NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

Sample Answer for NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders Included After Question

NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

According to the Schizophrenia and Related Disorders Alliance of America, approximately 3.5 million people in the United States are diagnosed with schizophrenia (n.d.), and it is one of the leading causes of disability. In practice, patients may present with delusions, hallucinations, disorganized thinking, disorganized or abnormal motor behavior, as well as other negative symptoms that can be disabling for these individuals. Not only are these symptoms one of the most challenging symptom clusters you will encounter, many are associated with other disorders, such as depression, bipolar disorder, and disorders on the schizophrenia spectrum. As a psychiatric nurse practitioner, you must understand the underlying neurobiology of these symptoms to select appropriate therapies and improve outcomes for patients. 

This week, as you examine antipsychotic therapies, you explore the assessment and treatment of patients with psychosis and schizophrenia. You also consider ethical and legal implications of these therapies. 

Reference:
Schizophrenia and Related Disorders Alliance of America. (n.d.). About  schizophrenia.https://sardaa.org/resources/about-schizophrenia/#:~:text=Quick%20Facts%20About%20Schizophrenia.%20Schizophrenia%20can%20be%20found,is%20one%20of%20the%20leading%20causes%20of%20disability 

Learning Objectives 

Students will: 

  • Assess client factors and history to develop personalized therapy plans for patients with insomnia 
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring therapy for insomnia 
  • Assess patient factors and history to develop personalized plans of antipsychotic therapy for patients 
  • Analyze factors that influence pharmacokinetic and pharmacodynamic processes in patients requiring antipsychotic therapy 
  • Synthesize knowledge of providing care to patients presenting for antipsychotic therapy 
  • Analyze ethical and legal implications related to prescribing antipsychotic therapy to patients across the lifespan 

 

Learning Resources 

 

Required Readings (click to expand/reduce) 

 

Freudenreich, O., Goff, D. C., & Henderson, D. C. (2016). Antipsychotic drugs. In T. A. Stern, M. Favo, T. E. Wilens, & J. F. Rosenbaum. (Eds.), Massachusetts General Hospital psychopharmacology and neurotherapeutics (pp. 72–85). Elsevier. 

 

American Psychiatric Association. (2019). Practice guideline for the treatment of patients with schizophrenia. https://www.psychiatry.org/File%20Library/Psychiatrists/Practice/Clinical%20Practice%20Guidelines/APA-Draft-Schizophrenia-Treatment-Guideline.pdf 

 

Clozapine REMS. (2015). Clozapine REMS: The single shared system for clozapine. https://www.clozapinerems.com/CpmgClozapineUI/rems/pdf/resources/Clozapine_REMS_A_Guide_for_Healthcare_Providers.pdf 

 

Funk, M. C., Beach, S. R., Bostwick, J. R., Celano, C. M., Hasnain, M., Pandurangi, A., Khandai, A., Taylor, A., Levenson, J. L., Riba, M., & Kovacs, R. J. (2018). Resource document on QTc prolongation and psychotropic medications. American Psychiatric Association. https://www.psychiatry.org/File%20Library/Psychiatrists/Directories/Library-and-Archive/resource_documents/Resource-Document-2018-QTc-Prolongation-and-Psychotropic-Med.pdf 

 

Kay, S. R., Fiszbein, A., & Opler, L. A. (1987). The Positive and Negative Syndrome Scale (PANSS) for schizophrenia. Schizophrenia Bulletin, 13(2), 261–276. https://doi.org/10.1093/schbul/13.2.261 

 

Levenson, J. C., Kay, D. B., & Buysse, D. J. (2015). The pathophysiology of insomnia. Chest, 147(4), 1179–1192. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4388122/ 

 

McClellan, J. & Stock. S. (2013). Practice parameter for the assessment and treatment of children and adolescents with schizophrenia. Journal of the American Academy of Child and Adolescent Psychiatry, 52(9), 976–990. https://www.jaacap.org/article/S0890-8567(09)62600-9/pdf 

 

Naber, D., & Lambert, M. (2009). The CATIE and CUtLASS studies in schizophrenia: Results and implications for clinicians. CNS Drugs, 23(8), 649–659. https://doi.org/10.2165/00023210-200923080-00002 

 

A Sample Answer For the Assignment: NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

Title: NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

Antipsychotic agents, also called neuroleptic or major tranquilizers, are used primarily to treat schizophrenia. Schizophrenia is characterized primarily by a clear sensory but marked thinking disturbance. Second-generation/ Atypical antipsychotics are widely used due to their broad spectrum of receptor activity since they affect Serotonin, dopamine, and GABA neurotransmitters (de Miranda et al., 2020). Besides, they are better at alleviating negative symptoms and cognitive dysfunction than typical antipsychotics. The purpose of this assignment is to develop a study guide for an antipsychotic agent.

