Reply to psychosis case study
Reply to psychosis case study
Critique the decision making of two of your peers in your response posts.
Do you agree/disagree with their medication choice? Why?
Is there anything else you recommend including?
Compare peer’s decision making to yours—what are the advantages and disadvantages of each?
Your response should include evidence of review of the course material through proper citations using APA format.
Offers both supportive and alternative viewpoints to the discussion, using two or more scholarly references per peer post. Post provides additional value to the conversation.
Re: Week 4 Discussion 1: Psychosis Case Study
Case Study Questions
Identification of target symptoms/problems
1. What information, if any, would you like to know that was not included in the case?
For additional information, it would have been great if there was family history including any family history of mental illness as family history is an important risk of mental illness including diseases such as schizophrenia, depression and bipolar disorder to name a few (Lu et al., 2018). Dr. Taylor did briefly ask Andy if he was currently under stress, but I would have also appreciated information on whether Andy has a trauma history as trauma is associated with severity of psychosis symptoms in high-risk individuals as well as the development of psychotic disorders (Russe et al., 2014).
2. Which psychiatric symptoms are a treatment priority for this case?
The immediate treatment concern is the suicidal ideation that Andy reports experiencing. Suicidal ideation is considered a psychiatric emergency and adequate assessment, management and suicide prevention are needed (Weber et al., 2017). After assessment, if the patient is deemed safe and not a threat to themselves or others, the psychosis should be addressed. Psychosis is associated with poor life outcomes and is a leading cause of disability worldwide (Wood et al., 2019). Andy is experiencing symptoms that include paranoia, delusions, hallucinations and other negative symptoms associated with psychosis (Calabrese, 2021).
3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?
Non-pharmacologic issues include Andy’s use of substances including cannabis and speed. Cannabis use is considered a risk factor for schizophrenia. Research shows that cannabis can assist in the development of schizophrenia in patients who would not have developed the disease if they never used the drug. Cannabis use is also used in patients who suffer from schizophrenia to lessen the symptoms associated with the disease (Hamilton and Monaghan, 2018). Andy also admitted to using speed which is directly associated with delusions, hallucinations and other symptoms of acute psychosis (Mullen et al., 2021). It’s unclear if Andy’s psychosis is associated with substance use or other underlying mental illness.
Medication Choice 1
4. List one medication that would be appropriate for this case. Include the name and starting dose.
Clozapine 12.5 mg 1–2 times daily initially and increased by 25–50 mg/day over a period of 2 weeks up to the target dose of 300–450 mg/day (davisdrugguide.com)
5. Describe your clinical decision making. What is your rationale for choosing this medication? Also, include the mechanism of action for this medication choice, and the neurotransmitters and areas of the brain in which the medication is proposed to act on.
Clozapine was chosen due to the drug being considered the most effective antipsychotic (Puzantian and Carlat, 2016). Another reason clozapine was chosen was for its well-documented benefits of reducing suicidal ideation and behaviors (Patchan et al., 2015). Clozapine is an atypical antipsychotic that acts as an antagonist to dopamine and serotonin receptors. Clozapine is a partial 5-HT1A agonist, a muscarinic M1, M2, M3, M5, histamine, and alpha-1 adrenergic-receptor antagonist and binds to dopamine D4 with higher affinity than dopamine D2 receptors which help reduce negative and EPS. The drug is metabolized by the cytochrome P450 enzymes CYP1A2, CYP3A4, CYP2C19, CYP2C9 and CYP2D6 (Haidary and Padhy, 2020).
6. What laboratory testing/monitoring is needed for safely prescribing this medication?
Absolute neutrophil counts (ANC) need to be monitored due to the possibility of agranulocytosis which usually occurs within the first six weeks to six months of treatment. Monitoring the patient’s weight is also important as well as factors such as blood glucose and increased lipids due to the medications effects on the metabolic system. Orthostatic hypotension may also occur and blood pressure should be monitored if patient is symptomatic. Because of the cardiovascular risks a baseline cardiovascular workup should also be included. Seizures could also be a risk in epileptic patients due to clozapine’s impact on lowering the serizure threshold and in this case an EEG and clapine blood levels would be appropriate (Haidary and Padhy, 2020).
7. Are there any contraindications or safety issues associated with this medication?
The below information is from Davis Drug Guide (davisdrugguide.com) Contraindications: Hypersensitivity, Bone marrow depression, Severe CNS depression/coma, Uncontrolled epilepsy, Clozapine-induced agranulocytosis or severe granulocytopenia, Lactation.
• Long QT syndrome;
• Risk factors for QT interval prolongation or ventricular arrhythmias (i.e., recent myocardial infarction, heart failure, arrhythmias);
• Concurrent use of CYP1A2, CYP2D6, or CYP3A4 inhibitors or QT-interval prolonging drugs;
• Hypokalemia or hypomagnesemia;
• Presence/history of constipation, urinary retention, or prostatic hypertrophy
• Angle-closure glaucoma;
• Malnourished or dehydrated patients, patients with cardiovascular, cerebrovascular, hepatic, or renal disease, or patients on antihypertensives (use lower initial dose, titrate more slowly);
• Risk factors for stroke (↑ risk of stroke in patients with dementia);
• Seizure disorder;
• Patients at risk for falls;
• OB: Neonates at ↑ risk for extrapyramidal symptoms and withdrawal after delivery when exposed during the 3rd trimester; use only if potential maternal benefit justifies potential fetal risk;
• Pedi: Children <16 yr (safety and effectiveness not established);
• Geri: ↑ risk of mortality in elderly patients treated for dementia-related psychosis.
Non pharmacologic Interventions
8. What non-pharmacologic interventions do you recommend? Do you recommend including but not limited to psychotherapy, complimentary and holistic therapies? Substance use counseling/treatment would be helpful in assisting the patient with discontinuing his cannabis and speed use. Healthy lifestyle changes such as diet and exercise would be recommended due to clozapine’s effects on weights, insulin resistance and increased lipids as antipsychotic-induced weight gain is a worry (Dayabandara et al., 2017). Cognitive Behavioral Therapy (CBT) would also be recommended due to its impact on positive outcomes of those suffering from psychosis and it’s ongoing positive effects on symptoms like delusions (Andreou and Moritz, 2016).
Safety Risk Assessment
9. What are the safety concerns, if any, associated with this case? How will you address safety?
A thorough safety/risk assessment would need to be conducted because of the patients disclosed suicidal ideation with history of a plan to overdose on pills. The patient also has access to a knife and bat and has reported being in fear and appears to be paranoid and self-isolating. A safety plan would need to be developed with the patient and the patient mother who he agreed to have join the therapy session. If the patient was unable to remain safe and not a harm to himself or others, he may need to enter inpatient hospitalization for crisis care.
10. When would you follow up with this patient?
I would choose to follow-up with this patient in 1 week. The patient symptoms need to be monitored closely, especially the changes that should take place based on different factors like cannabis and speed cessation, starting clozapine (therapeutic effects take much longer), CBT and other areas that will need to be monitored including patient safety regarding suicidal ideation for example.
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