Antipsychotic Therapy Case Study
Psychosis is a mental health condition that manifests in the case of patients experiencing episodes of hallucinations as described by Saha, et al. (2016). Patients with the psychotic conditions may hear or see things that do not exist in real life. Psychosis may result from bipolar condition, the schizophrenia or personality disorder condition besides occurring even in the absence of these conditions. The pharmacological treatment of the psychosis is through the use of the antipsychotic medications (Opler, Yavorsky, & Daniel, 2017). Antipsychotic drugs are used to treat several types of mental health disorders such as the dementia, major depression condition schizophrenia and schizoaffective disorder. The process of developing suitable features that would be associated with the increase in the quality of healthcare. antipsychotics occur in two types; first generation antipsychotics and second generation antipsychotics. Second generation antipsychotics were introduced to the market after the 1990s and are known to have less side effects as compared to the first generation types as agreed by Opler, Yavorsky, and Daniel, (2017). This paper discusses the choice of antipsychotic treatment for managing the presented case study. The rationale for selecting the medication and the expected impact of the medication is also discussed in this case.
Decision #1
Start Invega Sustenna 234 mg intramuscular X1 followed by 156 mg intramuscular on day four and monthly thereafter.
Rationale for Choice
The patient differential diagnosis is schizophrenia paranoid type. The presented antipsychotic medication options are all second generation antipsychotics (Saha, et al. 2016). All the conditions could be considered to have similar effectiveness in the management of the patient condition. The patient is middle aged adult and thus the limitation due to the elderly sides effects do not apply in all the presented options. The patient is presented to have stopped the use of the Risperdal and thus indicating the signs of non-adhering to medication instructions. Thus the most appropriate choice would be to have an intravenous medication. From the provided options, the other two are orally administered while Invega Sustenna is intravenous.
Expected Outcome
The patient condition is expected to respond positively the PANSS positive score is expected to increase by at least 30% after the four weeks’ period. The PANSS negative score is also expected to reduce by the at least 25% while the composite scale score is expected to improve by at least 25% (Opler, Yavorsky, & Daniel, 2017). The episodes of hallucination are also expected to have reduced significantly over the period as a response to the medication. The frequency of the signs of paranoid condition will also be expected to have reduced. Considering the positive responses to the treatment, the patient would also be expected to be tolerant to the medication.
Variation Between Actual Outcome and the Expected Outcome
After the four weeks, the patient returns to office for the appointment. The patient presented a 25% reduction in the negative PANSS score. The patient is also observed to be tolerate to the medication considering that she managed to turn up for the injection appointment. The PANSS positive score had not improved by the expected 30% and the composite score had also not improved by the expected 25%. The patient had gained 2 pounds within the four weeks and this was also not expected. This could be attributed to the side effects of using the medication as explained by Spertus, et al. (2018) The other unexpected patient experience was the pain at the injection site that made the patient to stay without the sitting for hours.
Decision #2
Continue Invega Sustenna. Begin injections into the deltoid and add on Abilify Maintena 300 mg intramuscular monthly with oral Abilify 10 mg in the MORNING for 2 weeks
Rationale for Choice
The patient has proved to be positively responsive to the medication as the has been a 25% reduction in the PANSS negative score. Thus in order to obtain continuously positive responses, the patient should continue with the medication. The patient has also proved to be tolerant to the medication and thus making it a suitable option (Keks, Schwartz, & Hope, 2019). One of the side effects of using the Invega Sustenna is that it may cause weight gain and thus explains the 2 pound gained by the patient within the short period. The additional Abilify Maintena 300 mg intramuscular monthly with oral Abilify 10 mg orally every morning is aimed at increasing the rate of response. Since this is reversible, the patient should not be bothered. In order to address the issue of the pain at the injection site, the injection will be done on the deltoid. Deltoid injection would not deny the patient to sit down despite the pain.
Expected Outcome
Continuous use of Invega Sustenna is expected to further improve the condition of the patient. The PANSS negative score is also expected to reduce by 50% within the next four weeks. The PANSS positive score is also expected to increase by at least 50% before the next appointment. The hallucination symptoms are expected to continuously increase due to the additional Abilify Maintena. Since the deltoid injection will be adopted, the patient is not likely to complain of the pain that affected her sitting down for several hours after the injection (Saha, et al. 2016). One of the side effects that will be expected is the weight gain of an additional 1 to 2 pounds by the next visit.