Drug Description

Quetiapine, whose brand name goes by Seroquel, is used in treating schizophrenia. It is FDA-approved for treating schizophrenia, Bipolar disorder, and major depressive disorder (MDD) as an adjunctive treatment (de Miranda et al., 2020).

Non-FDA uses

The non-FDA uses of Seroquel include the treatment of generalized anxiety disorder (GAD), Alcohol Dependence, and Insomnia.

  • According to Ansara (2020), Seroquel exhibits efficacy in managing treatment-resistant-GAD as an adjunctive agent. In this case, smaller doses than those prescribed for schizophrenia and bipolar disorder are usually needed for symptom improvement.
  • Seroquel has been found to reduce alcohol consumption in heavy drinkers and has the potential for treatment for alcohol dependence, particularly among heavy drinkers (Vatsalya et al., 2020).
  • Low doses of quetiapine are usually prescribed for insomnia, although this is a non-FDA use due to potential adverse effects like weight gain and akathisia (Boafo et al., 2020).

Drug classification

Seroquel is an antipsychotic under second-generation antipsychotics.

MOA Pharmacokinetics Pharmacodynamics
An antagonist for D2 receptors and serotonin receptors. Absorption: Bioavailability: 100%

Peak plasma time: Immediate release-1.5 hr; extended release-6 hrs

Reduces the hallucinations and delusions associated with schizophrenia by blocking dopamine receptors in the mesolimbic system of the brain.
Acts on dopaminergic D1 and D2 receptors. Metabolism: Metabolized in the liver by CYP3A4
Elimination:

 

Excretion: Urine (73%), feces (20%).

 

Appropriate dosing: 150-750 mg/day (Immediate release); 400-800 mg/day (extended release).

Children <12 years: safety not established.

Children >12 years: Dose range 400-800 mg/day (de Miranda et al., 2020).

Geriatrics: 50-200 mg/day (Immediate); 50 mg/day (Extended)

Pregnant and breastfeeding women: Not recommended.

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Route of Administration:  Orally.

Considerations for dosing alterations: Elderly and patients predisposed to hypotensive reactions.

Half-life:  The time it takes for the concentration of a drug to decrease to half of its initial dose in the body.

  • Understanding half-life is important because it determines a drug’s excretion rates and steady-state concentrations. After one half-life has passed, half of the starting drug amount is eliminated from the body (Smith et al., 2018).
  • Seroquel has a half-life of 6 hours for immediate release formulation and 7 hours for extended-release formulation.

Side effects/adverse reaction potentials

Seroquel is associated with various adverse effects, including somnolence fatigue, dry mouth, constipation, increased appetite, weight gain, orthostatic hypertension, and dizziness (de Miranda et al., 2020). Neuroleptic malignant syndrome is a possible adverse effect due to the drug’s D2 receptor blockage.

Contraindications for use including significant drug-to-drug interactions

  • Currently, no identified FDA contraindications of quetiapine.
  • It is contraindicated in patients with documented hypersensitivity.
  • However, quetiapine is associated with an increased risk of death in elderly patients with dementia-related psychosis (Osborne et al., 2020).
  • Precaution is needed with drugs that prolong QT intervals and patients with prolonged QT intervals.

Contraindications due to drug-to-drug interactions

  • Amisulpride
  • Goserelin
  • Lefamulin
  • Leuprolide

Overdose Considerations

Seroquel can be life-threatening if taken in an overdose. Toxicity occurs with levels > 1500 ng/mL.

Supportive care is the mainstay of treatment in an overdose.

Measures for acute toxicity include: Maintaining the airway; Ensuring adequate oxygenation; Ventilation (Osborne et al., 2020).

Gastric lavage and administration of activated charcoal with a laxative can prevent more drug absorption if promptly given.

