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Psychopharmalogical Approaches to Treat Psychopathology 

Assignment: 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:
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 of five 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.
 

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Pakistan Female with Delusional Thought Process  

Schizophrenia is a chronic illness that impacts negatively on the affected. After the first episode, many patients often have recurrent episodes with a slow remission of symptoms in every relapse (Peuskens, Rubio & Schreiner, 2014). The course of the illness may also get worse with subsequent episodes (Peuskens, Rubio & Schreiner, 2014). It, therefore, demands long term treatment for the affected. In this long term management, switching of antipsychotics may be necessary based on the presenting issue (Peuskens, Rubio & Schreiner, 2014). However, in doing so, the psychiatrist must always maintain ethical issues in the treatment plan and be keen on the patient's concerns.

Decision 1

What options were listed? The first option for the patient is to start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter. There is also the choice of starting Zyprexa 10 Mg orally at bed-time, or Abilify 10 mg orally at Bed-time.

What option did you choose? My choice is to start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter.

Why did you select that option? Invega is a brand name for Paliperidone. It is a dopamine, serotonin receptor antagonist. It works to block dopamine 2 receptors which, in turn, reduce symptoms of psychosis and stabilize affective symptoms (Stahl, n.d.). It is a choice for this patient because it is a long-acting antipsychotic and can be taken once a month. Her compliance failure in taking Risperidone as prescribed earlier shows that the injections may be a better choice for her treatment. It will eliminate the chances of non-compliance in taking tablets while working to alleviate her symptoms.

A side effect of Invega Sustenna is weight gain (Stahl, n.d.). However, the client has a BMI of 23.3 which is within the normal weight category. It, therefore, becomes a better option for her condition and symptoms.

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Why didn’t you select the other two options? Zyprexa, like Invega Sustenna, is a dopamine and serotonin antagonist (Stahl, n.d.). I would not choose it for the patient since it would raise the probability of non-compliance. The same would be the issue with Abilify Po. Farooq & Naeem, (2014) show that a shift to long-acting injections has the benefit of achieving compliance for patients. A reduction in the drug dosing frequency is a factor to consider in promoting adherence (Peuskens, Rubio & Schreiner, 2014). In this case, the option of Invega Sustenna every month better promotes adherence compared to Abilify and Zyprexa at bed-time.

What was your goal of treatment? The goal of treatment is to have a complete remission of symptoms and achieve drug-compliance.

Was the outcome what you expected? The patient returns after four weeks with a 25% decline in symptoms. She also reports tolerance to the medication. A 25% decline in symptoms in four weeks is an indication of treatment success since the drug may not show success for up to 6 weeks. I would say that the outcome is as expected. However, there is the issue of weight gain and pain at the injection site which is a common side effect of Invega Sustenna. It requires changes for the client to continue benefitting from the therapeutic effects of the drug.

 

Decision 2

What options were listed? There is the option to stop the Invega Sustenna from the gluteus to the deltoid in subsequent visits or discontinue it and start Haldol Decanoate 50 Mg IM q2 weeks with oral Haldol 5 Mg BID for the next 3 months. There is also the option of continuing with Invega Sustenna but beginning the injections at the deltoid and addition of Abilify Maintena 300 Mg intramuscular monthly with oral Abilify 10 mg in the morning for 2 weeks. 

What option did you choose?  My choice is to continue the initial decision but ask the nurse to administer the injections at the deltoid in this visit and subsequent visits.

Why did you select that option? Proschyn et al., (2016) assert that change of the injection is patient specific. There are records of better outcomes and efficiency from changing the injection from the gluteus to the deltoid (Proschyn et al., 2016). In this patient, due to complaints of pain at the injection site, the best option would be to change the site. There is also a possibility of breakthrough improvements with the patient due to the difference in rate and extent of drug absorption between the injection sites.

Why didn’t you select the other two options? Treatment failure is one of the indications for switching an antipsychotic. (Keks, Schwartz & Hope, 2019) To discontinue Invega Sustenna is not right since the patient has already recorded a 25% decline in symptoms within the first four weeks which is an indication that the drug is working for the client. The pain at the injection site is a common side effect of the intramuscular Invega Sustenna and is not an indication for switching to Haldol Decanoate, another antipsychotic. It is also not appropriate to start Abilify Maintena since the patient is responding well to Invega Sustenna.

What was your goal of treatment? The goal of treatment is to continue achieving symptom remission with no pain at the injection site enough for the client to perform her activities of daily living.

Was the outcome what you expected? Why? The patient is having less pain with the injection at the deltoid which is according to the treatment plan in her previous visit. She has attained a 50% drop in her symptoms which is a favorable response with Invega Sustenna within 8 weeks. However, she has added a total of 4.5 pounds in the last two months and she expresses the fact that her husband does not like it. The weight gain is a side effect of Invega Sustenna and the client can get alternatives for weight management and control.

