Delusional Disorders
Pakistani Female With Delusional Thought Processes

Hispanic male

 

Decision Point One


Start Zyprexa (olanzapine) 10 mg po orally at BEDTIME

RESULTS OF DECISION POINT ONE

Decision Point Two
Select what the PMHNP should do next:


Decrease Zyprexa to 7.5 mg BEDTIME

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Patient worsens. Her PANNS increases by 10% (negative symptoms are getting worse) but weight becomes stabilized and excessive hunger abates
  • Husband explains that she is becoming less manageable at home and he is having to take time off from work because he is fearful of leaving her alone
Decision Point Three
Select what the PMHNP should do next:


Increase Zyprexa 10 MG orally at BEDTIME
Guidance to Student

Weight gain is a significant problem with Zyprexa. Next to Clozaril (clozapine), Zyprexa causes the most weight gain of all the atypical antipsychotics. This is a side effect that a significant number of clients will experience. There also appears to be an increased association of newly diagnosed diabetes mellitus in clients treated with Zyprexa. Although this can be disease related in this population, Zyprexa is above what would be considered coincidental. Risperdal is a good option, although it is dosed twice daily and compliance in this population can be problematic. There is evidence that shows giving Risperdal all at once can be efficacious and therefore could be an option down the road should compliance become an issue. Weight gain is also possible with Risperdal, but it is not as great as that seen with Zyprexa. If compliance does become an issue with this client, Risperdal has a long-acting injectable formulation, Risperdal Consta, that could be used. Remember, Risperdal Consta has to be given every 2 weeks at the provider’s office, and therapeutic blood levels take time to achieve (on average 3–6 weeks or 2–3 injections). Oral overlapping therapy is required to bridge this period of time. Another option in someone who responds to

Risperdal would be Invega Sustenna (paliperidone palmitate), which is the first metabolite of Risperdal and has greater activity at the D2 receptor than Risperdal. An advantage of Invega Sustenna over Risperdal Consta is that therapeutic blood levels are attained within the first 4–7 days, and overlapping oral therapy is usually not necessary. A disadvantage is that during the initiating phase of medication, the first two doses need to be given within 4–7 days of one another. This is followed by monthly injections. There is another product on the market called Invega Trinza, which is given once every 3 months. This product is for clients who have been stabilized on Invega Sustenna for at least 4 months where the last two doses were the same strength (two months of 156 mg injections).

Increasing Zyprexa to 15 mg at bedtime will only worsen the weight gain side effect. While additional benefits from increasing the dose may be possible from an efficacy standpoint, side effects always need to be taken into consideration. “First, do no harm.” Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).


Change to Risperdal 1 mg orally BID
Guidance to Student

Weight gain is a significant problem with Zyprexa. Next to Clozaril (clozapine), Zyprexa causes the most weight gain of all the atypical antipsychotics. This is a side effect that a significant number of clients will experience. There also appears to be an increased association of newly diagnosed diabetes mellitus in clients treated with Zyprexa. Although this can be disease related in this population, Zyprexa is above what would be considered coincidental. Risperdal is a good option, although it is dosed twice daily and compliance in this population can be problematic. There is evidence that shows giving Risperdal all at once can be efficacious and therefore could be an option down the road should compliance become an issue. Weight gain is also possible with Risperdal, but it is not as great as that seen with Zyprexa. If compliance does become an issue with this client, Risperdal has a long-acting injectable formulation, Risperdal Consta, that could be used. Remember, Risperdal Consta has to be given every 2 weeks at the provider’s office, and therapeutic blood levels take time to achieve (on average 3–6 weeks or 2–3 injections). Oral overlapping therapy is required to bridge this period of time. Another option in someone who responds to

Risperdal would be Invega Sustenna (paliperidone palmitate), which is the first metabolite of Risperdal and has greater activity at the D2 receptor than Risperdal. An advantage of Invega Sustenna over Risperdal Consta is that therapeutic blood levels are attained within the first 4–7 days, and overlapping oral therapy is usually not necessary. A disadvantage is that during the initiating phase of medication, the first two doses need to be given within 4–7 days of one another. This is followed by monthly injections. There is another product on the market called Invega Trinza, which is given once every 3 months. This product is for clients who have been stabilized on Invega Sustenna for at least 4 months where the last two doses were the same strength (two months of 156 mg injections).

Increasing Zyprexa to 15 mg at bedtime will only worsen the weight gain side effect. While additional benefits from increasing the dose may be possible from an efficacy standpoint, side effects always need to be taken into consideration. “First, do no harm.” Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).


