Assessing and Treating Clients With Psychosis and Schizophrenia Case Study
Background on the Disease State
The client in the case study is diagnosed with schizophrenia. She suffers from symptoms of psychosis that cause her to be paranoid and suffer from perceptual distortions, which cause her to hear hallucinatory voices. Stahl (2013) explains, “Paranoid projection includes preoccupation with delusional beliefs; . . . believing one is being persecuted or being conspired against” (Stahl, 2013). This patients suffers from paranoid delusions. She believes her husband wants to leave her for another woman even though that does not appear to be true, but she hallucinates that voices in the television tell her this is true.
Other issues related to schizophrenia include suicidal tendencies. The patient says she is not suicidal at this time, but between 25% and 50% of patients with paranoid schizophrenia attempt suicide and 10% of the succeed (Stahl, 2013). Others die young from heart disease from lack of exercise, smoking and the effects of the medications used to treat schizophrenia such as weight gain.
Purpose Statement
The purpose of this study is to determine the best treatment for this patient.
Goals of Therapy
The goal of therapy for this patient is to reduce the symptoms of schizophrenia. Initially, the patient presented in a calm state although she believes her husband is wants a new wife because the television tells her this is the case. She is 5’5” and weighs 140 lbs. The choices for therapy include starting Zyprexia 10 mg orally at bedtime, starting Invega Sustenna 234 g intramuscularly once followed by 156 intramuscularly on day 4 and monthly thereafter, or start patient on Abilify 10 mg. orally at bedtime. The second option, the Invega Sustenna, was chosen.
Several reasons for choosing the Invega Sustenna exist. One is that it is approved by the Food and Drug Administration (FDA) for schizophrenia. Invega Sustenna also works by blocking the dopamine 2 receptors, which reduce the positive symptoms of psychosis such as the hallucinations and the delusions (Stahl, 2014b). These seem to be the symptoms that trouble this patient most. Other reasons for choosing Invega Sustenna over other possible treatments include the fact that the treatment is monthly after the initial 2 doses, which may be easier for the patient to manage than taking a pill every day. Invega Sustenna does not have the side effects of the conventional medications for schizophrenia either such as dry mouth, constipation, blurred vision and drowsiness. Finally, according to Alphs, et al. (2015) of the Journal of Clinical Psychiatry say, “Invega Sustenna® (paliperidone palmitate) significantly delayed time to first treatment failure >6 months longer than commonly prescribed oral antipsychotics” (Alphs, et al., 2015, p. 4). Since treatment failures are common among those being treated for schizophrenia, this is an important feature.
When the patient returned to the clinic 4 weeks later, her PANSS score had decreased by 25%. She is tolerating the medication well and her husband has made sure that she makes it to her appointments for injections so she is adhering to the treatment plan. She complains of injection site pain and says she cannot sit down after she has them. She has gained 2 pounds, but is not concerned about it.
After seeing the patient this second time, the decision was made to continue the Invega Sustenna but to give the injections in the deltoid so that the pain from the injections will not be as troublesome. Another choice might be to discontinue the Invega Sustenna and start Haldol Decanoate (haloperidol decanoate) 50 mg intramuscularly for 2 weeks with oral Haldol 5 mg BID for the next 3 months. However, relying on this patient to take oral medication may not be a good idea. She could hide them or pretend to take them thinking her husband is poisoning her for example. Finally, the patient could continue Invega Sustenna injections, but in the deltoid, and Abilify Maintena 300 mg intramuscularly monthly with 10 mg of oral Abilify every morning for 2 weeks.
