rather than using medication to promote her safety and well-being.

Conclusion

            Schizophrenia is a common disabling mental disorder that normally impairs the patient’s interpretation of reality. Treatment for this disorder is lifelong hence the need for critical consideration of the pharmacokinetic and pharmacokinetic factors in selecting the best psychotropic agent for the patient (DeBattista, 2018). In the provided case study, factors such as the patient’s age, diagnosis, symptoms, previous history of the disorder, and body weight among other factors contributed to the selection of drugs to include in the patient care plan. The initial decision was to initiate the patient on Invega Sustenna administered intramuscularly once every month. The drug is a long-acting atypical antipsychotic agent approved by the FDA, and recommended by most clinical guidelines for the management of schizoaffective disorders among adults (Barnes et al., 2020). Studies also show the great effectiveness of the drug in the management of schizophrenia with a favorable safety profile (Maroney, 2020). Other medications such as Zyprexa and Abilify could not be considered given their undesirable safety profile and weight gain side effects, since the patient is already overweight.

The second decision was to continue with the same drug at the same dose, as the patient displayed great tolerance and adherence to the medication (Krogmann et al., 2019). However, the patient complained of pain at the injection site, which was managed by changing the site of injection to the deltoid muscles. The last decision was to continue the same medication as the patient was continuously enjoying the befits of the drug with no substantial side effects reported (Cerveri et al., 2019). The patient however experience weight gain, which she did not like. As such, it was necessary to advise the patient to consider dietary and exercise intervention, rather than introducing another drug to manage the weight gain (Ganguly et al., 2018). In all three decisions, the PMHNP encountered several ethical considerations such as upholding the patient autonomy, among other ethical principles such as beneficence and non-maleficence.

 

 

References

Barnes, T. R., Drake, R., Paton, C., Cooper, S. J., Deakin, B., Ferrier, I. N., … & Yung, A. R. (2020). Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology. Journal of Psychopharmacology, 34(1), 3-78.

Cerveri, G., Gesi, C., & Mencacci, C. (2019). Pharmacological treatment of negative symptoms in schizophrenia: update and proposal of a clinical algorithm. Neuropsychiatric Disease and Treatment.

DeBattista, C. (2018). Basic & clinical pharmacology. New York: McGraw-Hill.

Ganguly, P., Soliman, A., & Moustafa, A. A. (2018). Holistic management of schizophrenia symptoms using pharmacological and non-pharmacological treatment. Frontiers in public health, 6, 166.

Krogmann, A., Peters, L., Von Hardenberg, L., Bödeker, K., Nöhles, V. B., & Correll, C. U. (2019). Keeping up with the therapeutic advances in schizophrenia: a review of novel and emerging pharmacological entities. CNS spectrums, 24(S1), 38-69. https://doi.org/10.1017/S109285291900124X

Maroney, M. (2020). An update on current treatment strategies and emerging agents for the management of schizophrenia. Am J Manag Care, 26(3 Suppl), S55-S61. https://doi.org/10.37765/ajmc.2020.43012