Schizophrenia Treatment Decision Tree

Perkins

1 year ago

Schizophrenia Treatment Decision Tree

Schizophrenia is a debilitating mental illness. For most patients with schizophrenia, it is difficult to ensure full recovery without the use of antipsychotic agents. Prompt initiation of treatment is usually recommended within five years of the first event of an acute episode. The American Psychiatric Association recommends 2^nd generation (atypical) antipsychotics (SGAs) as the first-line treatment of choice for schizophrenia (Keepers et al., 2020).

This Assignment discusses the case of a 34-year-old Pakistani female who presented with symptoms of psychosis after being hospitalized for 21 days. A diagnosis of ‘brief psychotic disorder was given because her symptoms had lasted for less than a month. Most of the symptoms she presented with were positive symptoms, such as hallucinations, paranoia, and delusions. She reported that she had visions of Allah. She reported being the prophet Muhammad at some point and believed she would deliver the world from sin. Her husband was concerned after she went out of control one evening. During the assessment, her paranoia is revealed when she blames her husband for exaggerating her symptoms. She reports her husband is out to get her because she has always wanted an American woman. Physical examination is nonremarkable. The patient reports a good mood but occasionally becomes hostile during the interview. She reports that she stopped taking her medication (Risperdal) because of fear of being poisoned by her husband. The patient has poor insight into her condition and denies any of the symptoms. The patient reports no suicidal ideations. A PANSS score reveals a score of 60 for general psychopathology and 40 for the positive symptom scale.

A diagnosis of paranoid schizophrenia is made. To manage this patient, various decisions will have to be made. This paper discusses the series of decisions that will be made to aid in the treatment of this patient.

Decision 1

My first decision was to start the patient on Zyprexa (olanzapine) 10 mg orally. Olanzapine is an atypical antipsychotic. Atypical antipsychotics are the preferred first-line drug of choice for the treatment of schizophrenia. The mechanism of action of olanzapine is to antagonize the dopamine and serotonin receptors in the brain. The principal receptors affected are dopamine D2 in the mesolimbic system and 5HT2A receptors in the frontal cortex. Olanzapine binds loosely to dopamine D2 receptors and dissociates quickly. This is beneficial as it allows for normal dopamine neurotransmission. The action on D2 receptors decreases the positive symptoms of hallucination, delusion, and paranoia (Citrome et al., 2019). Antagonism at the 5HTA2 receptors in the frontal cortex leads to a reduction in the negative symptoms. The side effects associated with olanzapine include metabolic side effects such as weight gain and hyperphagia. I chose olanzapine because of its relative efficacy and speed in reducing positive symptoms of schizophrenia.

Aripiprazole is also a good option as it is also an atypical antipsychotic. It is FDA-approved for the management of symptoms of schizophrenia. It acts as an antagonist to 5HT2A receptors and a partial antagonist to D2 and 5HT1A receptors. It, however, demonstrates functional selectivity. I did not choose aripiprazole because it takes a long time to be clinically active. It requires more than a 90% occupancy rate at the D2 receptors (Preda & Shapiro, 2020). This makes the drug to be more tolerable. It, however, reduces its efficacy in treating acute episodes of schizophrenia. Likely, this medication might not be effective for this patient.

The reason I chose not to go with Invega Sustenna 234mg IM is because it is an extended-release antipsychotic. It is usually advised that test doses of these drugs are administered first before initiating the drug. This is important because it helps to determine the drug’s efficacy and tolerability (Kverno & Rozenberg, 2021). Test dosing is done using an oral counterpart of the drug.

By starting the patient on olanzapine, I hoped to see an improvement in the patient’s PANSS score with a reduction in the positive symptoms. After four weeks, the patient comes back for follow-up. She reports an improvement in the PANSS score and a 25% reduction in the positive symptoms. She, however, complains of an increased appetite, hyperphagia, and weight gain. This is an expected side effect of SGAs. Olanzapine has the most metabolic side effects when compared to other antipsychotics.

Decision 2

The second decision is to change the medication to Geodon (ziprasidone) 40 mg. Switching of medication is common practice in psychiatry. Ziprasidone is effective in the treatment of positive symptoms because of D2 antagonism. It also has 5HT2A antagonism, which is helpful in the treatment of negative symptoms. I chose this medication because it is equally efficacious in treating positive symptoms with minimal metabolic side effects (Bouchette et al., 2017). It will, therefore, reduce the chances of further weight gain.

I did not choose the dose reduction of Zyprexa to 7.5 mg because this would make the drug less efficacious. At 10 mg, the drug’s efficacy has been established since a reduction in symptoms by 25% Is noted. Reducing the dose might affect the patient’s progress and, therefore, be counterproductive. Changing to Geodon is the best option. I also did not choose Wellbutrin because it is mainly used to treat negative symptoms (Shawen & Drayton, 2018). Most of the patient’s symptoms are positive, which would not make Wellbutrin the ideal option. Also, the risk of using Wellbutrin outweighs the benefits as it can induce psychosis.

I hoped to improve the patient’s condition further by administering Geodon. I was also hoping to see an improvement in the patient’s weight. This is because ziprasidone has a lesser effect on metabolism than olanzapine. The patient reports to the clinic after four weeks and reports a significant improvement in the PANSS score. Her positive symptoms show a reduction of 40%. This shows an excellent response to medication. She does not report any side effects with the drug. Her only issue is compliance, as she reports frequently forgetting to take the 2^nd dose in the afternoon. This information leads to a third decision.

