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Assessing and Treating Patients With Psychosis and Schizophrenia
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.
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Assessing and Treating Patients With Psychosis and Schizophrenia
Pakistani Female with Delusional Thought Process
Schizophrenia is a disabling mental condition characterized by a disruption in thought process, social interactions, and emotional responsiveness. Although its course is different from one individual to another, it can be severe and persistent for others. Symptoms appear in late adolescence or early adulthood but they sometimes manifest in early childhood. Persistent multiple symptoms may be a later manifestation of the disorder indicative of environmental influence and interruptions in brain development. As such, early intervention is necessary to improve on the course of the disorder for better outcomes.
A major challenge for health professionals is medication non-adherence for schizophrenic patients on long-term maintenance therapy. Although is it easily underestimated by health professionals, it affects about a third of all patients every year. It is a cause for re-hospitalization, increasing medical costs, and a lowered quality of life. The causes are numerous but the major distinction is between intentional and non-intentional non-compliance. Effective interventions to promote adherence include long-acting injections, psychosocial interventions, electronic reminders, and financial incentives. Measures may overlap, but the adopted intervention has to be patient-specific based on a thorough assessment and physical examination.
The Pakistani woman is suffering from Paranoid schizophrenia. Although she is previously treated with Risperdal, she stops taking it a week after discharge from the hospital with the thought that her husband is going to poison her. It is consistent with the disordered thought process of schizophrenia resulting in medication non-adherence. It makes her unfit in her caretaker role to her children and a threat to their safety. Effective management requires addressing her non-adherence while adhering to the ethical standards of communication and psychiatric prescribing.
Decision Point One
Based on the available choices for decision point one, my choice would be to start Invega Sustenna 234 Mg intramuscular x1, 156 mg intramuscular on day 4 and monthly thereafter. It is a long-acting injectable (LAI), a second-generation antipsychotic with the active formulation of Paliperidone. It works for schizophrenia by blocking dopamine 2 receptors, reducing positive symptoms of psychosis, and stabilizing affective symptoms. It also blocks serotonin 2A receptors which enhance dopamine release in the brain which reduces motor side effects, improves cognitive and affective symptoms. The patient is not adherent to oral prescriptions. The LAI Invega Sustenna provides a better alternative for increasing adherence and improving her symptoms.
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The Reasoning for Other Options
The basis for psychiatric prescribing is based on a thorough diagnostic evaluation and review of a patient's history which includes a past response to treatment. Zyprexa and Abilify are also atypical antipsychotics with a high efficacy on schizophrenia. However, the patient has not shown adherence to oral medications. Prescribing oral Zyprexa and Abilify does not solve the issue of non-compliance for the patient.
The decision for Invega Sustenna is aimed at achieving gradual symptom remission. According to Stahl (2014b), the patient can have a reduction in psychotic symptoms within a week although it is necessary to wait for 4-6 weeks to determine the efficacy of the drug. The goal is that the patient will have a lower PNSS score within 1 week to 6 weeks.
Ethical Considerations
Ethical consideration is necessary for all health professional decisions in patient care. The initial ethical consideration in this situation is the psychotic presentation of the patient with a score of 60 on the PANSS scale. An appropriate therapeutic intervention must consider achieving a lower score with minimal symptoms and score. Moreover, the patient's prior response to oral Risperdal is not sufficient due to non-compliance. Therefore, changing into a LAI approach is consistent with ethical guidelines of psychiatric prescribing.
Decision Point Two
The patient returns to the clinic after four weeks with a score of 25% on the PNSS scale. She is tolerating the medication well and the husband is acting as a source of support for her wife by bringing her to the visit. However, the patient reports of pain at the injection site a few hours after the injection and a 2-pound weight gain.
At this point, the decision is to continue with Invega Sustenna but instruct the nurse to begin injections at the deltoid at this visit moving forward. The patient is already showing improvements with the medication evident in her PNSS scale with minimal side effects. The injection site pain with the Invega Sustenna is a common side effect of the drug occurring in 10% of patients (Citrome, 2010). A randomized control trial reveals that there is no significant difference in the level of pain between the deltoid and the gluteal muscle (Hough et al., 2009). However, the patient’s concern is the inability to sit a few hours after the injection. Changing the route to the deltoid region would be a better approach to managing her concerns. Moreover, the deltoid region increases the bioavailability of the drug through an increased rate of absorption (Procyshyn et al., 2016). It is an opportunity for increased symptom remission in the subsequent visit.
