NURS-6630 Week 7: Assignment Assessing and Treating Patients with Psychosis and Schizophrenia,100% CORRECT

NURS-6630 Week 7: Assignment Assessing and Treating Patients with Psychosis and Schizophrenia NURS-6630- Psychopharmalogical Approaches to Treat Psychopathology Week 7: Assignment Walden University Introduction The provided case study is of 34 years old Pakistani woman who was diagnosed as “brief psychotic disorder” during her 21 days hospitalization. Patient is married (her husband was selected for her when she was 9 years old). Patient has 4 children. Patient got settled in United States after getting married in her 20’s. She was diagnosed as psychotic because the psychosis persisted for less than one month. Her husband reported that she believed that she is Prophet Mohammad and she gets messages from Allah through TV. He also reported that one evening she got out of control due to which he called police and as a result she got admitted as an inpatient in psych unit. She was asked about that incident but she denied by saying that “the entire incident is blown out of proportion”. She also denied about her believe that she is a prophet and stated that her husband is making these statements about her because he wants to get rid of her as he never loved her and he always wanted an American wife. She added that she knows the intentions of her husband because TV is telling her so. During hospitalization she was taking Risperdal but after getting discharged, she stopped taking Risperdal (about a week ago) because she thinks that through Risperdal her husband will poison her so that he can marry an American wife. The pertinent positive information that will impact the decision making when prescribing medication for this patient includes diagnosis of paranoid type Schizophrenia, scores of PANSS (40 for positive symptoms, 20 for negative symptoms and 60 for psychopathology), symptoms of Schizophrenia (persistent reflection of paranoid and delusional thought processes, presence of auditory hallucinations, slow speech, no demonstrations of tics, gestures and mannerism, judgment and insight is impaired), incompliant behavior towards medications, lab studies showing good health, BMI of patient is 23.29 (weight is 140 lbs and height is 5’5”) which indicates that patient is not underweight or overweight and patient denied homicidal or suicidal ideation. Assessing and Treating Patients with Psychosis and Schizophrenia Decision 1 The selected decision one is “start Invega Sustenna 234mg IM followed by 156mg IM on day 4 and monthly thereafter”. I selected this decision by considering the noncompliant behavior and scores of PANSS. Invega Sustenna is also known as Paliperidone which is recommended to schizophrenic patients in the form of injectable (Sustenna- injection administered after one month interval and Trinza- injection administered after three months interval). According to the study of Chang, Huang and Yang (2021) the major problem of schizophrenic patients is their non-compliant behavior towards the treatment. As the patient shows non-adherence to treatment therefore, achievement of desired outcomes becomes difficult. In such scenarios, it is recommended that long-acting injections should be prescribed as compared to oral antipsychotics. The study of Chang, Huang and Yang (2021) clearly indicated that those patient with schizophrenia who are treated by long-acting injections show reduced rates of re- hospitalization and noncompliance as compared to those patients with schizophrenia who are treated by oral antipsychotics. Considering this fact, the Invega Sustenna is selected for decision one because the background information of this patient has shown her noncompliant behavior towards treatment. Moreover, Invega is selected for decision one because it is an effective antipsychotic with increased safety profile. The studies of Chang, Huang & Yang (2021), Kverno & Rozenberg (2021) and Canady (2019) have briefly discussed that drugs like Invega possess superior efficacy in reducing both negative and positive symptoms of schizophrenia. This drug possess low risk of causing extrapyramidal effects. Patients treated with Invega have shown lower weight gain, lower relapse rates, lower withdrawal rate, better cost-benefit ratio and increased tolerability and safety. The other option of Zyprexa was not selected because of its mode of administration (which is oral) and reduced safety profile. According to the study of Krzystanek et al (2019) the noncompliance behavior of schizophrenic patients is associated with worsening of PANSS scores and therefore the medication should be selected on the basis of mode of administration. The study also mentioned that Olanzapine is an effective medication with good tolerability but as the schizophrenic patients show noncompliant behavior towards oral treatment regimen therefore such medications fail to produce the desired outcomes. The study of Li et al (2020) had discussed that olanzapine-induced dyslipidemia with schizophrenia is characterized by increased levels of plasma triglycerides, total cholesterol and low density lipo-proteins. This indicates that Zyprexa possess the tendency of improving cholesterol levels and therefore increases BMI of patient. Due to this side effect, Zyprexa requires continuous monitoring of cardiovascular status because increased lipid profile has reduced the safety profile