Decision Point 3

What options were listed? To manage the client’s weight, the options available include continuing with Invega Sustenna but counsel her on the fact that the weight gain is from the drug and is not as much compared to other drugs with the same efficacy can cause. She could also make appointments with a dietician and an exercise physiologist and make follow-ups in a month. She could also discontinue Invega Sustenna and start Abilify Maintena 400 Mg IM monthly (after a tolerance test) with overlapping oral Abilify 10 mg orally in the morning. Another option is to continue Invega Sustenna and add-on Qsymia for weight loss.

What option did you choose? My choice would be to continue Invega Sustenna but counsel her on the fact that the weight gain is from the drug and is not as much compared to other drugs with the same efficacy can cause. She could also make appointments with a dietician and an exercise physiologist and make follow-ups in a month.

Why did you select that option? Weight gain is a common side effect of Invega Sustenna and the client is showing favorable progress with the medication. She has added 4.5 pounds which can be managed with exercise and diet under the guidance of a dietician and an exercise physiologist (Emsley & Killian, 2018).

Why didn’t you select the other two options? I did not change to Abilify Maintena since one can only consider changing a drug based on its efficiency, non-adherence, and tolerance (Peuskens, Rubio & Schreiner 2014). The patient is showing proper tolerance, efficiency through a 50% decline in symptoms within a short time, and is also taking her time to attend the follow-up visits.  There is, therefore, no indication for a change in drug to Abilify Maintena. Additionally, Abilify Maintena may not achieve therapeutic control in some patients which may hurt the already achieved success with Invega Sustenna.

Qsymia is an obesity medication with a combination of phentermine and topiramate. It works by suppressing appetite and works in weight loss combined with diet and exercise. The client is 5.5 inches tall with a current weight of 144.5 pounds. Her BMI is 24.0 which is within the normal weight category. Starting Qsymia for her is inappropriate.

What was your goal of treatment? The goal of treatment is to attain symptom remission with weight control while on Invega Sustenna towards total symptom remission.

Ethical Issues

The health care world remains to change over the decades and so is the issue of ethics in patient care. Mental health issues are no exception. Scientists now advocate for improving a patient's quality of life by allowing them to have a contribution to their care (Noordsy, 2016). In the case study, the patient verbalizes the issue of weight gain with a need for measures towards changing the status quo. In response, there was an initiation of measures towards her concern. In this regard, the health provider must provide the patient with information in making that decision compared to other available options (Noordsy, 2016). By doing so, the provider gives the patient more to her treatment approach than informed consent and decreases the power asymmetry that exists between providers and their patients by giving them control over their treatment options.

Conclusion

Schizophrenia is a common psychiatric condition. However, with the right treatment options and healthy-provider-patient relationship, it is possible to attain success in treatment. Nonetheless, it must be clear that psychiatrists will often face ethical issues in the treatment of their patients. The conflict lies between providing the necessary measures towards symptom remission and respecting their right to autonomy. It also involves making the right decisions with the available options to achieve the set treatment goals. Nevertheless, the patient’s right to autonomy must always prevail with the value of doing well to the patient.

 

 

 

 

 

 

 

 

References

Emsley, R., & Kilian, S. (2018). Efficacy and safety profile of paliperidone palmitate injections in the management of patients with schizophrenia: an evidence-based review. Neuropsychiatric disease and treatment, 14, 205.

Farooq, S., & Naeem, F. (2014). Tackling nonadherence in psychiatric disorders: current opinion. Neuropsychiatric disease and treatment, 10, 1069.

Keks, N., Schwartz, D., & Hope, J. (2019). Stopping and switching antipsychotic drugs. Australian Prescriber, 42(5), 152.

Noordsy, D. L. (2016). Ethical Issues in the Care of People With Schizophrenia. Focus, 14(3), 349-353.

Procyshyn, R. M., Banasch, J. L., Barr, A. M., & Honer, W. G. (2016). Breakthrough symptoms after switching long-acting injectable paliperidone palmitate from the gluteal to the deltoid site of administration. Journal of psychiatry & neuroscience: JPN, 41(3), E56.

Peuskens, J., Rubio, G., & Schreiner, A. (2014). Dosing and switching of paliperidone ER in patients with schizophrenia: recommendations for clinical practice. Annals of general psychiatry, 13(1), 10.

Stahl, S. M. (n.d.). Stahl online. Retrieved from https://stahlonline.cambridge.org/prescribers_drug.jsf?page=9781316618134c114.html.therapeutics&name=SERTRALINE&title=Therapeutics

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