Diagnostics and labs monitoring

The prescribing clinician should monitor the patient’s metabolic panel focusing on fasting glucose, cholesterol and triglyceride levels,

NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders
NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

weight, and blood pressure (before and during treatment). Besides, patients on long-term treatment should have a lens exam every six months for cataract monitoring (Osborne et al., 2020). Leukopenia, neutropenia, and agranulocytosis can occur with Seroquel treatment, and thus a complete blood count (CBC) should be performed during the first few months of treatment (Osborne et al., 2020). In addition, orthostatic vital signs should be monitored in patients vulnerable to hypotension like geriatrics, patients with dehydration, hypovolemia, and those on antihypertensives.

Comorbidities considerations

  • Precautions should be taken in patients with hypokalemia, cardiac arrhythmia, and hypomagnesemia. Metabolic panels should be obtained before initiating the drug (Osborne et al., 2020).
  • Patients with diabetes mellitus should have their glucose monitored to avoid hyperosmolar coma.

Legal and ethical considerations

  • The clinician prescribing Seroquel should uphold beneficence by ensuring that the drug will have the maximum benefit in treating a patient’s psychotic, bipolar, or MDD symptoms. Nonmaleficence should be upheld by considering the drug’s side effects and ensuring that the benefits outweigh the risks.
  • The clinician should obtain consent from the patient before initiating treatment with Seroquel and explain the potential benefits and side effects for the patient to make an informed decision.
  • Confidentiality of the patient’s health information should be maintained to prevent legal consequences.

Pertinent patient education considerations

The patient should be educated about the drug’s indications, benefits, and side effects. Patients should be informed that the drug can be discontinued if they experience severe side effects and if they have a decrease in WBCs (de Miranda et al., 2020). Besides, they should be educated that abrupt drug discontinuation poses a risk for withdrawal symptoms.

Conclusion

Seroquel is a second-generation antipsychotic, FDA-approved for treating schizophrenia, Bipolar disorder, and MDD. It is also used off-label in treating insomnia, treatment-resistant GAD, and alcohol dependence. Seroquel is an antagonist for D2 receptors and serotonin receptors, which results in reduced psychotic symptoms. Patients on Seroquel should be monitored for cholesterol and triglyceride levels, weight, blood pressure, fasting glucose, cataracts, complete blood count, and orthostatic vital signs. Ethical principles of beneficence, nonmaleficence, confidentiality, and consent should be upheld when prescribing patient Seroquel.

 

NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders References

Ansara, E. D. (2020). Management of treatment-resistant generalized anxiety disorder. The mental health clinician10(6), 326–334. https://doi.org/10.9740/mhc.2020.11.326

Boafo, A., Greenham, S., Sullivan, M., Bazaid, K., Suntharalingam, S., Silbernagel, L., Magner, K., & Robillard, R. (2020). Medications for sleep disturbance in children and adolescents with depression: a survey of Canadian child and adolescent psychiatrists. Child and adolescent psychiatry and mental health14, 10. https://doi.org/10.1186/s13034-020-00316-8

de Miranda, A. S., Ferreira, R. N., Teixeira, A. L., & de Miranda, A. S. (2020). Mood Stabilizers: Quetiapine. NeuroPsychopharmacotherapy, 1-23.

Osborne, V., Davies, M., Evans, A., & Shakir, S. (2020). Observational assessment of safety in Seroquel (OASIS): a specialist cohort event monitoring (SCEM) study in England. Therapeutic advances in psychopharmacology10, 2045125320954616. https://doi.org/10.1177/2045125320954616

Smith, D. A., Beaumont, K., Maurer, T. S., & Di, L. (2018). Relevance of Half-Life in Drug Design. Journal of medicinal chemistry61(10), 4273–4282. https://doi.org/10.1021/acs.jmedchem.7b00969

Vatsalya, V., Kong, M., Marsano, L. M., Kurlawala, Z., Chandras, K. V., Schwandt, M. L., Ramchandani, V. A., & McClain, C. J. (2020). Interaction of Heavy Drinking Patterns and Depression Severity Predicts Efficacy of Quetiapine Fumarate XR in Lowering Alcohol Intake in Alcohol Use Disorder Patients. Substance abuse: research and treatment14, 1178221820955185. https://doi.org/10.1177/1178221820955185

Schizophrenia is characterized mainly by a clear sensory but a marked thinking disturbance. The psychotic disorder is highly linked with abnormalities of amine neurotransmitter function, especially dopamine. Antipsychotic medications, also called neuroleptic or major tranquilizers, are the first-line drug therapy for schizophrenia. They target the positive symptoms of schizophrenia, like hallucinations, delusions, and disorganized behavior. Antipsychotics act by controlling neurotransmitter dopamine and serotonin levels in the brain. They are classified into two major groups: Typical and Atypical. The antipsychotic effects of Typical antipsychotics owe their competitive blockage to dopamine receptors. Atypicals have fewer extrapyramidal adverse effects than the typical and block both serotonin and dopamine receptors. The purpose of this assignment is to develop a study guide for Risperidone.