Variation Between Obtained outcome and the Expected Outcome
After the next four weeks the patient was punctual to honor the appointment and thus indicating a high level of compliance. The PANSS negative score had reduced by 50% just as it had been anticipated. The patient condition had indicated high rate of responsiveness and this was encouraging. The frequency of hallucinations had reduced significantly as well as the paranoid nature. The aspect of weight gain increased beyond the expected outcome. The patient had gained 2.6 pounds over the four weeks. The other unexpected conditions that developed as was that the patient had developed salivary gland disorder besides the stiffening of feet. The patient had failed to complied to the oral medication instructions.
Decision #3
Discontinue Abilify. Continue with the Invega Sustenna
Rationale for Decision
The discontinuation of the Abilify medication is due to the fact that the patient experienced more side effects from using this drug. The continuation with the use of Invega Sustenna based on the fact that the patient had consistently responded positively at the initial stage (Keks, Schwartz, & Hope, 2019). The patient had also experienced limited side effects since the only side effect was weight gain. Patient education on the approach to cope to normal life will also be made to accompany the injection.
Expected Patient Outcome
With the last four weeks of treatment period, the patient negative PANSS score would be expected to have reduced by 80%. The patient is also expected to be 100% tolerant to the medication as at this time, she will have adopted to the medication. The patient is expected to experience at most two episodes of hallucinations (Saha, et al. 2016). The patient is also expected to gain up to 4 pounds within the period of four weeks. The patient is also expected to further honor appointments with the assistance of the husband has they have been in the past appointments. The salivary gland disorder is also expected to stop after the four weeks.
Variation Between Obtained outcome and the Expected Outcome
The PANSS negative score had reduced by 75% contrary to the expected 80% reduction. The salivary glands had reduced by 75% while the patient had also gained 1.5 pounds within the four weeks. The patient was 100% compliant to the treatment and thus patient education was also provided at the period. The patient education will be targeted to improve further adherence to the medication instructions.
Impact of Ethical Consideration on the Treatment Approach
The treatment of psychotic health conditions should be considerate of the ethical factors for the improvement of the patient condition as elaborated by Hunt-Grubbe, (2020). The decisions made by the PMHNP should align to the ethical requirements. The aspect of the informed consent was strongly adhered to in the process of providing treatment to the patient. With the consideration of the patient religion, the hallucination of being Prophet Mohamed was also handled with adherence to the required ethics. The aspect of being paranoid was also addressed with ethical caution in order to avoid victimization of the husband. The false stigma due to her religion and ethnicity was also handled with consideration of ethics as the patient demonstrated possibility of false stigmatization.
Summary
Antipsychotic treatments could be considered to be the most critical procedure that should be adhered to steadily. Critical thinking should also be applied when selecting the antipsychotic medication during the treatment plan. Response to treatment should be monitored at every appointment so as to determine whether to change the treatment approach. Ethical consideration should also be adhered to so as to maintain autonomy throughout the treatment process. Informed consent on the choice of antipsychotics is also important throughout the process. In the situation where the patient is from a different religious and cultural background, the PMHNP should always focus to maintain a suitable relationship with the patient.
References
Hunt-Grubbe, H. (2020). Ethical Issues Arising from the Prescription of Antipsychotic Medication in Clinical Forensic Settings. In Ethical Issues in Clinical Forensic Psychiatry (pp. 99-114). Springer, Cham.
Keks, N., Schwartz, D., & Hope, J. (2019). Stopping and switching antipsychotic drugs. Australian Prescriber, 42(5), 152.
Opler, M., Yavorsky, C., & Daniel, D. G. (2017). Positive and Negative Syndrome Scale (PANSS) Training: Challenges, Solutions, and Future Directions. Innovations in clinical neuroscience, 14(11-12), 77–81.
Saha, K. B., Bo, L., Zhao, S., Xia, J., Sampson, S., & Zaman, R. U. (2016). Chlorpromazine versus atypical antipsychotic drugs for schizophrenia. Cochrane Database of Systematic Reviews, (4).
Spertus, J., Horvitz-Lennon, M., Abing, H., & Normand, S. L. (2018). Risk of weight gain for specific antipsychotic drugs: a meta-analysis. NPJ schizophrenia, 4(1), 1-7.