of drug and has increased the risks of developing cardiovascular complications. Although the presented patient is not obese but getting obese due to Zyprexa and its oral mode of administration can cause her to withdraw from the treatment plan. Similarly, the third option of Abilify was also not selected because of its mode of administration (oral) and its side effect of sedation or sleep disturbance. The studies of Suba & Yetkin (2019) and Kobayashi & Takano (2018) have mentioned that Abilify (also known as Aripriprazole) induce sleep related eating disorder and affects the regulation of sleep-wake system. The study of Suba & Yetkin (2019) has thoroughly discussed that drugs like Abilify cause sedation by increasing the activity of systems that provide sleep or by reducing the activity of systems that provide alertness. It means that this drug is prone to develop sleep disorders. By making the decision of Invega Sustenna injectable, I was hoping that after four weeks patient will come and will show that her PANSS scores have reduced and she is responding to medication with good tolerability (Canady, 2019). Decision 2 For decision two I selected “continue same made but instruct administering nurse to begin injections into the deltoid at this visit and moving forward”. I selected this decision because of the results of decision one. As the patient came after four weeks and showed decreased in PANSS scores of 25% (in positive symptoms). Patient also showed good tolerability. However, patient reported 2 pounds of weight gain but it does not seem to bother her. The only complaint made by patient is injection- site pain. As the patient showed positive response towards decision one along with good tolerability therefore, the medication is not changed. Instead, the injection site is changed and the nurse is instructed to administer the injection into the deltoid muscles. According to the study of Zolezzi et al. (2021) long-acting injectable are introduced for the treatment of schizophrenia because of increased rates of noncompliant behavior showed by schizophrenic patients. The most common side effect of these injections is pain at injection site. Specifically, if the injection is administered via gluteal region, then the pain intensity is more because a significant percentage of drug shows poor absorbance within the gluteal muscles that cause pain. It means that administration of injectable via gluteal region contributes to the loss of drug and the complete dose of drug is not delivered. As a result, the complete efficacy of the treatment plan is not achieved. Therefore, deltoid region is recommended for Intramuscular (IM) injectable because deltoid muscles show increased absorbance as compared to gluteal muscles. The study of Zolezzi et al. (2021) has discussed that deltoid muscles are used for injecting long- acting injectable because it is viewed by patients as less intrusive than the gluteal injection site. The other option of “DC Invega Sustenna and start Haldol Decanoate” was not selected because the patient showed positive response towards the decision one. The other medications would be considered if the patient had failed to show reduction in symptoms. Moreover, Haldol Decanoate is reported to cause severe neuromuscular disorders and tardive dyskinesia is the prominent side effect of Haldol Decanoate. According to the study of Khelfi et al. (2018) the Anti-Poisoning Centers of Algiers have reported that Haldol (also known as Haloperiodl) is the most effective inducer of causing neuromuscular and muscular disorders among all antipsychotics. Due to poor safety profile of Haldol Decanoate, this drug was not selected for decision one. Moreover, the treatment algorithm of Schizophrenia have indicated that if one drug shows positive response without causing any side effect then it should not be changed or an alternative treatment plan should not be considered until the patient reports serious side effects. According to the study of Remington et al. (2017) if the patient shows resolution of positive symptoms then the treatment plan should be maintained with the same antipsychotic medication for 5 years or longer until the patient reports no serious issues. As the presented case study has mentioned that patient is showing resolution of symptoms (indicated by reduction in PANSS scores), therefore on the basis of pharmacotherapy guideline, the medication Invega Sustenna will not be discontinued and any other medication (including, Haldol Decanoate) would not be recommended until the patient reports any serious side effects. The third option of “combination therapy of Abilify Maintena (oral) with Invega Sustenna (IM)” was not selected because the monotherapy of Invega was sufficient in reducing the PANSS scores and severity of symptoms without causing any side effect. Therefore, there is no need to adopt a treatment regimen of polypharmacy. The more drugs a patient will take, the more chances of developing side effects and drug-drug interactions will increase. According to the study of Kadra et al. (2018) those patients of schizophrenia who were discharged on polypharmacy treatment regimen were more likely to be readmitted into hospital as compared to those who were discharged on monotherapy. By making decision 2, I was hoping that the patient will come exhibiting improved mental health status and will show further reduction of PANSS