Discussion: Treatment for a Patient With a Common Condition, Assessing and Treating Patients with Psychosis and Schizophrenia, and Case: An elderly widow who just lost her spouse.
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Insomnia is one of the most common medical conditions you will encounter as a PNP. Insomnia is a common symptom of many mental illnesses, including anxiety, depression, schizophrenia, and ADHD (Abbott, 2016). Various studies have demonstrated the bidirectional relationship between insomnia and mental illness. In fact, about 50% of adults with insomnia have a mental health problem, while up to 90% of adults with depression experience sleep problems (Abbott, 2016). Due to the interconnected psychopathology, it is important that you, as the PNP, understand the importance of the effects some psychopharmacologic treatments may have on a patient’s mental health illness and sleep patterns. Therefore, it is important that you understand and reflect on the evidence-based research in developing treatment plans to recommend proper sleep practices to your patients as well as recommend appropriate psychopharmacologic treatments for optimal health and well-being.
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Reference: Abbott, J. (2016). What’s the link between insomnia and mental illness? Health. https://www.sciencealert.com/what-exactly-is-the-link-between-insomnia-and-mental
For this Discussion, review the case Learning Resources and the case study excerpt presented. Reflect on the case study excerpt and consider the therapy approaches you might take to assess, diagnose, and treat the patient’s health needs.
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Case: An elderly widow who just lost her spouse.
Subjective: A patient presents to your primary care office today with the chief complaint of insomnia. Patient is 75 YO with PMH of DM, HTN, and MDD. Her husband of 41 years passed away 10 months ago. Since then, she states her depression has gotten worse as well as her sleep habits. The patient has no previous history of depression prior to her husband’s death. She is awake, alert, and oriented x3. The patient normally sees PCP once or twice a year. The patient denies any suicidal ideations. A patient arrived at the office today by private vehicle. Patient currently takes the following medications:
- Metformin 500mg BID
- Januvia 100mg daily
- Losartan 100mg daily
- HCTZ 25mg daily
- Sertraline 100mg daily
Current weight: 88 kg
Current height: 64 inches
Temp: 98.6 degrees F
BP: 132/86
By Day 3 of Week 7
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Post a response to each of the following:
- List three questions you might ask the patient if she were in your office. Provide a rationale for why you might ask these questions.
- Identify people in the patient’s life you would need to speak to or get feedback from to further assess the patient’s situation. Include specific questions you might ask these people and why.
- Explain what, if any, physical exams and diagnostic tests would be appropriate for the patient and how the results would be used.
- List a differential diagnosis for the patient. Identify the one that you think is most likely and explain why.
- List two pharmacologic agents and their dosing that would be appropriate for the patient’s antidepressant therapy based on pharmacokinetics and pharmacodynamics. From a mechanism of action perspective, provide a rationale for why you might choose one agent over the other.
- For the drug therapy, you select, identify any contraindications to use or alterations in dosing that may need to be considered based on the client’s ethnicity. Discuss why the contraindication/alteration you identify exists. That is, what would be problematic with the use of this drug in individuals of other ethnicities?
- Include any “check points” (i.e., follow-up data at Week 4, 8, 12, etc.), and indicate any therapeutic changes that you might make based on possible outcomes that may happen given your treatment options chosen.
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Read a selection of your colleagues\’ responses.
By Day 6 of Week 7
Respond to at least two of your colleagues on two different days in one of the following ways:
- If your colleagues’ posts influenced your understanding of these concepts, be sure to share how and why. Include additional insights you gained.
- If you think your colleagues might have misunderstood these concepts, offer your alternative perspective and be sure to provide an explanation for them. Include resources to support your perspective.
- Read a selection of your colleagues’ responses and respond to at least two of your colleagues on two different days
Assessing and Treating Patients with Psychosis and Schizophrenia
Introduction to the Case
The case is about a Pakistani woman who is 34 years old. She has been living in the USA since she was about 19/20 years old and is in an arranged marriage (Laureate Education, 2016). She presents a brief psychotic disorder diagnosis from persistent symptoms of less than one month. Her medical history indicates that the client had Allah visions, and she was convinced she is Prophet Mohammad. She is convinced that she is destined to deliver the world from sin. There was a time she was out of control to the extent the her husband called the police on her, and she was admitted into a psychiatric unit.
