Case #3
A young girl with strange behaviors

A young girl with strange behaviors

 

Decision Point One


 Early Onset Schizophrenia
Decision Point Two
BASED ON THIS DIAGNOSIS, SELECT YOUR CHOICE OF ACTIONS:


Refer for psychological testing

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Although there are no specific psychometric tests available for schizophrenia, the consulting psychologist administered a comprehensive psychological battery of tests in order to assess personality and cognitive functioning as well as to identify any underlying intellectual disabilities that could account for the difficulty Carrie is having in school. Tests administered included the Minnesota Multiphasic Personality Inventory; Kaufman Adolescent and Adult Intelligence Test; Rorschach test; Whitaker Index of Schizophrenic Thinking (WIST) test; Wide Range Achievement Test – 4th Edition (WRAT-4); and the Millon Adolescent Clinical Inventory (MACI). The consulting psychologist opined that early-onset schizophrenia was strongly suspected in this client.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Begin Clozapine 100 mg orally daily
Guidance to Student

It is not always necessary to procure a consult with a psychologist. However, psychologists by virtue of their advanced training and licensure are able to conduct comprehensive psychological testing on clients more advanced than those tests that could be conducted by the psychiatric/mental health nurse practitioner. In this case, we would like to know if the poor academic performance was the result of an intellectual disability, versus poor premorbid intellectual functioning that is often seen in schizophrenia.

In terms of treatment decisions, Clozapine is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). Clozapine 100 mg would most likely cause significant side effects that both the child and parents would find objectionable, thus making compliance an issue.

Although not FDA-approved for use in children, Lurasidone is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label”; however, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. Therefore, Lurasidone would be the best choice. Additionally, Lurasidone may be the preferred antipsychotic, as it appears to have the least impact on body weight and lipid profile.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Family interventions are important as well, as they do have a positive benefit on symptom relapse and admission/readmission to the hospital. Family interventions should include teaching about the disease, medications, and anticipatory guidance.


Begin family interventions
Guidance to Student

It is not always necessary to procure a consult with a psychologist. However, psychologists by virtue of their advanced training and licensure are able to conduct comprehensive psychological testing on clients more advanced than those tests that could be conducted by the psychiatric/mental health nurse practitioner. In this case, we would like to know if the poor academic performance was the result of an intellectual disability, versus poor premorbid intellectual functioning that is often seen in schizophrenia.

In terms of treatment decisions, Clozapine is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). Clozapine 100 mg would most likely cause significant side effects that both the child and parents would find objectionable, thus making compliance an issue.

Although not FDA-approved for use in children, Lurasidone is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label”; however, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. Therefore, Lurasidone would be the best choice. Additionally, Lurasidone may be the preferred antipsychotic, as it appears to have the least impact on body weight and lipid profile.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Family interventions are important as well, as they do have a positive benefit on symptom relapse and admission/readmission to the hospital. Family interventions should include teaching about the disease, medications, and anticipatory guidance.


Begin Lurasidone 40 mg orally daily
Guidance to Student

It is not always necessary to procure a consult with a psychologist. However, psychologists by virtue of their advanced training and licensure are able to conduct comprehensive psychological testing on clients more advanced than those tests that could be conducted by the psychiatric/mental health nurse practitioner. In this case, we would like to know if the poor academic performance was the result of an intellectual disability, versus poor premorbid intellectual functioning that is often seen in schizophrenia.

In terms of treatment decisions, Clozapine is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). Clozapine 100 mg would most likely cause significant side effects that both the child and parents would find objectionable, thus making compliance an issue.

Although not FDA-approved for use in children, Lurasidone is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label”; however, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. Therefore, Lurasidone would be the best choice. Additionally, Lurasidone may be the preferred antipsychotic, as it appears to have the least impact on body weight and lipid profile.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.

Family interventions are important as well, as they do have a positive benefit on symptom relapse and admission/readmission to the hospital. Family interventions should include teaching about the disease, medications, and anticipatory guidance.


Begin Clozaril 100 mg orally daily

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Upon return to your office, Carrie’s parents report that they stopped giving Carrie the medication 3 days after it was begun. “We just couldn’t wake her up,” explains Carrie’s mother. Carrie continues to exhibit symptoms, and basically, nothing has changed from the initial presentation.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Restart Clozapine and explain to Carrie’s parents that Clozapine can initially cause sedation and that it will eventually pass
Guidance to Student

Clozapine (Clozaril) is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). The 100-mg dose prescribed in this case has resulted in the significant sedation that Carrie experienced. As we saw, the parents became concerned about this and withdrew the medication, and several weeks may have lapsed between the cessation of medication and the presentation of Carrie in your office again (assuming the parents would bring her back to see you). Restarting the medication at 100 mg would result in the same sedation. While sedation is common with Clozapine, we attempt to minimize it by starting at a much lower dose and titrating upward. This type of dosing error (initiating treatment at 100 mg orally daily) would result in a delay in treatment, and possible injury to the client.

While Lamotrigine is sometimes used as adjunctive therapy in the treatment of schizophrenia, it is by no means an acceptable first-line treatment.

Risperdal 0.5 mg orally twice a day is the best choice in this scenario as the dose is the most appropriate. We can use a smaller dose and titrate upward as needed to achieve symptom control. At this starting dose, side effects would be minimized. It is also FDA-approved for the treatment of schizophrenia in those aged 13 years and older.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.


