Assignment: Assessing and Treating Clients With Psychosis and Schizophrenia Psychosis and schizophrenia greatly impact the brain’s normal processes, which interferes with the ability to think clearly. When symptoms of these disorders are uncontrolled, clients may struggle to function in daily life. However, clients often thrive when properly diagnosed and treated under the close supervision of a psychiatric mental health practitioner. For this Assignment, as you examine the client case study in this week’s Learning Resources, consider how you might assess and treat clients presenting with psychosis and schizophrenia. Learning Objectives Students will: • Assess client factors and history to develop personalized plans of antipsychotic therapy for clients • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in clients requiring antipsychotic therapy • Evaluate efficacy of treatment plans • Analyze ethical and legal implications related to prescribing antipsychotic therapy to clients across the lifespan To prepare for this Assignment: The Assignment Examine Case Study: Pakistani Woman with Delusional Thought Processes. (Decisions have already been made. See decision results in the attached case study) You will be asked to make three decisions concerning the medication to prescribe to this client. Be sure to consider factors that might impact the client’s pharmacokinetic and pharmacodynamic processes. I want you to answer the questions given to you (decision points one, two, and three) before you click on the option. The answers will be based on your decisions made and patient outcomes during the decision tree. I am looking for an essay that is long enough to cover the topic BUT short enough to keep my interest. I do not need you to tell me the treatment options available to you – I am very familiar with the cases. Remember this is a Pharmacology class that incorporates Pharmacotherapy and not a class on diagnosing disease. I want you to tell me why you selected an option (why is it the best option- using clinically relevant and patient specific data) AND why you did not choose the other options (with clinically relevant and patient specific data). At each decision point stop to complete the following: * Decision #1 Select what the PMHNP should do next: • You decided to start patient on Invega Sustenna (Paliperidone) 234 mg IM followed by 156 mg IM on day 4 and monthly thereafter. (see attachment for result of decision#1) • Why did you select this decision? Support your response with evidence and references to the Learning Resources. Assessing and Treating Clients with Psychosis and Schizophrenia Essay. • Why did you not choose Zyprexa (Olanzapine) 10 mg by mouth at bed time, or Ability (Aripiprazole) 10 mg by mouth at bed time? • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. • Explain any difference between what you expected to achieve with Decision #1 and the results of the decision. Why were they different? Decision #2 Select what the PMHNP should do next: • You decide to continue with the same drug as in decision one but from now on to be injected in the deltoid.(see attachment for result of decision#2) • Why did you select this decision? Support your response with evidence and references to the Learning Resources. • Why did you not choose the options to either Invega Sustenna and start Haldol Decanoate 50 mg IM every two weeks with oral Haldol 5 mg BID or to continue Invega Sustenna IM in to the deltoid and add Abilify Maintena 300 mg intramuscular monthly plus Abilify 10 mg PO in the morning for two weeks • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. • Explain any difference between what you expected to achieve with Decision #2 and the results of the decision. Why were they different? Decision #3 Select what the PMHNP should do next: • You decide to continue with 156mg IM in the deltoid monthly in line with decision #1 and reassess in 4 weeks (see attachment for result of decision#3) • Why did you select this decision? Support your response with evidence and references to the Learning Resources. • Why did you not choose the options to either Invega Sustenna and start Abilify Maintenna 400 mg IM monthly with overlapping oral Abilify 10 mg in the morning or Continuing Invega Sustenna and add -on Qsymia for weight loss. • What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources. • Explain any difference between what you expected to achieve with Decision #3 and the results of the decision. Why were they different? Also include how ethical considerations might impact your treatment plan and communication with clients.

Introduction

A 34-year-old client presented to the office after a “brief psychotic disorder” diagnosis. She is delusional and at times “out of control”. Her thought process appears delusional and paranoid while her judgment and insight are impaired. After a comprehensive assessment, the client is diagnosed with schizophrenia, paranoid type. This assignment will focus on making three decisions about the client’s treatment and justifying the choice. Finally, ethical considerations that might affect the client’s treatment will be discussed.

Decision Point One

The selected decision is to have the client start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day 4 and monthly thereafter. The rationale for selecting this decision is because Invega Sustenna has been shown to be effective in treating exacerbated schizophrenia with substantial improvement in psychotic symptoms and improved social functioning (Chue & Chue, 2016). Therefore, the medication will improve the psychotic symptoms in the client. The medication works by restoring the balance of specific neurotransmitters within the brain. This is because Invega Sustenna acts as an antagonist at dopamine-2 (D₂) receptors and 5-hydroxytryptamine receptors and as an antagonist at α₁-adrenoceptors; and thereby balancing the neurotransmitters within the brain (Fang et al, 2016). Assessing and Treating Clients with Psychosis and Schizophrenia Essay.