scores (because deltoid muscles will facilitate the complete delivery of drug and hence will show further improvements in symptoms). I was also expecting that the patient will not complaint about pain at injection site (Zolezzi et al., 2021). Decision 3 For decision 3, I selected “continue with 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”. I selected this decision on the basis of results of decision 2. As the patient came after four weeks and showed 50% reduction in PANSS score (in positive symptoms). The patient also mentioned that the injectable is much better in the arm. Patient came alone which indicates improvement in her life quality and independency levels. However, the patient is now concerned about her weight gain because her weight has increased by an additional 2.5 pounds (total of 4.5 pounds in a 2 month of treatment plan). Patient reported that her husband is not liking her increased weight and she was wondering that if there is any other drug like Invega Sustenna that would not cause the weight gain. Patient also reported that she likes how she feels on Invega Sustenna. Considering these facts, the continuation of Invega Sustenna was selected. The treatment algorithm has also stated that the medication should not be changed if the patient shows positive response and good tolerability levels at least for five years or longer until the patient reports serious complications (Remington et al., 2017). In addition to this, the patient is concerned about her weight gain for which a dietician and exercise physiologist is referred. The second option of discontinuing Invega Sustenna and starting Abilify Maintena was not selected because patient is showing positive response towards Invega Sustenna, therefore there is no need to change the medication (as discussed above). Moreover, the mode of administration of Abilify Maintena is IM with overlapping oral. As discussed above, the oral antipsychotics are not selected for this patient due to compliance issue. If the patient is showing positive response towards Invega Sustenna, then changing medication at this point is full of risk because it will again require monitoring of progress along with the side effects. Such practices will also be against the treatment algorithm designed for the treatment of schizophrenia. The third option of continuing Invega Sustenna along with the addition of Qsymia for weight loss is not selected. One reason for not selecting this option is to follow the treatment algorithm which states that if monotherapy is effective then polypharmacy should not be considered. The polypharmacy should be considered only if the side effect of the drugs requires such decisions and weight gain is not a serious side effect (Kadra et al., 2018). The other reason for not selecting Qsymia is its side effects which are cardiovascular complications. According to the study of Zand, Ibrahim & Patham (2018) Qsymia is one of the newer agents for treating obesity but this drug possess possible concerns related to elevations in heart rate and teratogenic potentials. With this decision, I was hoping that the patient’s quality of life will be improved. As the treatment goal of achieving 50% reduction in symptoms is achieved, therefore I was not hoping further improvements in symptoms. However, the monitoring of treatment progress will be required in order to ensure that the drug remains effective for longer time. I was also hoping that dieticians and exercise physiologist will be helpful in reducing her weight and this will further increase the patient’s satisfaction level. The most important thing that I am hoping with this treatment plan is increased patient’s adherence levels in order to achieve the maximum benefits of medication. Ethical Considerations It is important to educate patient about the significance of compliance and how non- adherence can reduce the efficacy of treatment plan. Patient should be educated that weight gain is a common side effect of antipsychotic drugs and Invega Sustenna is considered as the most effective drug that causes least production of fats. Patient needs to understand that weight gain is not a major issue and it could be resolved with non-pharmacological approaches instead of considering other drugs and increasing risks of developing side effects and drug-drug interactions (due to polypharmacy). E-reminders will be set for patient in order to keep the patient updated about her injectable and to make adherence with the treatment plan easier for her. An informed consent will be obtained from patient and patient will be educated about her treatment options and relevant side effects. It is also important to help and guide patient towards the selection of most effective treatment option with fewer side effects (Canady, 2019). Conclusion As the background information of patient has indicated that her husband was selected for her when she was in her childhood years. This indicates that the patient had suffered from emotional trauma during childhood and when the patient got transitioned into adulthood, then that childhood trauma became the trigger for Schizophrenia development (Xie et al., 2018). Besides this, the patient was observed to be in continuous stress or anxiety related to insecurity. As she continuously said that her husband wants an American wife, her husband does not love her and her husband is not happy with her weight gain