Begin Risperdal 0.5 mg orally twice a day
Guidance to Student

Clozapine (Clozaril) is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). The 100-mg dose prescribed in this case has resulted in the significant sedation that Carrie experienced. As we saw, the parents became concerned about this and withdrew the medication, and several weeks may have lapsed between the cessation of medication and the presentation of Carrie in your office again (assuming the parents would bring her back to see you). Restarting the medication at 100 mg would result in the same sedation. While sedation is common with Clozapine, we attempt to minimize it by starting at a much lower dose and titrating upward. This type of dosing error (initiating treatment at 100 mg orally daily) would result in a delay in treatment, and possible injury to the client.

While Lamotrigine is sometimes used as adjunctive therapy in the treatment of schizophrenia, it is by no means an acceptable first-line treatment.

Risperdal 0.5 mg orally twice a day is the best choice in this scenario as the dose is the most appropriate. We can use a smaller dose and titrate upward as needed to achieve symptom control. At this starting dose, side effects would be minimized. It is also FDA-approved for the treatment of schizophrenia in those aged 13 years and older.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.


Begin Lamotrigine 25 mg orally daily
Guidance to Student

Clozapine (Clozaril) is FDA-approved for treatment-resistant schizophrenia. Since the child has not yet been treated with any agent, we have no way of knowing if her schizophrenia is treatment resistant. Additionally, if we were to use Clozapine, the starting dose is approximately 25 mg in adults (perhaps 12.5 mg in a child, depending on body weight). The 100-mg dose prescribed in this case has resulted in the significant sedation that Carrie experienced. As we saw, the parents became concerned about this and withdrew the medication, and several weeks may have lapsed between the cessation of medication and the presentation of Carrie in your office again (assuming the parents would bring her back to see you). Restarting the medication at 100 mg would result in the same sedation. While sedation is common with Clozapine, we attempt to minimize it by starting at a much lower dose and titrating upward. This type of dosing error (initiating treatment at 100 mg orally daily) would result in a delay in treatment, and possible injury to the client.

While Lamotrigine is sometimes used as adjunctive therapy in the treatment of schizophrenia, it is by no means an acceptable first-line treatment.

Risperdal 0.5 mg orally twice a day is the best choice in this scenario as the dose is the most appropriate. We can use a smaller dose and titrate upward as needed to achieve symptom control. At this starting dose, side effects would be minimized. It is also FDA-approved for the treatment of schizophrenia in those aged 13 years and older.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.


Begin psychotherapy using a psychodynamic approach

RESULTS OF DECISION POINT TWO

  • Client returns to clinic in four weeks
  • Carrie appears to be engaged with her therapist, and reports that she “looks forward” to seeing her therapist, but her parents are not reporting any appreciable change in psychotic symptoms.
Decision Point Three
BASED ON THE ABOVE INFORMATION, SELECT YOUR NEXT ACTION. BE CERTAIN TO DISCUSS THE RATIONALE FOR YOUR DECISION.


Increase the frequency of psychodynamic psychotherapy sessions
Guidance to Student

Some authorities have suggested that psychodynamic psychotherapies can be effective in the treatment of schizophrenia, especially modern psychoanalysts. Psychotherapy definitely has a place in terms of helping individuals with schizophrenia (especially in the treatment of residual symptoms), but is not considered a first-line treatment for the disorder.

Although not FDA-approved for use in children, Lurasidone (Latuda) is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label”; however, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. In consideration of an antipsychotic, Lurasidone may be the preferred antipsychotic as it appears to have the least impact on body weight and lipid profile.

Haldol should be initiated at 0.5 mg orally daily, with a target dose of 0.05 to 0.15 mg/kg per day for psychotic disorders. It is generally considered to be a second-line drug after second-generation antipsychotics have been attempted/failed. Haldol can also cause significant weight gain and alter lipid profiles significantly.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.


Begin Haloperidol 5 mg orally daily
Guidance to Student

Some authorities have suggested that psychodynamic psychotherapies can be effective in the treatment of schizophrenia, especially modern psychoanalysts. Psychotherapy definitely has a place in terms of helping individuals with schizophrenia (especially in the treatment of residual symptoms), but is not considered a first-line treatment for the disorder.

Although not FDA-approved for use in children, Lurasidone (Latuda) is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label”; however, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. In consideration of an antipsychotic, Lurasidone may be the preferred antipsychotic as it appears to have the least impact on body weight and lipid profile.

Haldol should be initiated at 0.5 mg orally daily, with a target dose of 0.05 to 0.15 mg/kg per day for psychotic disorders. It is generally considered to be a second-line drug after second-generation antipsychotics have been attempted/failed. Haldol can also cause significant weight gain and alter lipid profiles significantly.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.


Begin Lurasidone 40 mg orally daily
Guidance to Student

Some authorities have suggested that psychodynamic psychotherapies can be effective in the treatment of schizophrenia, especially modern psychoanalysts. Psychotherapy definitely has a place in terms of helping individuals with schizophrenia (especially in the treatment of residual symptoms), but is not considered a first-line treatment for the disorder.

Although not FDA-approved for use in children, Lurasidone (Latuda) is used as an off-label drug in this population. There are no legal prohibitions against any prescriber using drugs “off-label”; however, attention must be given to the concept of informed consent. When working with children/adolescents, the PMHNP must explain pros/cons, discuss therapeutic endpoints/goals of treatment, etc. The parent/guardian must have all of the information needed to make an informed consent. In consideration of an antipsychotic, Lurasidone may be the preferred antipsychotic as it appears to have the least impact on body weight and lipid profile.

Haldol should be initiated at 0.5 mg orally daily, with a target dose of 0.05 to 0.15 mg/kg per day for psychotic disorders. It is generally considered to be a second-line drug after second-generation antipsychotics have been attempted/failed. Haldol can also cause significant weight gain and alter lipid profiles significantly.

Recall that with any antipsychotic medication, you should determine fasting plasma glucose levels, monitor weight and BMI during treatment, as well as blood pressure and fasting triglycerides.