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The reason why options of Zyprexa (Olanzapine) 10 mg by mouth at bedtime, or Ability (Aripiprazole) 10 mg by mouth at bedtime was not selected is due to the psychotic symptoms for the client which may make her not adhere to treatment while at home. According to Kane et al (2013), intramuscular preparations of antipsychotics are preferred for patients whose psychosis is likely to affect oral medication adherence. In addition, evidence shows that psychotic individuals reported high incidences of non-adherence and poor adherence to the treatment regimen (Kane et al, 2013).   In addition, Invega Sustenna is a second-generation antipsychotic with minimal neurological side effects when compared to first-generation medications.

With this decision, it was hoped that the psychotic symptoms would reduce and that she will be able to tolerate the medication, with minimal or no side effects. This is because evidence shows that Invega Sustenna is effective in significantly improving psychotic symptoms and treating exacerbated schizophrenia (Chue & Chue, 2016).

The actual outcomes of the decision and the expected results were slightly different. This is because even though there was an improvement on the psychotic symptoms as indicated by the reduced PANSS score of 25% and the client seemed to be tolerating the medication as expected; the client manifested a side effect in form of notable weight gain and reported of pain at the injection site. Weight gain is a common side effect with Invega Sustenna (Kim et al, 2013).

Decision Point Two

The selected decision is to continue the same decision made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward. The rationale for continuing with the same decision is because the client is responding to the current treatment as manifested by reduced PANSS score. The rationale for changing the injection site to deltoid is because the client reported concerns of being unable to walk or sit comfortably and pain after being injected. In order to ensure the client continues to adhere to the treatment and medication schedule, it was important to switch the injection site (Strohfus et al, 2018).

The reason for not stopping Invega Sustenna and starting Haldol Decanoate 50 mg IM every two weeks with oral Haldol 5 mg BID was not selected is because the client is already showing response Invega Sustenna. In addition, compliance is high for IM than oral medications in patients experiencing psychotic symptoms (Kane et al, 2013).  The reason for not selecting the decision to continue with Invega Sustenna IM in to the deltoid and add Abilify Maintena 300 mg intramuscular monthly plus Abilify 10 mg PO in the morning for two weeks is because Abilify Maintena has serious side effects such as akathisia, abnormal heart rhythm problem and tardive dyskinesia, a syndrome that is irreversible (Sciascio & Riva, 2015).

With this decision, it was hoped that the psychotic symptoms will continue reducing and that the client would no longer experience pain at the injection site after being administered with the medication. It was also hoped that she would tolerate the medication, adhere to treatment and report minimal side effects.

The actual outcomes of the selected decision and the expected results were almost similar. This is because the symptoms significantly improved and the client continued to respond to the treatment as indicated by a 50% reduction of the PANNs. In addition, the client was compliant to the treatment as she brought herself to the clinic and also the injection site was no longer painful. However, the weight gain persisted and the client was somehow bothered by the weight gain. As indicated, weight gain is a common side effect with Invega Sustenna (Kim et al, 2013). Assessing and Treating Clients with Psychosis and Schizophrenia Essay.

Decision Point Three

The selected third decision is to continue with the Invega Sustenna and counsel the client about weight gain. In addition, an appointment was to be made with a dietician and an exercise physiologist. Follow up in one month. The rationale for this decision is because evidence recommends natural weight loss and weight gain from Invega can be managed through proper diet and appropriate physical activities. More importantly, it is important to manage weight gain for the client to improve treatment adherence and reduce the risk of metabolic syndrome that can result due to the weight gain (Dayabandara et al, 2017).

The option of continuing Invega Sustenna and add-on Qsymia for weight loss was not selected to adverse side effects associated with Qsymia and the medication is only recommended to treat obesity (Shin & Gadde, 2013).  The option of starting Abilify Maintena 400 mg IM monthly with overlapping oral Abilify 10 mg in the morning was not selected due to adverse effects associated with Abilify.

With this decision, it was hoped that the client would continue exhibiting significant improvement, adhere to treatment and have the weight gain managed and controlled.

