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.
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.
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, DSM-5 295.90. Persecutory type: This subtype applies when the central theme of the delusion involves the individual’s belief that he or she is being conspired against, cheated, spied on, followed, poisoned or drugged, maliciously maligned, harassed, or obstructed in the pursuit of long-term goals (American Psychiatric Association, 2013).
Examine Case Study: Pakistani Woman with Delusional Thought Processes. 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.
Decision #1
The decision was made to start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day four and monthly thereafter. This medication was selected because it blocks dopamine two receptors, reducing positive symptoms of psychosis and stabilizing affective symptoms, blocks serotonin 2A receptors, causing the enhancement of dopamine release in specific brain regions and thus reducing motor side effects and possibly improving cognitive and affective symptoms, and serotonin seven antagonist properties may contribute to antidepressant actions. Psychotic symptoms can improve within one week, but it may take several weeks for full effect on behavior and cognition. Classically recommended to wait at least 4–6 weeks to determine drug efficacy, but in practice, some patients may require up to 16–20 weeks to show a good response, especially cognitive symptoms (Stahl, S., 2014b). My goal was to reduce the patient’s psychosis and delusions of persecution. When the patient returned, her symptoms improved, with her only complaint being irritated at the injection site, a common complaint of IM injectable medications. The pharmaceutical company developed the medication to dissolve slowly after deep intramuscular injection before being hydrolyzed to paliperidone and absorbed into the systemic circulation. The pharmacokinetic (PK) profile of the INVEGA SUSTENNA® formulation is biphasic. Comprised of an initial relatively fast zero-order input, this allows rapid attainment of therapeutic concentrations without oral supplementation; and a subsequently maintained second-stage, first-order input, allowing for once-monthly administration (Procyshyn, R., Lamoure, J., Katzman, M., Skinner, P., & Sherman, S., 2019). Having the advantage of not needing to worry if the patient receives the correct dose in the face of her significant psychiatric instability, this medication is the best choice. With Zyprexa and Abilify as alternate options, both were oral. Given how ill the patient was, neither of those medications would be in her best interest for compliance reasons. The best choice was the IM Invega Sustenna, which is why it was selected for this patient.
Decision #2
I chose to continue the same dose but instead changing the location of the site to the deltoid. By changing the site, my goal was to decrease soreness in the patient's IM site. When the patient returned in four weeks for a follow-up, the result was the patient continued to have improved, with a 50% reduction in symptoms. She reported an additional 2.5 pounds of weight gain and was concerned about this. Considering the pharmacokinetics, Paliperidone palmitate is a benzoxazole derivative that is hydrolyzed to the active moiety, paliperidone, and absorbed into the systemic circulation. The palmitate ester of paliperidone is an aqueous suspension that utilizes nanoparticle technology. The resulting increased surface area leads to a rapid release of medication and a relatively short time to steady-state. Following an injection, active paliperidone plasma levels have been detected from day 1; therefore, coadministration with oral paliperidone on the initiation of therapy is not required. Following the intramuscular administration of single doses in the deltoid muscle, on average, a 28% higher peak concentration is observed compared with injection in the gluteal muscle (U.S. National Library of Medicine, 2020). At this point, adding additional medications would not be appropriate. Alternate options included adding Haldol and Abilify to the Invega Sustenna. Given that Invega had positive results, other than the injection site's discomfort, the best choice was to remain on the same dose and change the injection locations.
Decision #3
I chose to remain on the same dose of Invega Sustenna due to its efficacy and the fact that the patient has been on the medication for less than six months. A referral to a dietician was made for the patient to counsel her on proper nutritional needs and exercise regimen now that her negative symptoms have subsided. The patient is to follow up in one month. If she is still having untoward symptoms after six months, Abilify Maintena will be considered for the patient at that time. Any other medications would be unnecessary at this time.
Legal and ethical considerations for the patient include that her negative symptoms of schizophrenia affected her quality of life and possibly her safety. With the immediate need to protect the patient and ensure she received her medication in the proper doses, the injection mediation was best. Having her husband as an advocate also helped ensure the patient’s success.
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders
(5th ed.). Washington, DC: Author.
Procyshyn, R., Lamoure, J., Katzman, M., Skinner, P., & Sherman, S. (2019).
Need for Bioequivalence Standards that Reflect the Clinical Importance of the Complex Pharmacokinetics of Paliperidone Palmitate Long-Acting Injectable Suspension. Journal Of Pharmacy & Pharmaceutical Sciences: A Publication Of The Canadian Society For Pharmaceutical Sciences, Societe Canadienne Des Sciences Pharmaceutiques, 22(1), 548–566. https://doi-org.ezp.waldenulibrary.org/10.18433/jpps30669
Stahl, S. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical
applications (4th ed.). New York, NY: Cambridge University Press.
Stahl, S. (2014b). The prescriber’s guide (5th ed.). New York, NY: Cambridge University Press.
U.S. National Library of Medicine (2020). Once-monthly paliperidone injection for the treatment
of schizophrenia. Retrieved from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2938305/
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