The choice to continue the Invega Sustenna as before with the injections in the deltoid was made for several reasons. McEvoy, et al. (2014) of the Journal of the American Medical Association (JAMA) completed a random control trial that compared the effects of the injectable paliperidone palmitate and haloperidol decanoate. They found that in adults with schizophrenia “the use of paliperidone palmitate vs haloperidol decanoate did not result in a statistically significant difference in efficacy failure, but was associated with more weight gain and greater increases in serum prolactin, whereas haloperidol decanoate was associated with more akathisia” (McEvoy, et al., 2014, p. 1978). Since the weight gain is not an issue at this time for the patient, and the increased prolactin levels probably are not also since the patient already has children, it is best to keep the patient on the Invega Sustenna since she appears to be doing well. Mustafa, et al. (2019) of BMC Psychiatry did an assessment of Abilify’s effectiveness for schizophrenia. There was a progression from serious to mild impairment, but “one quarter of patients did show clinically significant (≥7%) weight gain” (Mustafa, et al., 2019, p. 7). Again, weight gain may not be a problem for this patient, but changing medications could be, so it is better to stay with the Invega Sustenna.
The outcome of the second decision to maintain the Invega Sustenna treatment occurred when the patient returned to the clinic 4 weeks later. Her PANSS had reduced by 50%. The injection site pain was reduced having it in the arm. She had gained 2.5 pounds and was concerned about this because she feared her husband would not like it. This could be a legitimate concern or one brought on by her paranoia related to her illness. She asked if there was another medication she could try.
At this point the decision could be made to continue the Invega Sustenna and counsel the patient about the weight gain of the medication not being as bad as the other drugs with similar efficacy. An appointment with a dietician and an exercise physiologist could also be made with a follow up in a month’s time. Another option would be to discontinue the Invega Sustenna and start Abilify Maintenna 400 mg intramuscularly monthly (after a few test doses of Abilify oral have been tried and tolerated) with overlapping oral Abilify 10 mg orally every morning. Or, the Invega Sustenna could be continued with Qsymia added for weight loss. The decision made was the first option: continue with the Invega Sustenna and include a dietician and exercise physiologist
The reason for this decision is partly because Invega Sustenna does not cause the weight gain that other similar medications do. It is probably better to control the patient’s weight with a dietician and exercise physiologist before trying another medication. Abilify does not bind to the D2 receptor for a long period of time like Invega Sustenna does, which makes it less effective for some individuals. Akathisia may be a side effect also. The oral Abilify is necessary because the injected Abilify may lag in dosing, and the oral is needed to sustain blood levels of the medication. Prescribing the Qsymia for weight loss medication that is only indicated to treat obesity. This patient is not obese. Qsymia contains Phentermine which has blood toxicity issues.
Ethical Considerations
The patient is Pakistani and a Muslim. Pakistan has had a great deal of associations with illicit drugs making Pakistanis skeptical about taking any drug. For this reason, the injectable medications may be better for this patient because she is not taking pills that might be seen lying around the house for her friends to see. The family is also Muslim. Muslims do not believe in taking drugs, so, again, the injectable is better for this particular patient.
References
Alphs, L. B., Cheshire-Kinney, K., Lindenmayer, J. P., Mao, L., Rodriguez, S. C., & Starr, H. L. (2015). Real-world outcomes of paliperidone palmitate compared to daily oral antipsychotic therapy in schizophrenia: a randomized, open-label, review board-blinded 15-month study. Journal of Clinical Psychiatry, 76(5), 1-10. Retrieved from https://pdfs.semanticscholar.o...
McEvoy, J. P., Byerly, M., Hamer, R. M., Dominik, R., Swartz, M. S., Rosenheck, R. A., . . . Stroup, T. S. (2014). Effectiveness of Paliperidone Palmitate vs Haloperidol Decanoate for Maintenance Treatment of Schizophrenia: A Randomized Clinical Trial. Journal of the American Medical ASsociation, 1978-1986. Retrieved from https://jamanetwork.com/journa...
Mustafa, S., Bougie, J., Miguelez, M., Clerzius, G., Rampakakis, E., Proulx, J., & Malla, A. (2019). Real-life assessment of aripiprazole monthly (Abilify Maintena) in schizophrenia: a Canadian naturalistic non-interventional prospective cohort study. BMC Psychiatry, 114, 1-9. Retrieved from https://bmcpsychiatry.biomedce...
Stahl, S. M. (2013). Stahl’s essential psychopharmacology: Neuroscientific basis and practical applications (4th ed.). New York: Cambridge UP.
Stahl, S. M. (2014b). The Prescriber’s Guide (5th ed.). New York: Cambridge UP.