Increase Zyprexa 15 mg orally at BEDTIME and add on Qsymia (phentermine and topiramate) for weight loss
Guidance to Student

Weight gain is a significant problem with Zyprexa. Next to Clozaril (clozapine), Zyprexa causes the most weight gain of all the atypical antipsychotics. This is a side effect that a significant number of clients will experience. There also appears to be an increased association of newly diagnosed diabetes mellitus in clients treated with Zyprexa. Although this can be disease related in this population, Zyprexa is above what would be considered coincidental. Risperdal is a good option, although it is dosed twice daily and compliance in this population can be problematic. There is evidence that shows giving Risperdal all at once can be efficacious and therefore could be an option down the road should compliance become an issue. Weight gain is also possible with Risperdal, but it is not as great as that seen with Zyprexa. If compliance does become an issue with this client, Risperdal has a long-acting injectable formulation, Risperdal Consta, that could be used. Remember, Risperdal Consta has to be given every 2 weeks at the provider’s office, and therapeutic blood levels take time to achieve (on average 3–6 weeks or 2–3 injections). Oral overlapping therapy is required to bridge this period of time. Another option in someone who responds to

Risperdal would be Invega Sustenna (paliperidone palmitate), which is the first metabolite of Risperdal and has greater activity at the D2 receptor than Risperdal. An advantage of Invega Sustenna over Risperdal Consta is that therapeutic blood levels are attained within the first 4–7 days, and overlapping oral therapy is usually not necessary. A disadvantage is that during the initiating phase of medication, the first two doses need to be given within 4–7 days of one another. This is followed by monthly injections. There is another product on the market called Invega Trinza, which is given once every 3 months. This product is for clients who have been stabilized on Invega Sustenna for at least 4 months where the last two doses were the same strength (two months of 156 mg injections).

Increasing Zyprexa to 15 mg at bedtime will only worsen the weight gain side effect. While additional benefits from increasing the dose may be possible from an efficacy standpoint, side effects always need to be taken into consideration. “First, do no harm.” Qsymia is a weight loss medication that is a combination of phentermine and topiramate. It is only indicated to treat obesity. This client’s BMI (28.9 kg/M2) does not fit the definition of obesity (BMI >30 Kg/M2- Following from CDC website: Class 1: BMI of 30 to < 35, Class 2: BMI of 35 to < 40, Class 3: BMI of 40 or higher. Class 3 obesity is sometimes categorized as “extreme” or “severe” obesity). There are two things wrong with this therapy option. First, there are only a few occasions where add-on therapy to treat a side effect is acceptable, and weight gain is not one of those scenarios. Secondly, phentermine has a lot of cardiovascular toxicities (such as elevated BP, HR, and increased workload on the heart).


Change medication to Geodon 40 mg orally BID with meals

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client has a significant reduction in her PANSS (reduction of 40%)
  • Client notices her weight is down slightly from the previous visit (lost 2 pounds) and that her hunger has been curbed since starting this med
  • Client does complain that it is difficult to remember the second dose and admits to missing afternoon doses on several occasions over the past month
Decision Point Three
Select what the PMHNP should do next:


Give her a few test doses of Risperdal 1 mg orally BID for 3 days to see if she tolerates the medication. If tolerated, start Invega Sustenna at an appropriate starting and maintenance dose
Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a patient who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that patients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the patient may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell and there information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in patients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon but is taken only once daily. This makes it a good option for someone who responds to Geodon but has compliance problems with the twice daily dosing. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Patients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.


Change the Geodon to 80 MG orally at bedtime daily and monitor for breakthrough symptoms throughout the day
Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a patient who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that patients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the patient may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell and there information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in patients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon but is taken only once daily. This makes it a good option for someone who responds to Geodon but has compliance problems with the twice daily dosing. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Patients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.


Discontinue Geodon and start Latuda 40 mg orally Daily
Guidance to Student

Changing to Risperdal oral therapy to test for side effects and then switching to Invega Sustenna is a good option in a patient who has problems with compliance and who shows good effect from oral therapy. The manufacturer advertises that patients can be switched from an entirely different medication to Invega Sustenna if tolerability can be shown through oral therapy. From a clinical standpoint, the patient may or may not respond to the medication and therefore this could be a waste of time. Remember, manufacturers have a product to sell and there information should always be verified before implementing into clinical practice.