During the assessment, she shows calmness, insisting that the incident in which the police were called was not as significant as it was put. She denies believing that she was Prophet Mohammad. She is convinced that her husband is only determined to tame her because the television tells her the husband does not love her and instead needed an American wife.
Subjectively, the client reports that she is in a good mood and has no audio or visual hallucinations. She believes that Allah is sending her message through television. She shows hostility towards onwards the primary mental health practitioner (PMHP). Her medical workup indicates her health is generally good while other medical test results are within the normal limits. She admits to stopping taking Risperdal because she fears her husband will imprison her and marry an American woman.
A mental examination reveals she is psychologically aware of herself and her surroundings. Her dressing is appropriate. She does not behave appropriately with her gestures, manners, and tics. She has slow, euthymic, and interrupted speech. She also shows the constricted effect and appears to be listening to something. She has a delusional thought process; her intuition and judgment are impaired. She also denies being homicidal and suicidal. The PANSS score reveals that she has paranoia schizophrenia (Kay et al., 1987).
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Decision One
I selected the decision to start Invega Sustenna (Paliperidone palmitate) 234 mg intramuscular X1 followed by 156 mg intramuscular on day four and monthly after that. Paliperidone is an atypical antipsychotic drug that helps restore dopamine balance in the brain (Stevens et al., 2016). Stevens et al. (2016) place paliperidone as a significant intervention in treating the symptoms of schizophrenia, such as hallucinations and facilitating clear thought processes and positive self-perception. Besides, the medication reduces agitation and increases the performance of daily activities.
I did not select Zyprexa 10mg due to its significant side effects such as increased body weakness, drowsiness, appetite, extrapyramidal symptoms, and weight gain (Citrome et al., 2019). Equally, Abilify 10 mg orally at bedtime option was not selected because of its adverse side effects such as akathisia, insomnia, restlessness, and agitation (Mossaheb & Kaufmann, 2012). Sedation, excessive salivation, metabolic abnormalities, weight gain, granulopenia, and delirium or seizures are potential life-threatening side effects of Abilify (Mossaheb & Kaufmann, 2012). The expectation for this selection was a decrease in the PANSS score and adequate toleration of the client’s medication.
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It is crucial to uphold the rule of informed consent (Slim & Bazin, 2019)). In this case, the practitioner should inform the client and her husband of the health conditions, the available treatment interventions, their benefits, and their effects to make informed decisions while contributing to their care. Through effective communication, the practitioner should not coerce the client to accept a given treatment intervention. This would reduce trust from the client and contravene her right to informed consent.
Decision Point Two
The second decision was to continue the same decision to administer Invega Sustenna 234mg intramuscular X1 and 156mg intramuscular on the fourth day and monthly after that. The administering nurse, on the other hand, will commence injections into the deltoid muscle. This decision was because the client was already responding well to medication save for the pain at the injection point, limiting her ability to sit for long hours. This necessitated a change in administering the selected medication to the arm’s deltoid area to allow her to sit without pain.
I did not select the option to discontinue Invega Sustenna and start Haldol because the patient responded well to the initial medication. There was to need to discontinue the regimen. Further, Haldon is associated with severe neurotoxicity causing an inability to walk or talk appropriately when used with other antipsychotic drugs. In contrast, I did not select the option to augment Invega Sustenna with Abilify Maintena because of its side effects, such as tardive dyskinesia and neuroleptic malignant syndrome. Equally, a combination of Abilify with Invega Sustenna is associated with an increase in side effects such as drowsiness, confusion, akathisia, and other significant memory problems.
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The expectation for this selection was a further decrease in the client’s symptoms and PANSS score. According to Stevens et al. (2016), paliperidone is well tolerated and has a significant effect on dopamine D2 neurotransmitters leading to a positive psychological outcome. In this sense, it is also expected that paliperidone will have minimal side effects on the client. At this phase, it is significant to uphold the ethical value of non-maleficence. As a practitioner, it is crucial to act in ways that promote positive health outcomes. In this case, the practitioner should consider all possible treatment interventions and decide on the option with the client’s best possible outcome to promote her well-being.
