W6 PsychoPharmacol

Assessing and Treating Clients with Psychosis and Schizophrenia

Psychopharmacologic Approaches to Treatment of Psychopathology

Delusional Disorders

H

W

2020.

Introduction

           Worryingly, there exists a societal stigma on some of the mental health conditions that people suffer. This stigma is why experts in this field claim there being underreporting and undertreating mental disorders like psychosis. Researchers Goodby and MacLeod in their 2016 publication define psychosis as a severe mental disorder that manifests as a collection of symptoms in which thoughts and emotions with severe impairment in physical, functional, psychological, and social capabilities of the individuals suffering from it and is not in contact with external reality. Individuals with these disorders display behaviors that impact normal brain functions and clear thinking. Patients with this condition might experience delusions, hallucinations, and disorganized thinking, all symptoms showing how psychosis impacts the regular brain operation. There are psychosis patients who suffer comorbidity of the condition and experience a wide range of mental health illnesses, acute, physical, and chronic illnesses. The clinical manifestations that arise in some situations necessitate the use of pharmacotherapy interventions. Patients in the past have shown a positive response to these interventions.

There is more recent research on the mental health-related barriers and stigmas that exist that have enhanced access to currently used treatments (Hoge et al. 2016 pp. 3-4). The practitioner will analyze a case scenario of a 34-year-old female patient from Pakistan, who, after three weeks of hospitalization, has been diagnosed with a 'brief psychotic disorder. After stabilizing, she is put on medication and released to go home. At the clinic today, she reveals that due to her paranoid and delusional thought processes she had stopped taking one of the prescribed medications, Risperdal, about one week after discharge from the hospital. Her Positive and Negative Syndrome Scale (PANSS) test reveals scores that indicate severe symptoms of schizophrenia paranoid type. This case scenario requires the practitioner to decide on the best practice to assess and treat the condition of the client considering the legal and ethical implications of the practitioner's chosen intervention. The following section of the document justifies the three decisions that the practitioner takes when treating the client. 

Decision One

Zyprexa 10mg orally at bedtime

           The practitioner's rationale for this decision is the knowledge that antipsychotic drugs with the capacity to treat positive psychotic symptoms are dopamine D2 receptor blockers. Zyprexa has a high efficacy capacity with less undesirable side effects. According to researcher Stahl (2013), a practitioner's decision to deal with antipsychotic drugs will need to consider the undesirable side effects of the drug. Neuroleptic is the undesirable side effects of antipsychotic drugs. Zyprexa is a dopamine and serotonin receptor antagonist (DS-RAn). Author Stahl states that Zyprexa is a mood stabilizer and a second-generation antipsychotic. Notably, Zyprexa is a drug that has the potential of treating psychiatric disorders such as schizophrenia or its acute agitation. With this knowledge, the practitioner believes that the Zyprexa will be ideal for the client due to the age factor (34 years) and has visible paranoid and delusions thought processes. Client, now with a diagnosis of Schizophrenia paranoid type, stopped taking Risperdal one week after release from the hospital because the client thinks the husband is using the 'Risperdal' medication to poison her. The practitioner decides to change the medication from Risperdal to Zyprexa to remove the belief she has about Risperdal.  

           The other two options the practitioner has is the administering intramuscular Invega according to the recommended guideline or offer Abilify 10mg orally at bedtime. However, Stahl (2014b) states that both Invega and Abilify belong in the same class of dopamine and serotonin receptor antagonist (DS-RAn) just as Zyprexa. Notably, the recommended daily safe dose Zyprexa is between10–20 mg/day. If the practitioner administers Invega Sustenna 234 mg intramuscular, the practitioner runs a high chance of going above the standard expected monthly maintenance dose of 39-234mg/month. It may be an unsafe practice sending client home with intramuscular (IM) medications. The client may become noncompliant due to discomfort of injections sites, and or client/family members do not have the needed experience to give an intramuscular injection or the certification. Abilify 10 mg, on the other hand, is below the recommended daily dosage and has a disadvantage of being a partial dopamine serotonin receptor agonist (DS-RPA), thereby disqualifying it from being the first-line choice of treating schizophrenia (Stahl 2014b). 