due to treatment. All these statements indicate two facts. One fact is related to the behavior of husband. There are chances that her husband is actually not concerned about her (as she mentioned that her husband is not liking her weight gain). In this case, it is important to educate her husband about the current mental health status of his wife, its severity and ways that she needs to be treated. Cooperative behavior of her husband towards her can eliminate such insecurities and can cause the patient to feel good about her. The other fact is that she is assuming that her husband is not concerned about her. In this case, the patient needs to be counseled that these are her insecurities which are amplified by her schizophrenic thought process and therefore she needs to avoid such negative thoughts. The other recommendations include Invega Trinza in decision one. Invega Trinza is the IM injectable that needs to be administered after every three months interval. If that option was available, then I would have selected Invega Trinza instead of Invega Sustenna because of increased compliance levels and same efficacy profile as that of Invega Sustenna (Chang, Huang & Yang, 2021). In decision two, the recommendation was the adoption of shotblocker technique and interventions for reducing pain at injection- site. According to the study of Bilge et al. (2019) shotblocker is an effective non-pharmacological technique that reduces IM related injection pain. Another study of Şanlialp Zeyrek, Takmak, Kurban & Arslan (2019) has discussed that interventions like Z-technique and application of manual pressure during the administration of IM injection is effective in reducing pain at injection-site. So if any of these interventions would be available along with the continuation of Invega Sustenna or Invega Trinza, then I would have selected these non-pharmacological interventions in decision two. References Bilge, S., Aydin, A., Gun, C., Aldinc, H., Acar, Y. A., Yaylaci, S. & Balci, V. (2019). Comparison of the efficacy of ShotBlocker and cold spray in reducing intramuscular injection-related pain in adults: A prospective, randomized, controlled trial. Saudi Medical Journal, 40(10), 996. Canady, V. A. (2019). Long‐acting injectables good option for schizophrenia patients. Mental Health Weekly, 29(15), 6-7. Chang, C. L., Huang, Y. C., & Yang, P. (2021). Improving of cognition and quality of life in schizophrenia with one-month and three-month Paliperidone Palmitate treatment. Kadra, G., Stewart, R., Shetty, H., MacCabe, J. H., Chang, C. K., Kesserwani, J. & Hayes, R. D. (2018). Antipsychotic polypharmacy prescribing and risk of hospital readmission. Psychopharmacology, 235(1), 281-289. Khelfi, A., Azzouz, M., Abtroun, R., Reggabi, M., & Alamir, B. (2018). Antipsychotic-induced disorders: Reported cases and prospective study on muscle biomarkers after high exposure to haloperidol. Toxicology and Applied Pharmacology, 352, 1-8. Kobayashi, N., & Takano, M. (2018). Aripiprazole-induced sleep-related eating disorder: A case report. Journal of Medical Case Reports, 12(1), 1-4. Krzystanek, M., Krysta, K., Janas-Kozik, M., Martyniak, E., & Rybakowski, J. (2019). Risk factors for noncompliance with antipsychotic medication in long-term treated chronic schizophrenia patients. Psychiatria Danubina, 31(Suppl 3), 543-548. Kverno, K., & Rozenberg, I. (2021). Long-acting injectable antipsychotics in the treatment of schizophrenia: Practical considerations. Journal of Psychosocial Nursing and Mental Health Services, 59(7), 7-12. Li, R., Zhang, Y., Zhu, W., Ding, C., Dai, W., Su, X. & Huang, X. (2020). Effects of olanzapine treatment on lipid profiles in patients with schizophrenia: A systematic review and meta- analysis. Scientific Reports, 10(1), 1-14. Matsui, K., Tokumasu, T., Takekita, Y., Inada, K., Kanazawa, T., Kishimoto, T. & Takeuchi, H. (2019). Switching to antipsychotic monotherapy vs. staying on antipsychotic polypharmacy in schizophrenia: A systematic review and meta-analysis. Schizophrenia Research, 209, 50-57. Remington, G., Addington, D., Honer, W., Ismail, Z., Raedler, T., & Teehan, M. (2017). Guidelines for the pharmacotherapy of schizophrenia in adults. The Canadian Journal of Psychiatry, 62(9), 604-616. Şanlialp Zeyrek, A., Takmak, Ş., Kurban, N. K., & Arslan, S. (2019). Systematic review and meta‐analysis: Physical‐procedural interventions used to reduce pain during intramuscular injections in adults. Journal of Advanced Nursing, 75(12), . Suba, E., & Yetkin, S. (2019). Effects of second generation antipsychotics risperidone, olanzapine and aripiprazole on sleep structure in the treatment of first-episode psychosis patients. Klinik Psikofarmakoloji Bulteni, 29, 280-283. Xie, P., Wu, K., Zheng, Y., Guo, Y., Yang, Y., He, J. & Peng, H. (2018). Prevalence of childhood trauma and correlations between childhood trauma, suicidal ideation, and social support in patients with depression, bipolar disorder, and schizophrenia in southern China. Journal of Affective Disorders, 228, 41-48. Zand, A., Ibrahim, K., & Patham, B. (2018). Prediabetes: why should we care? Methodist DeBakey Cardiovascular Journal, 14(4), 289. Zolezzi, M., Abouelhassan, R., Eltorki, Y., Haddad, P. M., & Noorizadeh, M. (2021). Long- acting injectable antipsychotics: A systematic review of their non-systemic adverse effect profile. Neuropsychiatric Disease and Treatment, 17, 1917.