Question

Saul Kahneman is a 42-year-old, single white male with a diagnosis of schizophrenia. His current symptoms include auditory hallucinations, disorganized speech, and diminished emotional expression. His father, David, brings Saul to the inpatient psychiatric unit for treatment. David reports that Saul stopped taking his Seroquel 400 mg BID for psychosis and his melatonin 6 mg for sleep a week ago. He also reports that Saul has been responding to internal stimuli, talking to himself, not sleeping, and believes the government has bugged their home. This is the third psychiatric admission for Saul in two years.

When you, the psychiatric nurse practitioner, talk to Saul, he reports, “The medication isn’t working anymore.”

• Vital signs: BP 148/72, HR 88, R 18, pulse ox 98%
• HT: 6’ 1”
• WT: 230 pounds
• Appearance: Unkempt, poor hygiene, dressed in several layers of clothing (current season is late spring, average temperature outside is 70 degrees)
• Blood work: A1C 6.2, total cholesterol 188 mg/dl, HDL 22 mg/dl, LDL 176 mg/dl
• Triglycerides: 148 mg
• All other lab results are within normal limits.

Questions

You know you will change Saul’s antipsychotic medication.

1. Based on the information in the case study—vital signs, HT/WT, and appearance, as well as the lab results—what recommendations relative to medications would you make? Name the type of typical or atypical antipsychotic you would prescribe and identify the dosing and administration.
2. Decide whether you would add any other medication, and if so, identify the medication, dose, and time of administration. Provide current literature (EBP, research article, and/or textbook reference) to support your decision.
3. Based on the medications you would prescribe, what education would you provide to Saul?
4. Identify any laboratory testing you would order and explain your rationale.
5. Would you refer Saul to any other providers? If so, to whom would you refer him? Provide your rationale for any referrals.

Answer 1

• All antipsychotic medications—both first and second generations forms—act by blocking dopamine receptors in the cortical and limbic areas of the brain. They also affect a number of other neurotransmitters, including serotonin, norepinephrine, and acetylcholine. Most second-generation antipsychotics produce a broader range of neurochemical actions in the brain than do the traditional drugs, which act primarily on dopamine receptors. Clozapine and olanzapine, for example, produce a relatively strong blockade of serotonin receptors. This increased affinity of some atypical drugs for serotonin receptors might explain why they can have beneficial effects on symptoms of schizophrenia while producing few motor side effects. I would suggest the patient take second-generation antipsychotic in specific manners to reduce the symptoms of cognitive deviation as well as I would suggest him to participate in psychosocial treatment such as social-skill training, Cognitive therapy, and assertive community treatment.
• Antipsychotic drugs produce unpleasant motor side effects so I am not willing to prescribe any other specific medications because it’ll not be helpful for long term treatment process, instead of this I would suggest him to take some institutional programs and psychosocial treatments. Actually, the role of medication is to control the immediate problems but they are not helpful to treat a patient without leaving other problems.
• I would help him to develop confidence that he is getting good and fine gradually, trust is very important during treatment because our brain needs support not during treatment because the effects of antipsychotic drugs change the neural process that opposed by our brain. Psychological treatment is a little harder than physical treatment because drugs affect the thought process and the brain develops negative experiences that affect the process of treatment and make is long.
• I would refer him to participate in non-mediational treatment programs such as the ACT, CBT, SST, and family-oriented aftercare.

The central aspects of treatment for schizophrenia are antipsychotic medication. These drugs help to resolve acute psychotic episodes. They can also delay relapse and improve the level of the patient’s functioning between episodes. Unfortunately, they often produce critical motor and cognitive effects and the substantial minority of schizophrenic patients are resistant to antipsychotic medications.