Expectations of the Provider:

In the next four weeks follow up appointment, the practitioner expects a reduction in the PANSS score of between 30-35%. The practitioner expects a reduction in symptoms of paranoid and delusions; the client is portraying to determine the efficacy of the drug. Researchers Woodward et al. (2014), point out that the PANSS test is an acceptable tool used to assess the severity of illness and helps to track down any changes in symptoms that patients show in response to a specific treatment. Outcome: The client reports to the next visit with 5 pounds gain in weight. The client reports an increase in appetite with frequent snacking in between meals. Her PANSS test score indicates a 25% decrease resulting from partial response to the Zyprexa. This outcome shows that the Zyprexa has not only a therapeutic response but can also increase appetite and weight gain, an impact the practitioner must manage. Stahl (2013), in his book, states that antipsychotic medications such as Zyprexa contain the class warning of causing dyslipidemia, obesity, diabetes, and accelerated cardiovascular disease, with the risk greater clozapine and olanzapine.

Decision Two

Geodon 40mg orally twice daily with food

           Based on the above outcome, as opposed to the practitioner's expectation, the practitioner can switch the medication of the client from Zyprexa 10 mg to Geodon 40 mg orally twice daily with food. Gedeon is a dopamine and serotonin receptor antagonist (DS-RAn), as well as a second-generation antipsychotic mood stabilizer approved for the treatment of schizophrenia (Stahl, 2014b). Noteworthy, Stahl (2014b) has been able to prove that weight increase in patients using Geodon is not typical, especially with low BMI in contrary to Zyprexa. 

The decision to change the medication is to avoid decreasing the Zyprexa dosage to 7.5 mg at bedtime. The new dosage would be insignificant in treating the psychosis condition client is suffering from due to age. Also, sticking with the Zyprexa medication means that the client will continue getting an increase in appetite and weight gain, side effects that might trigger the patient to noncompliance with the medication. 

Adding on Wellbutrin XL 150 mg orally in the morning will not be an excellent third option. Further analysis of this third option by the provider indicates that Wellbutrin belongs to the class of norepinephrine dopamine reuptake inhibitor (NDRI). This medication treats major depressive disorders, depression, bipolar, attention deficit-hyperactivity disorder (ADHD), and sexual dysfunction (Stahl, 2014b). 

Expectations of the Provider:

           Due to the above decisions, the provider is confident that the client will show a more positive response to the treatment during the next clinic visit. On the next clinic visit, the clinic shows improvement in psychotic symptoms, reports that hunger drive had gone down and, has lost two pounds in weight. There is a decrease in PANSS score by 40%. However, the client admits forgetting to take the second dose missing her afternoon doses several times during that period. Despite this setback, though, there is evidence that the client shows a steady progressive response to the treatment with a continual decrease in side effects. Outcome: The positive outcome indicates the client is tolerating treatment with Geodon very well, and the intervention can be more effective if the provider can deal with the recurring issue of noncompliance by forgetting afternoon doses. 

Decision Three

Geodon 8-mg orally bedtime

           Based on the above information, the provider decides to change the Geodon to 80 MG orally at bedtime daily. This action is because there will be a significant symptom reduction if the client continues with this positive response to the treatment. Within eight weeks of taking the medication, there is a PANNS score that will decrease by 40% with steady diminishing medication side effects. The beauty of the current dose of medicine is that it can be maintained for another 4-week, as the client continues to show a positive response to it. Maintaining the dosage would help in the further evaluation of the effectiveness of the medicine. However, prolonging it increases the risk of the client getting more side effects of the medication. The American Psychiatric Association (2015) guides that if after the additional 4-8 weeks course treatment is over and the patient shows no improvement or has minimal symptoms improvement, the psych mental provider needs to make changes to treatment plan after. This change can be achieved by first conducting a thorough review of the factors contributing to minimal improvement.