Although Geodon is recommended twice daily with meals, some providers will choose to give the dose once a day and monitor for efficacy in patients who have compliance issues with BID dosing regimens.

Latuda is a medication that behaves much like Geodon but is taken only once daily. This makes it a good option for someone who responds to Geodon but has compliance problems with the twice daily dosing. Tolerability can be an issue as doses are escalated. Particularly, nausea, vomiting and extrapyramidal side effects can be problematic and therefore good counseling is recommended for clients. Patients usually tolerate lower doses (40 mg) but significant GI distress and movement disorders can occur when doses are pushed upward toward the daily max of 160 mg.


Add-on Wellbutrin XL 150 mg orally in the MORNING

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Client does not get any better over the past 4 weeks
  • Client has ignored the directions on the bottle telling her to take this medication in the morning. She has been taking it at 8PM each night
  • Client's husband reports that she is not sleeping and seems to be declining in function
  • Client's delusions have progressively become worse
Decision Point Three
Select what the PMHNP should do next:


Admit patient to an acute psychiatric unit for observation and medication adjustments
Guidance to Student

In some instances, a decision to admit a client for an acute observatory stay leading into an admission can be necessary if the client is a danger to herself or others or functional decline is so great that outpatient treatment would be deemed nonadvantageous. The husband is telling the PMHNP that his wife is progressively becoming worse.

Wellbutrin add-on therapy is usually saved for clients who are on SSRI therapy for MDD (and possibly schizoaffective disorder with MDD present) to help manage sexual side effects. Clients typically treated in this manner are noticing a benefit from SSRI therapy. The client does not seem to be a candidate for this therapy even in light of seeing some weight loss on this medication.

Clozaril is a last-line therapy due to monitoring requirements and its adverse reaction profile. With this being said, Clozaril is very effective in significantly large numbers of clients who fail other therapies. It may become an option down the road, but it is way too early in the client’s treatment to consider this medication at this time. Certain populations suffer from something called benign neutropenia. Included in these populations are certain individuals of Arab descent. See the Clozapine REMS website (in the “Additional Reading” section above) for additional information and precautions.


Change Wellbutrin to IR formulation and re-iterate the need for taking first thing in the morning. Counsel husband as well
Guidance to Student

In some instances, a decision to admit a client for an acute observatory stay leading into an admission can be necessary if the client is a danger to herself or others or functional decline is so great that outpatient treatment would be deemed nonadvantageous. The husband is telling the PMHNP that his wife is progressively becoming worse.

Wellbutrin add-on therapy is usually saved for clients who are on SSRI therapy for MDD (and possibly schizoaffective disorder with MDD present) to help manage sexual side effects. Clients typically treated in this manner are noticing a benefit from SSRI therapy. The client does not seem to be a candidate for this therapy even in light of seeing some weight loss on this medication.

Clozaril is a last-line therapy due to monitoring requirements and its adverse reaction profile. With this being said, Clozaril is very effective in significantly large numbers of clients who fail other therapies. It may become an option down the road, but it is way too early in the client’s treatment to consider this medication at this time. Certain populations suffer from something called benign neutropenia. Included in these populations are certain individuals of Arab descent. See the Clozapine REMS website (in the “Additional Reading” section above) for additional information and precautions.


Discontinue Zyprexa and start Clozaril at 25 mg daily titrating in an upward fashion. Educate client on ANC monitoring (weekly for 6 months, q2weeks for 6 months and monthly thereafter while on clozapine)
Guidance to Student

In some instances, a decision to admit a client for an acute observatory stay leading into an admission can be necessary if the client is a danger to herself or others or functional decline is so great that outpatient treatment would be deemed nonadvantageous. The husband is telling the PMHNP that his wife is progressively becoming worse.

Wellbutrin add-on therapy is usually saved for clients who are on SSRI therapy for MDD (and possibly schizoaffective disorder with MDD present) to help manage sexual side effects. Clients typically treated in this manner are noticing a benefit from SSRI therapy. The client does not seem to be a candidate for this therapy even in light of seeing some weight loss on this medication.

Clozaril is a last-line therapy due to monitoring requirements and its adverse reaction profile. With this being said, Clozaril is very effective in significantly large numbers of clients who fail other therapies. It may become an option down the road, but it is way too early in the client’s treatment to consider this medication at this time. Certain populations suffer from something called benign neutropenia. Included in these populations are certain individuals of Arab descent. See the Clozapine REMS website (in the “Additional Reading” section above) for additional information and precautions.