Drug Description

  • Risperidone is also called Risperdal.
  • It is an Atypical neuroleptic medication.
  • The FDA approves it for use in the USA in the treatment of:
  • Schizophrenia in adults and children aged above 13 years.
  • Bipolar I acute manic or mixed episodes as monotherapy in adults and children above 10 years (Álamo, 2022).
  • Bipolar I acute manic or mixed episodes adjunctive with lithium or valproate in adults.
  • Autism-associated irritability in children above five years.

Off-label uses include:

  • Borderline personality disorder
  • Delusional disorder
  • Delirium
  • Depression
  • Brain injury
  • Pedophilia
  • PTSD
  • Bipolar disorder
  • Conduct disorder
  • Lesch-Nyhan
  • Tourette Syndrome
  • Stuttering, movement disorders
  • Developmental disorders

 The medication mechanism of action

  • Risperidone has a high affinity for serotonin type 2 (5-HT2) receptors.
  • It binds to dopamine D2 receptors with 20 times lower affinity than that for 5-HT2 receptors (Zhao et al., 2022).
  • It antagonizes alpha1-adrenergic, alpha2-adrenergic, and histaminergic receptors.
  • Risperidone has a moderate affinity for serotonin type 1 receptors.
  • Has a weak affinity for dopamine D1 receptors.
  • No affinity for muscarinic, beta1-adrenergic, and beta2-adrenergic receptors (Zhao et al., 2022).

Pharmacokinetics

Pharmacodynamics

  • Risperidone decreases dopamine neurotransmission for the five classes of dopamine receptors (D1 to D5).
  • It reduces the hallucinations and delusions associated with schizophrenia by blocking dopamine receptors in the brain’s mesolimbic system (Zhao et al., 2022).

Appropriate dosing and administration route,

  • Oral: Initial dose at 2 mg/day; Recommended target dosage of 2-8 mg/day OD or BD.
  • The oral dose may be increased by 1-2 mg/day at intervals ≥24 hr.
  • Intramuscular: 12.5-50 mg into the deltoid or gluteal muscle every 2 weeks; The dose should not be adjusted more often than every 4 weeks.
  • Subcutaneous: 90 mg or 120 mg SC once monthly.

Considerations For Dosing Alterations

  • Renal Impairment: If Creatine clearance is below 30, PO Risperidone should be initiated at 0.5 mg BD.
  • It can be increased by up to 0.5 mg BD to a max of 1.5 mg BD.

Considerations of use and dosing in specific specialty populations

Geriatrics: Lower initial doses are recommended and should be adjusted more gradually.

PO initial dose at 0.5 mg q12hr; IM: 12.5-25 mg (Álamo, 2022).

Pediatrics >13 years: Initiated at lower doses of 0.5 mg/day PO in the morning or evening.

Half-life: This is the time taken for the plasma or blood level of a drug to fall by half.

  • Half-life is determined by drug distribution, metabolism, and excretion.
  • Half-life is important because drugs that have a short half-life stay in the body for a shorter period and thus have a shorter duration of action (Andrade, 2022).
  • Drugs with a short half-life thus need to be administered more frequently.
  • Drugs with a long half-life stay longer in the body and thus have a longer duration of action (Andrade, 2022).
  • These drugs can conveniently be dosed once a day or less frequently.
  • Extensive Risperidone metabolizers have a half-life of 3 hrs (parent and metabolite combined).
  • Poor metabolizers have a half-life of 20 hrs (parent and metabolite combined).