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Decision Three
I chose to have the client continue with Invega Sustenna and counsel her that weight gain from Invega Sustenna is little compared with other drugs with similar efficacy. This decision was made because the client already tolerated the initial medication and had a positive attitude. Besides, the client responded well to the initial medication, as exemplified by the 50% reduction of PANNS, minimal weight gain, and better injection site pain. An appointment with a dietician and exercise physiologist was necessary to help the client eliminate additional weight.
The option to discontinue Invega Sustenna and start Abilify Maintena was not selected for the same reasons that the client’s condition was already improving. Further, Abilify would not have been effective in this situation since it is associated with a two-week overlap following the first administration. On the other hand, the option to augment Invega Sustenna with a Qysimis drug as a remedy for weight gain was not selected since the latter is recommended for obesity management (Sliwa et al., 2011). The client, in this case, is not obese as her BMI is 28.9 kg/M2.
It is expected that the client will continue responding well to treatment since the selected medication is associated with significant improvement of clinical symptoms (Sliwa et al., 2011). During the following appointment, the PANSS score and weight gain are expected to be significantly low. Besides, it is expected that the patient will show no side effects from the medication. At this point, it is crucial to discuss with the client her health trajectory, particularly any potential side effects and the need to seek the practitioner’s attention in the event of any adverse effect (LeFevre, 2010). As a practitioner, compassion is a significant attribute as it facilitates a good rapport with a patient. Besides, it allows a practitioner to maintain awareness of the risks of mistreatment.
Conclusion
Invega Sustenna was selected as the first line of treatment for the case patient diagnosed with paranoia and schizophrenia. Invega Sutenna has been shown to have a significant effect in balancing the brain’s dopamine neurotransmitter associated with the development of schizophrenia. Besides, the medication has a significant effect on the symptoms of schizophrenia, causing minimal weight gain and side effects. The other available options, Zyprexa and Abilify, were not selected because of their significant side effects and associated weight gain. For instance, Zyprexa causes significant side effects of extrapyramidal symptoms and weight gain. On the other hand, Abilify causes akathisia, insomnia, restlessness, and agitation.
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The second decision was to continue the same medication and administer the medication through the deltoid muscle since the client had pain that hindered her ability to sit long. The decision was made since the client responded well to medication, exemplified by a significant PANNS score reduction. The other available choices were not selected because there was a need to maintain consistency, and there was no need to discontinue or augment the initial prescription. Further, Haldon was not selected due to its side effect of neurotoxicity. In contrast, Abilify Maintena to the Invega Sustenna regimen was not selected because of its side effects, such as tardive dyskinesia and neuroleptic malignant syndrome. This combination is also associated with drowsiness, akathisia, and confusion.
Lastly, the prescription was continued with counsel on the need for dietary control of weight gain. The client responded positively to the treatment regimen, and it was expected that the client would completely recover following the prescribed medication. The associated weight gain was insignificant and could be easily controlled through professional nutritional and exercise guidance as referred.
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References
Citrome, L., McEvoy, J. P., Todtenkopf, M. S., McDonnell, D., & Weiden, P. J. (2019). A commentary on the efficacy of olanzapine for the treatment of schizophrenia: the past, present, and future. Neuropsychiatric disease and treatment, 15, 2559. https://doi.10.2147/NDT.S209284
Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261-276.
Laureate Education. (2016). Case study: Pakistani woman with delusional thought processes [Interactive media file]. Baltimore, MD: Author
LeFevre, M. (2010). Discussing Treatment Options with Patients. American family physician, 81(5), 645. https://www.aafp.org/afp/2010/0301/p645.html
Mossaheb, N., & Kaufmann, R. M. (2012). Role of aripiprazole in treatment-resistant schizophrenia. Neuropsychiatric disease and treatment, 8, 235. https://doi.10.2147/NDT.S13830
Slim, K., & Bazin, J. E. (2019). From informed consent to shared decision-making in surgery. https://doi.10.1016/j.jviscsurg.2019.04.014
Sliwa, J. K., Bossie, C. A., Ma, Y. W., & Alphs, L. (2011). Effects of acute paliperidone palmitate treatment in subjects with schizophrenia recently treated with oral risperidone. Schizophrenia research.
Stevens, J.R, Fava M, & Rosenbaum, J.R. (2016). Psychopharmacology in the Medical Setting. In T. A. Stern, G.L. Fricchione, N.H. Cassem, M. Jelinek, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital Handbook of General Hospital Psychiatry. Elsevier.
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