Ethical Considerations for the Client’s Treatment

Ethical considerations include informed consent, the choice of treatment, confidentiality, and autonomy. This means that the client should be informed about the available treatment choices to enable her to make an informed choice and consent to treatment.  Confidentiality is also another aspect; no information should be shared without the client giving consent (Botkin et al, 2015).

References

Botkin, J, Belmont, J,., Berg, J, Berkman, B, Bombard, Y, Holm, I & Wilfond, S. (2015). Points to consider: ethical, legal, and psychosocial implications of genetic testing in children and adolescents. The American Journal of Human Genetics. 97(1), 6-21.

Chue P & Chue J. (2016). A critical appraisal of paliperidone long-acting injection in the treatment of schizoaffective disorder. Ther Clin Risk Manag. 1(12), 109–116.

Dayabandara M, Raveen H, Suhashini R, Sudarshi S & Varuni A. (2017). Antipsychotic-associated weight gain: management strategies and impact on treatment adherence. Neuropsychiatr Dis Treat. 1(13), 2231–2241.

Fang L, Turkoz I & Fan Z. (2016). Efficacy and safety of once-monthly injection of paliperidone palmitate in hospitalized Asian patients with acute exacerbated schizophrenia: an open-label, prospective, noncomparative study. Neuropsychiatr Dis Treat. 1(12), 15–24.

Kane J, Taishiro K & Corell C. (2013). Non-adherence to medication in patients with psychotic disorders: epidemiology, contributing factors, and management strategies. World Psychiatry. 12(3), 216–226.

Kim S, Hugo S, Peter W & Bishop J. (2013). Paliperidone palmitate injection for the acute and maintenance treatment of schizophrenia in adults. Patient Prefer Adherence. 1(6), 533–545.

Strohfus P, Oya P, Tindell C & Paula M. (2018). Evidence calls for practice change in intramuscular injection techniques. Journal of Nursing Education and Practice. 8(2). Assessing and Treating Clients with Psychosis and Schizophrenia Essay.

Sciascio G & Riva M. (2015). Aripiprazole: from pharmacological profile to clinical use. Neuropsychiatr Dis Treat. 1(11), 2635–2647.

Shin J & Gadde K. (2013). Clinical utility of phentermine/topiramate (Qsymia™) combination for the treatment of obesity. Diabetes Metab Syndr Obes. 1(6), 131–139.

Delusional Disorders
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 since she was 9 years old). She presents to your office today 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 tells you that she knows this because the television is telling her so.

She currently weighs 140 lbs, and is 5’ 5”

SUBJECTIVE

Client reports that her mood is “good.” She denies auditory/visual hallucinations, but believes that the television does talk to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards the PMHNP, but then calms down. Assessing and Treating Clients with Psychosis and Schizophrenia Essay/

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.

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, 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 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.

The PMHNP administers 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

• Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
• Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. Retrieved from https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf
• Paz, Z., Nalls, M. & Ziv, E. (2011). The genetics of benign neutropenia. Israel Medical Association Journal. 13. 625-629.

Decision Point One

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

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• A decrease in PANSS score of 25% is noted at this visit
• Client seems to be tolerating medication
• Client’s husband has made sure she makes her appointments for injections (one thus far)
• Client has noted a 2 pound weight gain but it does not seem to be an important point for her
• Client complains of injection site pain telling the PMHNP that she has trouble siting for a few hours after the injections and doesn’t like having to walk around for such a long period of time. Assessing and Treating Clients with Psychosis and Schizophrenia Essay.

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Decision Point One

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

RESULTS OF DECISION POINT ONE

• Client returns to clinic in four weeks
• A decrease in PANSS score of 25% is noted at this visit
• Client seems to be tolerating medication
• Client’s husband has made sure she makes her appointments for injections (one thus far)
• Client has noted a 2 pound weight gain but it does not seem to be an important point for her
• Client complains of injection site pain telling the PMHNP that she has trouble siting 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 decision 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
• Client’s PANNS has reduced by a total of 50% from the initiation of Invega sustenna
• When questioned about injection site pain, client states it is much better in the arm
• Client’s 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
• Client 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

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 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 affective 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 first before administering the first injection. Also a disadvantage to Abilify Maintena is 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 Phenteramine 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, Phenteramine has a lot of cardiovascular toxicities (such as elevated BP, HR, increased workload on the heart). Assessing and Treating Clients with Psychosis and Schizophrenia Essay.