Side effects/adverse reaction potentials

  • The most significant side effects are Weight gain, metabolic changes, and sedation.
  • It is associated with extrapyramidal symptoms (EPS): Acute dystonia, tardive dyskinesia, akathisia, and parkinsonian features (Hodkinson et al., 2021).
  • Neuroleptic malignant syndrome (NMS) is a serious side effect of Risperidone.
  • Other side effects: Somnolence, Insomnia, Agitation, Anxiety, Headache, Rhinitis, Fatigue, Increased appetite, Vomiting, Drooling, and Urinary incontinence (Hodkinson et al., 2021).

Contraindications for use and drug-to-drug interactions

  • Risperidone is contraindicated in patients with known allergy/hypersensitivity to Risperidone or paliperidone (Hodkinson et al., 2021).
  • Contraindicated in dementia-related psychosis due to increased risk of death.

Overdose Considerations

  • Risperidone overdose is life-threatening.
  • Patients with risperidone overdose should be monitored for hypotension, sedation, and respiratory depression.

Diagnostics and labs monitoring

  • Monitoring plasma concentrations for Risperidone is strongly recommended.
  • Monitor for leukopenia/neutropenia and agranulocytosis.
  • Monitor complete blood count frequently in the first few months of therapy in patients with a history of low WBC count (Álamo, 2022).
  • Specific parameters to be monitored: Serum prolactin level, hepatic functioning, metabolic functioning, thyroid functioning, blood pressure, fasting plasma glucose, fasting lipid profile, and QTc (Álamo, 2022).

Comorbidities considerations

  • It should be administered with caution in patients with a history of Parkinson’s disease, Lewy body dementia, seizures, cardiovascular disease, hypovolemia, and dehydration (Álamo, 2022).

 

Legal and ethical considerations

  • The prescribing clinician should consider legal and ethical factors of beneficence, nonmaleficence, informed consent, and confidentiality when prescribing Risperidone (Hodkinson et al., 2021).
  • Beneficence is fostered by prescribing the drug when evidence supports its efficacy and benefits in treating schizophrenia in patients.
  • Nonmaleficence is upheld by examining the associated side effects of Risperidone and ensuring the benefits outweigh the possible harm.
  • The clinician should obtain consent from the patient by explaining the mechanism of action, benefits, and potential side effects of Risperidone before starting treatment (Hodkinson et al., 2021).
  • The clinician should maintain the confidentiality of the patient’s diagnosis and treatment and seek consent before sharing the information with other providers.

Pertinent patient education considerations

  • Patient education with regard to Risperidone includes informing the patient of the drug’s benefits in alleviating schizophrenia symptoms and possible side effects.
  • Patients should be educated on extrapyramidal symptoms and signs of NMS (Hodkinson et al., 2021).
  • They should be instructed on the action to take when serious side effects occur.

NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders Conclusion

Risperidone is an Atypical neuroleptic used to treat schizophrenia in adults and children above 13 years. It is also FDA-indicated to treat Bipolar 1 acute manic or mixed episodes and Autism-associated irritability in children above 5 years. It exhibits its therapeutic effects by blocking serotonin and dopamine receptors. The most significant side effects of Risperidone are weight gain, metabolic changes, and sedation. Neuroleptic malignant syndrome and Extrapyramidal symptoms are serious side effects of Risperidone.

 

NURS 6630 Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders References

Álamo, C. (2022). Risperidone ISM as a New Option in the Clinical Management of Schizophrenia: A Narrative Review. Advances in therapy, 39(11), 4875–4891. https://doi.org/10.1007/s12325-022-02299-8

Andrade, C. (2022). The practical importance of half-life in psychopharmacology. The Journal of Clinical Psychiatry83(4), 41940. https://doi.org/10.4088/JCP.22f14584

Hodkinson, A., Heneghan, C., Mahtani, K. R., Kontopantelis, E., & Panagioti, M. (2021). Benefits and harms of Risperidone and Paliperidone for treatment of patients with schizophrenia or bipolar disorder: a meta-analysis involving individual participant data and clinical study reports. BMC medicine19(1), 195. https://doi.org/10.1186/s12916-021-02062-w

Zhao, M., Ma, J., Li, M., Zhu, W., Zhou, W., Shen, L., Wu, H., Zhang, N., Wu, S., Fu, C., Li, X., Yang, K., Tang, T., Shen, R., He, L., Huai, C., & Qin, S. (2022). Different responses to risperidone treatment in schizophrenia: a multicenter genome-wide association and whole exome sequencing joint study. Translational psychiatry12(1), 173. https://doi.org/10.1038/s41398-022-01942-w

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