Assignment: Case Study of a 34 Year-Old Female of Pakistani Origin Diagnosed with Schizophrenia: Psychopharmacology Decision Making

Assignment: Case Study of a 34 Year-Old Female of Pakistani Origin Diagnosed with Schizophrenia: Psychopharmacology Decision Making

Assignment: Case Study of a 34 Year-Old Female of Pakistani Origin Diagnosed with Schizophrenia: Psychopharmacology Decision Making

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. Be sure to consider factors that might impact the patient’s pharmacokinetic and pharmacodynamic processes.

At each decision point, you should evaluate all options before selecting your decision and moving throughout the exercise. Before you make your decision, make sure that you have researched each option and that you evaluate the decision that you will select. Be sure to research each option using the primary literature.

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Introduction to the case (1 page)

Briefly explain and summarize the case for this Assignment. Be sure 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)

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.

Conclusion (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.

BACKGROUND

The client is a 34-year-old Pakistani female who moved to the United States in her late teens/early 20s. She is currently in an “arranged” marriage (her husband was selected for her when she was 9 years old). She presents following a 21-day hospitalization for what was diagnosed as “brief psychotic disorder.” She was given this diagnosis as her symptoms have persisted for less than 1 month.

Prior to admission, she was reporting visions of Allah, and over the course of a week, she believed that she was the prophet Mohammad. She believed that she would deliver the world from sin. Her husband became concerned about her behavior to the point that he was afraid of leaving their 4 children with her. One evening, she was “out of control,” which resulted in his calling the police and her subsequent admission to an inpatient psych unit.

During today’s assessment, she appears quite calm and insists that the entire incident was “blown out of proportion.” She denies that she believed herself to be the prophet Mohammad and states that her husband was just out to get her because he never loved her and wanted an “American wife” instead of her. She says she knows this because the television is telling her so.

She currently weighs 140 lbs., and she is 5’ 5.

SUBJECTIVE

Client reports that her mood is “good.” She denies auditory/visual hallucinations but believes that the television talks to her. She believes that Allah sends her messages through the TV. At times throughout the clinical interview, she becomes hostile towards you but then calms down.

A review of her hospital records shows that she received a medical workup from a physician, who reported her to be in overall good health. Lab studies were all within normal limits.

Client admits that she was tolerating her Risperdal well but stopped taking about a week after she got out of the hospital because she thinks her husband is going to poison her so that he can marry an American woman.

MENTAL STATUS EXAM

The client is alert and oriented to person, place, time, and event. She is dressed appropriately for the weather and time of year. She demonstrates no noteworthy mannerisms, gestures, or tics. Her speech is slow and, at times, interrupted by periods of silence. Self-reported mood is euthymic. Affect is constricted. Although the client denies visual or auditory hallucinations, she appears to be “listening” to something. Delusional and paranoid thought processes as described above. Insight and judgment are impaired. She is currently denying suicidal or homicidal ideation.

You administer the PANSS which reveals the following scores:

-40 for the positive symptoms scale

-20 for the negative symptom scale

-60 for general psychopathology scale

Diagnosis: Schizophrenia, paranoid type

Decision Point One
Select what you should do:

Start Zyprexa (olanzapine) 10 mg orally at BEDTIME or
Start Invega Sustenna 234 mg IM X1 followed by 156 mg IM on day 4 and monthly thereafter or
Start Abilify (aripiprazole) 10 mg orally at BEDTIME

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Case Study of a 34 Year-Old Female of Pakistani Origin Diagnosed with Schizophrenia: Psychopharmacology Decision Making 

            This is the case study of a 34 year-old woman of Pakistani descent presenting with paranoid schizophrenia. This is a psychotic illness that is characterized by what are referred to as positive and negative symptoms. With a psychosis, the patient has an impaired sense of appreciation of reality. Positive symptoms that are additive in nature are like persecutory delusions, auditory hallucinations, impairment of the thought process, and disorganization of speech amongst others. Patients that have negative symptoms have been seen to have a poor prognosis in terms of therapeutic success. The negative symptoms are subtractive in nature and include poverty of speech, lack of motivation to do anything with a goal in mind (avolition), a lack of enjoyment of pleasurable activities or anhedonia, and apathy amongst others (APA, 2013; Sadock et al., 2015). The patient displays persecutory delusions by thinking her husband wants to poison her. She also has grandiose delusions by thinking that she is the Holy Prophet of Islam. She has a significant psychiatric history of psychosis and was recently discharged from hospital after a 21-day commitment. She had been given risperidone which she did not take as prescribed. She displays impaired judgment and insight. Her PANSS (positive and negative symptoms scale) score is positive for schizophrenia and its psychopathology (Leucht et al., 2019). The purpose of this paper is to outline the decision making on her pharmacotherapeutic treatment with medications.

