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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.
Please refer to the Grading Rubric for details on how this discussion will be graded. The described expectations meet the passing level of 80%. Students are directed to review the Discussion Grading Rubric for criteria which exceed expectations.
This Madelon Perkins post:
Case Study Questions
Based on the case study, answer the following questions.
Identification of target symptoms/problems
1. What information, if any, would you like to know that was not included in the case?
An assessment of psychosis during the acute phase would include:
• Complete general medical and psychiatric histories, including mental status and physical examinations (American Psychiatric Association [APA], 2004).
• Laboratory tests, including glucose, blood electrolytes, complete blood count, syphilis, thyroid, renal, and liver function, hepatitis C, HIV, and serum or urine toxicology screening (APA, 2004).
• Interview of individuals and family members who are knowledgeable about the patient’s behaviors.
• Identification of substance abuse disorders or comorbid medical or psychiatric conditions (APA, 2004).
• Identification of patient’s limitations and strengths (APA, 2004).
• Education and occupation (National Institute for Health and Care Excellence [NIHCE], 2014).
• Economic status (NIHCE, 2014).
2. Which psychiatric symptoms are a treatment priority for this case?
• Patient is exhibiting positive symptoms that include hallucinations, thought disorders, and delusions (Guzman, 2012). These are a treatment priority.
3. What are the non-pharmacologic issues in this case (problems/complaints that cannot be addressed by medication)?
• Non-pharmacologic concerns that cannot be addressed by medication include the patient’s use of speed, alcohol, and cannabis.
Medication Choice 1
4. List one medication that would be appropriate for this case. Include the name and starting dose.
• Initial dosing for olanzapine is 5-10 mg PO daily, increasing by 5 mg/day each week to a maximum dose of 20 mg/day (Stahl, 2017).
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.
• Olanzapine is considered the most effective antipsychotic medication after clozapine (Memorable Psychiatry and Neurology [MPN], n.d.). Clozapine is not considered a first line medication due to the risk for agranulocytosis (Guzman, 2012). Second generation antipsychotics are serotonin-dopamine antagonists, specifically with 5-HT2A and D2 antagonistic properties (Guzman, 2012). Second generation antipsychotics are also able to block H1, ACh1, and α1 receptors (Guzman, 2012). It is postulated that overactivity in the mesolimbic dopamine pathway can produce positive symptoms; second generation antipsychotics affect this part of the brain (Guzman, 2012). It is also postulated that dysfunction within the mesocortical dopamine pathway that projects to the ventromedial prefrontal cortex, resulting in a deficit of dopamine activity, can produce cognitive and negative symptoms (Guzman, 2012; Regis College [RC], n.d). The nigrostriatal dopamine pathway controls muscle movements; chronic dopamine blockade can produce movement-related disorders (RC, n.d.). The tuberoinfundibular dopamine pathway control prolactin levels; chronic dopamine blockade can produce excessive levels (RC, n.d.).
6. What laboratory testing/monitoring is needed for safely prescribing this medication?
• Prior to initiating olanzapine, baseline weight, BMI, waist circumference, fasting plasma glucose, fasting lipid profile, blood pressure, and both family and personal history of obesity, dyslipidemia, diabetes, cardiovascular disease and hypertension (Stahl, 2017).
• Fasting triglycerides monthly for several months if risk for metabolic complications are high (Stahl, 2017).
• BMI monthly for at least 3 months and then every 3 months (Stahl, 2017).
• Fasting plasma glucose, blood pressure, fasting lipids every 3 months and then annually; more frequently if patients have gained over 5% of baseline weight or have diabetes (Stahl, 2017).
• Monitor for diabetic ketoacidosis; signs and symptoms include nausea, vomiting, weight loss, polydipsia, polyuria, weakness, coma, clouding of sensorium, rapid respirations, or dehydration (Stahl, 2017).
• Yearly blood tests to monitor liver function for patients with liver disease (Stahl, 2017).
• Frequently monitor CBC during first few months if WBC is low or there is a history of drug-induced neutropenia/leucopenia (Stahl, 2017).
• Emergence of movement disorders (NIHCE, 2014).
• Medication nonadherence, poor medication absorption, or rapid medication metabolism (APA, 2004; NIHCE, 2014).
7. Are there any contraindications or safety issues associated with this medication?
• Contraindicated with angle-closure glaucoma (Stahl, 2017).
• Contraindicated with unstable medical condition that would include unstable angina pectoris, severe bradycardia, severe hypotension, recent heart surgery, sick sinus syndrome, or acute myocardial infarction (Stahl, 2017).
• Contraindicated with allergy to olanzapine (Stahl, 2017).
• Drug Reaction with Eosinophilia (DRESS) is associated with olanzapine and is a serious, but rare, skin condition that can cause death (Stahl, 2017).
• Caution should be used with patients at risk for aspiration pneumonia, in patients with prostatic hypertrophy or paralytic ileus, and in patients predisposed to hypotension (overheating or dehydration) (Stahl, 2017).
Non pharmacologic Interventions
8. What non-pharmacologic interventions do you recommend? Do you recommend including, but not limited to, psychotherapy, complimentary and holistic therapies?
• Cognitive behavioral therapy (CBT) (NIHCE, 2014).
• Family intervention (NIHCE, 2014).
• Art therapies to help alleviate negative symptoms (NIHCE, 2014).
Safety Risk Assessment
9. What are safety concerns, if any, associated with this case? How will you address safety?
• Use of alcohol, cannabis, and speed; consider home treatment teams and acute community treatment within crisis resolution or hospitalization to stabilize patient (NIHCE, 2014).
• Risk for suicide (APA, 2004). Use C-SSRS to assess for suicide risk; consider hospitalization.
10. When would you follow up with this patient?
• Weekly for six weeks, at three months, at one year, and then annually (NIHCE, 2014).
American Psychiatric Association (2004). Treating schizophrenia: A quick reference guide.
Guzman, F. (2012). Antipsychotics: Mechanism of action and pharmacological properties.
Memorable Psychiatry and Neurology (n.d.). Antipsychotics (memorable psychopharmacology 4).
National Institute for Health and Care Excellence (2014). Psychosis and schizophrenia in adults: Prevention
and management. https://www.nice.org.uk/guidance/cg178
Regis College (n.d.). Stahl’s Essential Psychopharmacology: Neuroscientific basis and practical applications.
Chapter 4: Psychosis and schizophrenia [PowerPoint slides].
Stahl, S. M. (2017). Stahl’s Essential Psychopharmacology Prescriber’s Guide (6th ed.). Cambridge University