The reasoning for the Other Options
There is no indication for discontinuing the Invega Sustenna and starting Haldol Decanoate 50 mg IM q2 weeks with Haldol 5 Mg BID for the next 3 months. Haldol Decanoate is a second-generation antipsychotic with weight gain and injection site pain as a common side effect similar to Invega Sustenna. The change would not be of any clinical significance. Additionally, Semahegn et al. (2020) state that the dosing frequency impacts a patient's adherence to antipsychotics. The BID dosing for oral Abilify Maitenna and Abilify increases the risk for medication non-compliance and the possibility of losing the achieved results with Invega Sustenna.
Goals of Treatment
The goal of treatment is to have continued symptom alleviation and reducing the possibility of non-compliance by solving the patient's concerns.
Ethical Considerations
Effective communication is a crucial component of psychiatry. The key components of effective communication include an open-ended inquiry, reflective listening, and empathy to address the patient's unique needs, values, and preferences (Cuz & Pincus, 2002). It also helps in building rapport and developing therapeutic relationships. Evidence shows a link between effective communication with medication adherence and better treatment outcomes (Cuz & Pincus, 2002). In the case study, effective communication is the key to enabling the patient to reveal her experiences with the Injections in her visit. It is also the health professional's role to address the patient's unique needs for better outcomes.
Decision Point Three
After four weeks, the patient is reporting reduced pain in the arm with a 50% decline in her symptoms. The outcomes are per the treatment goals. However, unlike the previous visit, the patient is concerned about weight gain. The decision, therefore, is to counsel the client that the weight gain from the injections is not as much compared to other drugs with the same efficacy. I will also link her to a dietician and exercise physiologist and monitor her progress in the next visit. The decision is an opportunity to address the weight gain and address her concerns about her husband's dislike for the changes. It will also reduce the possibility of non-compliance.
The reasoning for the Other Options
There is no indication for discontinuing Invega Sustenna at this point. The patient has already shown better efficiency by 50% with minimal reported effect of weight gain. Stahl. (2014b) states that although schizophrenic symptoms may improve, they do not resolve completely. Therefore, the current decline in symptoms is enough to allow the patient to continue on Invega Sustenna. Adding Qysmia is also not necessary. It is a combination of Phentermine and Topiramate used in treating obesity in addition to dietary changes and exercise. The patient’s weight gain is still within the normal BMI even after the additional weight gain. The medication also increases her chances for side effects like high blood pressure, mood changes, insomnia, and anxiety. It would risk the patient’s non-compliance and losing the already achieved benefits.
Goals of Treatment
The main goal of treatment is to have a sustained control of symptoms with Invega Sustenna. The patient will also have control over the weight gain towards increase adherence and better outcomes.
Ethical Considerations
Some of the ethical principles of medical practice include beneficence and non-maleficence. The major aim of maintaining the current medication is to offer the maximum benefit to the patient. The decision for referral to a dietician and exercise physiologist is intended to manage the side effects with the injections. The decision to avoid Qysmia is to avoid the possible side-effects that risk the patient’s progress. The decision upholds the ethical principles of beneficence and non-maleficence.
Conclusion
Schizophrenia is a life liming condition with a tremendous impact on the patient's quality of life. However, effective assessment and history taking provide health professionals with an opportunity to identify challenges in effective patient management towards individualized care. Patient follow-up is necessary for the provider to identify the efficacy of the treatment plan and learn about any challenges to therapy. Achieving the set goals requires effective patient-provider communication and adherence to the ethical psychiatric guidelines for better patient outcomes.
References
Citrome, L. (2010). Paliperidone palmitate–review of the efficacy, safety, and cost of a new second‐generation depot antipsychotic medication. International journal of clinical practice, 64(2), 216-239.
Cruz, M., & Pincus, H. A. (2002). Research on the influence that communication in psychiatric encounters has on treatment. Psychiatric Services, 53(10), 1253-1265.
Stahl, S. M. (2014b). Stahl online. https://stahlonline.cambridge.org/prescribers_drug.jsf?page=9781108926010c134
Hough, D., Lindenmayer, J. P., Gopal, S., Melkote, R., Lim, P., Herben, V., & Eerdekens, M. (2009). Safety and tolerability of deltoid and gluteal injections of paliperidone palmitate in schizophrenia. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 33(6), 1022-1031.
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.
Semahegn, A., Torpey, K., Manu, A., Assefa, N., Tesfaye, G., & Ankomah, A. (2020). Psychotropic medication non-adherence and its associated factors among patients with major psychiatric disorders: a systematic review and meta-analysis. Systematic reviews, 9(1), 1-18.
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