With this client, the practitioner intends to continue with the current dose client is using for four weeks. After this period, the practitioner will analyze if the medication will lead to a further reduction in the client's symptoms. If there is no remarkable reduction in symptoms, the practitioner will discuss with the client about the possibility of increasing Geodon's dosage in a bid of attaining full remission. Part of the discussions will talk about the potential side effects of the increase in dosage. Stahl (2014b) states to administer Geodon in divided doses of between 40-200 mg/day, orally, as tolerated. The author goes ahead to state that the Geodon's best efficiency in treating schizophrenia is successful if the daily doses are higher than 120 mg/day.

The other available option is to give Risperdal 1mg orally for a couple of days. In the event client tolerates it, the next move was to start giving Invega Sustenna. This option would be ideal for patients who experience psychosis. This option will create a room for noncompliance for the client since the client already has a history of forgetting to take medications more than once. 

           The other option attached to decision three that the practitioner has is to discontinue giving the client the Geodon medication and start on Latuda 40mg orally daily. Switching to Latuda may not be therapeutic as the client may not be able to tolerate it, putting the client at the risk of experiencing the unwanted side effects of vomiting, nausea, and extrapyramidal side effects that are typically problematic to patients (Laureate, 2016j). This practitioner is inclined to assume that the client positively responds to switching to Gedeon 80mg orally at bedtime daily due to the client having lost some weight with a reduction in PANSS score by 40%. 

Ethical Considerations:

           The practitioner's treatment plan will possess elements showing ethical considerations that are necessary before starting the medication. The first element showing this consideration is proper communication with the client. This engagement is essential as it gives the practitioner a chance to discuss the cons and pros of the treatment interventions. Conversations about the drug regimen is a way of ensuring that the patients are part of the decision-making process. Steinwach et al. (2011) document that psychiatric patients usually have personal preferences and expectations of the care given to them. Failure to readily and adequately communicate these to the patients prevents them from integrating into the treatment intervention. The authors go further in their research article to state that incorporating patient feedback and any recommendation during the schizophrenia treatment encourages patients to be active while trying to deal with treatment concerns and helps the psych mental provider settle on the best therapy option. 

It is imperative to note drugs that will incorporate into the treatment of psychosis, the treating practitioner overseeing the intervention needs to continuously have an attentive and empathic psychotherapeutic relation with the patients. Bandelow et al. (2013) also stated that practitioners must continually educate and remind their patients about drug behaviors and compliance that might interfere with the smooth progress of the treatment methodology. The authors go ahead to encourage practitioners to start discussions with the patients about possible medication side effects such as weight gain and sexual dysfunction.

The client in the scenario is 34 years old, meaning that she can give legal consent to the medical intervention used to deal with her mental disorder. This improves communication between the provider and the client. Experts encourage communication to be done in a language that the patient understands, as it is the only way to ensure that they have the necessary information that will enable them to make the correct medical decisions. The client has already exhibited some side effects attached to the chosen medical intervention. Thus, it is this provider prerogative as the health care practitioner to take a more proactive approach and research on how to minimize these effects using a change in dosages or switching to another medication altogether. 

Conclusion

           In conclusion, the information contained in this document shows that psychosis is one of the commonly unreported and untreated mental condition due to societal stigma amongst the population. Several factors complicate the treatment and diagnosis of the condition. Researchers have established that early therapy helps ease the effects of the condition and reduces its morbidity. Psych mental practitioners must handle clients diagnosed with psychosis and hold discussions with their clients when developing a treatment plan. These discussions would analyze the associated benefits and risks of new psychoactive medications or changes in the doses while at the same time, monitoring for the effectiveness. 

In the field of psychiatry, not adhering to medication is a common reason why clients are re-admitted to hospitals and or make frequent visits. Cases of non-adherence to treatment are high in outpatients. In the case scenario, the client confesses to skipping some required doses several times. Authors Lehner et al. (2007) advise psych mental practitioners to consider the potential risks and benefits attached to psychoactive medications providers intend to use on their clients. This is to ensure that they eliminate any hindrance to medication compliance in their clients. Staying current with the relevant information also enables practitioners to make correct legal and ethical implications considerations. All this is inclined towards achieving a balanced and informed decision-making process. 

References

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