Decision Point Number 1

            Three options of pharmacotherapeutic agents are presented (Laureate media, n.d.). These are olanzapine (Zyprexa) 10 mg by mouth HS; or paliperidone (Invega Sustenna) 234 mg IM STAT, 156 mg IM by the fourth day, and then 156 mg IM every month; or aripiprazole (Abilify) 10 mg by mouth HS (at bedtime). The decision is made to start her on paliperidone (Invega Sustenna) at the described doses and frequencies as above. The reason for choosing paliperidone over the other two is that it is FDA-approved for schizophrenia and also has a better safety profile to begin with (Stahl, 2017). Secondly, randomized controlled trials between paliperidone and olanzapine indicate that even through the efficacy profile of the two is almost the same (Huang et al., 2018), the fact that the paliperidone is give as a once-a-month injection encourages treatment compliance. This is especially important with this particular patient who has a history of stopping taking medications. The expectation in making this choice was that there will be an immediate reduction in symptoms at least after four weeks, showing therapeutic response. 

            Olanzapine (Zyprexa) was left because it causes significant weight gain; while aripiprazole (Abilify) was left also mainly because of its debilitating side effect of drowsiness (Stahl, 2017). The ethical consideration here was autonomy as the patient’s consent for treatment was sought despite the impairment in insight and judgment. Beneficence (Haswell, 2019) was also considered by putting her on the monthly Invega Sustenna IM doses, since she is unable to adhere to the daily oral doses of medications.

Decision Point Number 2

            There is a welcome symptom reduction of 25% as assessed by the PANSS test when the patient comes back after four weeks. She has gained two pounds of weight but overall has tolerated the Invega Sustenna well. The only issue the patient reports is that of injection site pain that makes her have difficulty sitting. The decision that is made at this point is to continue with the paliperidone (Invega Sustenna). The reason for this is that the patient has shown a positive therapeutic response and the evidence for this is the improved PANSS score. However, because of the complaint of injection site pain, the site for injecting the paliperidone 156 mg IM is changed to the deltoid muscle in the upper arm.

            The hope in making the above second decision is to realize an even bigger reduction in symptoms as measured by the next PANSS score. This would suggest that the patient is on her way to remission and recovery. The other two available options at this decision point were not considered because the patient is already responding positively to paliperidone and so there is no clinical reason to stop it. The bioethical principle of nonmaleficence would have been violated if the paliperidone to which the patient is responding well were to be stopped and a different drug tried.  

Decision Point Number 3

            This patient comes back for a follow up visit after another four weeks after receiving her 156 mg IM dose of paliperidone last month. She reports even further improvement and therapeutic response and this is confirmed by the PANSS tool that shows her symptoms have now reduced by about 50%. The only concern reported is another weight increase of two and a half pounds. The patient wonders whether there could be a similar medication but with no side effect of weight gain.

            At this decision point and considering all the facts, it os decoded that the patient should continue with the paliperidone (Invega Sustenna) 156 mg IM monthly. The benefits were far outweighing the risks of this medication. The patient is to be counselled and referred to a physical therapist and dietician for exercise prescription and dietary management to keep the weight gain in check. The patient has a normal body mass index (BMI) of 24 kg/m² and exercise with dietary discretion will help prevent her from becoming overweight (Chin et al., 2016). The above choice was made because the client was manifesting a great response to the medication. It was thus hoped that she would achieve complete remission in the following three to four weeks. Under these circumstances, the other two options could not be considered because the therapeutic goals were already being achieved. For instance, adding Qsymia is only going to expose the patient to more side effects.

Conclusion

            In this case study on schizophrenia in a 34 year-old female, decisions have been made purely based on scientific evidence (evidence-based practice or EBP). Given her noncompliance to daily oral medications, the monthly 156 mg IM paliperidone injection was the best for her. She showed amazing therapeutic response assessed using the PANSS tool.

References

American Psychological Association [APA] (2013). Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5^th ed. Author.

Chin, S.-H., Kahathuduwa, C.N. & Binks, M. (2016). Physical activity and obesity: What we know and what we need to know. Obesity Reviews, 17, 1226–1244. https://doi.org/10.1111/obr.12460

Haswell, N. (2019). The four ethical principles and their application in aesthetic practice. Journal of Aesthetic Nursing, 8(4), 177-179. https://doi.org/10.12968/joan.2019.8.4.177

Huang, M., Yu, L., Pan, F., Lu, S., Hu, S., Hu, J., Chen, J., Jin, P., Qi, H., & Xu, Y. (2018). A randomized, 13-week study assessing the efficacy and metabolic effects of paliperidone palmitate injection and olanzapine in first-episode schizophrenia patients. Progress in Neuro-Psychopharmacology & Biological Psychiatry, 2(81), 122-130. https://doi.org/10.1016/j.pnpbp.2017.10.021

Laureate Media (n.d.). Delusional disorders: Pakistani female with delusional thought processes. https://mym.cdn.laureate-media.com/2dett4d/Walden/NURS/6630/06/mm/delusional_disorders/index.html

Leucht, S., Barabássy, Á., Laszlovszky, I, Szatmári, B., Acsai, K., Szalai, E., Harsányi, J., Earley, W., & Németh, G. (2019). Linking PANSS negative symptom scores with the Clinical Global Impressions Scale: Understanding negative symptom scores in schizophrenia. Neuropsychopharmacology, 44, 1589-1596. https://doi.org/10.1038/s41386-019-0363-2

Sadock, B.J., Sadock, V.A., & Ruiz, P. (2015). Synopsis of psychiatry: Behavioral sciences clinical psychiatry, 11^th ed. Wolters Kluwer.

Stahl, S.M. (2017). Stahl’s essential psychopharmacology: Prescriber’s guide, 6th ed. Cambridge University Press.