W4 Psychosis Case Study

Post#2 Psychosis Case Study by Chouchouna Kalamba

1. What information, if any, would you like to know that was not included in the case?

Additional information that could be useful in diagnosing and treating Andy includes a personal history of mental health disorders, family history of mental health disorders, recent stressful life or traumatic events, sleep deprivation, withdrawal from social life (school, work, friends), the presence of cognitive symptoms, a personal and family history of medical problems, and a list of current medications.

2. Which psychiatric symptoms are a treatment priority for this case?

-hallucinations

-delusion

-suicidal ideation

-negative symptoms

3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?

Andy’s substance abuse can be managed using psychotherapy such as cognitive-behavioral therapy. His negative symptoms also be managed using a non-pharmacological approach.

Medication Choice 1

4. List one medication that would be appropriate for this case. Include the name and starting dose.

Ziprasidone

Initial dose 20 mg BID, titrate as needed

5. Describe your clinical decision-making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.

The rationale for choosing Ziprasidone is that it is a second-generation antipsychotics (SGA) known to block D2 receptors in the mesolimbic dopamine pathway while increasing dopamine in the prefrontal cortex. The American Psychology Association recommends the use of SGAs as the first-line treatment of schizophrenia except for clozapine due to its risk of agranulocytosis. Although SGAs are known to cause metabolic side effects and increase the risk of cardiovascular diseases; Ziprasidone has little or no effects on weight gain and does not cause dyslipidemia, high triglycerides, and insulin resistance as much as the other agents in the “dones family”. Ziprasidone is a D2 and 5HT2A receptors antagonists; it is an atypical antipsychotic that works by

- blocking D2 receptors, reducing positive symptoms, and stabilizing affective symptoms (Stahl, 2013).

-blocking 5HT2A receptors, causing enhancement of dopamine release, thus reducing motor side effects, and possibly improving cognitive and affective symptoms (Stahl, 2013)

- interacts at 5HT2C and 5HT1A receptors to improve affective and cognitive symptoms

-interacts at 5HT1D and 5HT7 receptors and at serotonin and norepinephrine transporters to improve affective symptoms.

6. What laboratory testing/monitoring is needed for safely prescribing this medication?

Although Ziprasidone has little to effects on weight, triglycerides, lipids, and glucose, Stahl (2018) recommends obtaining a baseline weight and truck BMI during treatment; baseline fasting glucose, and lipid profile prior to initiating treatment. For high-risk patients (overweight, prediabetics, hyperlipidemic, and prehypertensive), treatment of these conditions is needed prior to initiating treatment, BMI monitoring every 3 months, monthly lipid profile, blood pressure, and fasting glucose every 3 months. A routine EKG may be useful for patients with at-risk of QTc prolongation and cardiac problems, or those taking medications known to increase QTc. After initiating ziprasidone, patients at risk for electrolyte imbalances such as those on diuretics should have their potassium and magnesium monitored. Additionally, patients with a low WBC count or a history of drug-induced leucopenia/neutropenia should be monitored frequently during the first few months, if a patient becomes leucopenic/neutropenic while taking ziprasidone; it should be discontinued in the absence of other causative factors (Stahl).

7. Are there any contraindications or safety issues associated with this medication?

Ziprasidone is contraindicated in patients taking agents known to prolong QTc interval, these agents include pimozide, thioridazine, moxifloxacin, sparfloxacin, and class III antiarrhythmics. Patients with a recent MI, uncompensated heart failure, a history of QTc prolongation, and a history of cardiac arrhythmias should not take, ziprasidone. Patients with a known history of QTc prolongation, who are pregnant, and have an allergy to ziprasidone should not take it.

Non pharmacologic Interventions

8. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complementary and holistic therapies?

Cognitive-behavioral therapy has been found to be an effective add-on approach to the management of schizophrenia in a study conducted by Ganguly et al (2018). CBT was found to be effective in managing the following negative symptoms of schizophrenia: disorganized behaviors, sociality, and apathy. Additionally, positive symptoms of schizophrenia such as hallucinations and delusions were also effectively managed in this study using antipsychotics and CBT. Ganguly et al suggested the use of cognitive restructuring to challenge the patient to identify evidence proving that their distorted beliefs are real. Cognitive reconstruction helps the client identifies and challenges negative thoughts and replace those thoughts with more realistic and positive ones (Ganguly et al). Suicidal ideation was also managed using CBT. The administration of folic acid, Vitamin C, E, B (including B12 and B6), and vitamin D supplements were also found to be effective in managing negative and positive symptoms of schizophrenia symptoms (Ganguly, et al). A healthy diet rich in fiber, low fat, and carbohydrate can decrease cardiovascular diseases associated with schizophrenia. Substance use and abuse (smoking, illicit drugs, and alcohol) can also be managed using CBT to minimize the risk of mortality among individuals with schizophrenia. Routine exercise can minimize the risk of cardiovascular diseases associated with schizophrenia.

Safety Risk Assessment

9. What are the safety concerns, if any, associated with this case? How will you address safety?

Andy verbalized suicidal ideation with a plan. He plans on overdosing on some pills to end his life. To address this, I would develop a safety plan with Andy to help him overcome his suicidal ideation. A safety plan will include an emergency phone number (someone he trusts more), which he can call when he feels suicidal; a list of activities he finds pleasure in doing that he should engage in when he feels suicidal, and a national suicide hotline number to call when he is not able to overcome suicidal ideation with the other strategies. Another safety concerned is the use of “speed” cocaine which likely triggers the onset of Andy’s symptoms. Andy’s substance abuse can be clinically addressed with psychotherapy, specifically CBT.

10. When would you follow up with this patient?

I would follow up with Andy 4 to 6 weeks after initiating ziprasidone to assess its therapeutic effects. Stahl (2018) recommends waiting at least 4-6 weeks after initiating ziprasidone to assess its efficacy, although it may take up to 10-20 weeks to show a good response.

References

Ganguly, P., Soliman, A., and Moustafa, A. A. (2018). Holistic Management of Schizophrenia Symptoms Using Pharmacological and Non-pharmacological Treatment. Frontiers in Public Health, 6 (166), 1-9Stahl, S. (2013). Essentials of Psychopharmacology, (4th edition). United Kingdom, Cambridge University Press.

Stahl, S. (2018). Essential Psychopharmacology: Prescriber’s Guide, (6th edition). United Kingdom, Cambridge University Press.