Decision 3

The third decision would be to switch her to Latuda (Lurasidone) 40 mg daily. Latuda has the exact mechanism of action as Geodon. D2 and 5HT2A blockade make it practical for the treatment of schizophrenia as it is a full antagonist at these receptors (Meltzer et al., 2020). It is well tolerated in patients who can tolerate Geodon. It is also only given once daily making it appropriate for the patient with compliance issues. Latuda also offers a safety advantage when compared with other SGAs.

I did not take the option of giving a few test doses of Risperdal 1 mg orally to check for tolerance before starting her on Invega Sustenna because of the possible likelihood of failure. It is not guaranteed that the patient will respond to this medication. Failure may result in a relapse of symptoms. Changing to Geodon 80 mg once daily is also a viable option. However, I did not pick this option because it is recommended that the daily dose be split into two and given twice daily. Giving the drug once daily may interfere with the efficacy.

Ethical considerations

When treating any patient, various ethical considerations need to be made. Firstly, the nurse needs to take into consideration the patient’s autonomy. This should also cover informed consent. This can only be made possible after the nurse has availed of all the available treatment options and allows the patient to choose. Patients with schizophrenia may have altered judgment. The choice made by the patient should not be a harmful option (Sookhak et al.,2019). The nurse should know when to practice non-maleficence and not respect patient autonomy.

Another ethical consideration that can be made is dose adjustment. Dose adjustments should be made whenever necessary for the benefit of the patient. The doses should be titrated based on how the patient responds to the medication. Drugs should also be administered appropriately. Drugs that should be administered twice daily or intramuscularly should not be administered differently from what is recommended.

Conclusion.

Schizophrenia is a debilitating mental illness. Many treatment options have been availed over the years. This paper discusses the case of a 34-year-old Pakistani woman who is diagnosed with schizophrenia. Several decisions are made to help with the management of this patient. The first decision is to start the patient on Zyprexa (olanzapine) 10 mg orally. This choice led to an improvement in the patient’s symptoms. The patient complained of hyperphagia and weight gain. A second decision was made to change the patient to Geodon (ziprasidone) 40 mg. His further improved in the patient’s condition. The patient also, however, has issues with compliance as she missed doses frequently. A third decision was made to switch the patient to Latuda (Lurasidone). Finally, various ethical considerations need to be made when handling patients. These ethical considerations include autonomy, which allows patients to make informed consent. Nurses should also practice non-maleficence. Dose adjustments and proper drug administration should be practiced.

References

Bouchette, D., Fariba, K., & Marwaha, R. (2017). Ziprasidone. Europe PMC. Retrieved October 17, 2021, from https://europepmc.org/article/nbk/nbk448157.

Citrome, L., McEvoy, J. P., Todtenkopf, M. S., McDonnell, D., & Weiden, P. J. (2019). A commentary on the efficacy of olanzapine for treating schizophrenia: The past, present, and future. Neuropsychiatric Disease and Treatment, Volume 15, 2559–2569. https://doi.org/10.2147/ndt.s209284

Keepers, G. A., Fochtmann, L. J., Anzia, J. M., Benjamin, S., Lyness, J. M., Mojtabai, R., Servis, M., Walaszek, A., Buckley, P., Lenzenweger, M. F., Young, A. S., Degenhardt, A., Hong, S. H., & (Systematic Review) (2020). The American Psychiatric Association Practice Guideline for the Treatment of Patients With Schizophrenia. The American journal of psychiatry, 177(9), 868–872. https://doi.org/10.1176/appi.ajp.2020.177901

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. https://doi.org/10.3928/02793695-20210611-04

Meltzer, H. Y., Share, D. B., Jayathilake, K., Salomon, R. M., & Lee, M. A. (2020). Lurasidone Improves Psychopathology and Cognition in Treatment-Resistant Schizophrenia. Journal of Clinical Psychopharmacology, 40(3), 240–249. https://doi.org/10.1097/JCP.0000000000001205

Shawen, A. E., & Drayton, S. J. (2018). Review of pharmacotherapy for smoking cessation in patients with schizophrenia. The mental health clinician, 8(2), 78–85. https://doi.org/10.9740/mhc.2018.03.078

Sookhak, F., Rafi Bazrafshan, M., Ahmadi, A., & Kavi, E. (2019). Nurses’ level of awareness and observance of patients’ rights. Journal of Client-Centered Nursing Care, 167–174. https://doi.org/10.32598/jccnc.5.3.167

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Question

https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/DT/week_06/index.html
Examine Case Study: Pakistani Woman With Delusional Thought Processes. You will be asked to make three decisions concerning the medication to prescribe to this patient. Consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

Schizophrenia Treatment Decision Tree

You should evaluate all options at each decision point before deciding and moving throughout the exercise. Before making your decision, ensure that you have researched each option and evaluated the decision you will select. Be sure to research each option using the primary literature.

Introduction to the case (1 page)

Briefly explain and summarize the case for this assignment to include the specific patient factors that may impact your decision-making when prescribing medication for this patient.
Decision #1 (1 page)

Which decision did you select?
Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #2 (1 page)

Why did you select this decision? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
Why did you not select the other two options provided in the exercise? Be specific and support your response with clinically relevant and patient-specific resources, including the primary literature.
What were you hoping to achieve by making this decision? Support your response with evidence and references to the Learning Resources (including the primary literature).
Explain how ethical considerations may impact your treatment plan and communication with patients. Be specific and provide examples.
Decision #3 (1 page)

Summarize your recommendations on the treatment options you selected for this patient. Be sure to justify your recommendations and support your response with clinically relevant and patient-specific resources, including the primary literature.