Schizoaffective disorder is diagnosed in the presence of the following four characteristics as according to the American Psychiatric Association APA (2015). (I) An uninterrupted period of illness during which, at some time, there is either a Major Depressive Episode, a Manic Episode, or a Mixed Episode concurrent with symptoms that meet Criterion A for Schizophrenia. (II). During the same period of illness, there have been delusions or hallucinations for at least two weeks in the absence of prominent mood symptoms. (III). Symptoms that meet criteria for a mood episode are present for a substantial portion of the total duration of the active and residual periods of the illness. (IV). The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. The assignment involves the development of a pharmacology treatment Algorithm of a 36-year-old African American female with a past psychiatric history of schizoaffective disorder. The development of the algorithm will include an outline of four treatment stages.
Overview of Initial Patient Clinical assessment.
Chief complaint: In as much as the patient reports several schizophrenic signs and symptoms, she reports having a decrease in the symptoms due to administration of medication. She reports no longer experiencing auditory and visual hallucinations. The chief complaint that made her present herself in the hospital is, therefore, medication refills.
Patient history, including medical history, psychiatric history, psychosocial, and mental status examination. Multiple inpatient Hospitalizations starting in 2013. She was previously diagnosed with Bipolar disorder, PTSD, and schizoaffective disorder. Current Psychiatric Medications are Depakote DR 250 mg PO TID for mood, Abilify 15 mg PO QHS for psychosis, Lexapro 10 mg PO QAM for mood. Past Psychiatric Medications are Seroquel, Depakote, Abilify, Vistaril, and Haldol. The patient stopped her regular medication regimen (Depakote, Abilify, Vistaril) since October 2019. She has a history of intoxication with alcohol, marijuana, which landed her to jail. History of cutting herself due to auditory command hallucination, last time was in June 2020. Patient reports no history of physical, mental, and or sexual abuse. Both the patient’s father and uncle are reported to have a history of Schizophrenia. The patient is single as she reports having never been married and has no child. The patient is unemployed and currently lives with her cousin. She drinks alcohol socially, drinking one 24 oz can of beer and few shots once a month. Last use was in June 2020. She denies a history of blackouts or withdrawal. Patient stated she smokes seven cigarettes daily since the age of 19, smokes marijuana daily since the age of 13. Last use was in June 2020. Methamphetamine Snorts twice a week since 2011. Last use was in June 2020. Denies Cocaine, Heroin, and Spice use.
Considering mental state examination, the patient is alert and oriented to person, place, time and situation. Patient denies Visual Hallucinations, but admit to auditory Hallucinations. She denied having any thoughts of suicide or self-harm. Mildly disorganized, no apparent delusions. The patient is responding to internal stimuli during evaluation (self-talking). Patient states interest in compliance with medication patient reports interest in cooperating with the group home staff and following up with outpatient management.
Stage I medication management: Monotherapy
According to Patel et al. (2014), the American Psychiatric Association outlined second-generation (atypical) antipsychotics (SGAs) as the first-line agents for the management of Schizophrenia. This, however, is with the exception of Clozapine due to its risk of agranulocytosis. Other first-line antipsychotics, however, may have different forms of side effects, including neurological and metabolic side effects such as weight gain when chronically used. In clinical trials, the antipsychotic medications are the first line of choice as they are very efficient in managing schizophrenic behaviours and symptoms during clinical trials. However, given the possibility of antipsychotics to cause disturbing side effects when chronically used, a careful and continuous assessment and management of the potential side effects is essential in ensuring adequate care. (Sadock, Sadock, & Ruiz, 2015). In this case scenario, there is an administration of Risperidone in this stage. Risperidone may be administered IM into the deltoid or gluteal muscles in a dosage of 12.5-50 mg every two weeks.
A frequency of dosage adjustment of more than once in every four weeks should be avoided. While choosing Risperidone, it is recommended to establish tolerability of PO risperidone before initiating treatment with IM risperidone. The medication should be taken for two weeks for continuing patients and three weeks for those starting the treatment. Despite the tremendous increase in atypical antipsychotic drugs in the United States, it is associated with significant cardiometabolic side effects including tachycardia, weight gain, dyslipidemia and hyperglycemia, hence the increased risk of mortality, mainly due to MI or stroke. (Siafis et al., 2018; Brunton et al. 2018 & Rostama et al., 2020). The potential notable side effects, therefore, lead to pretreatment assessment (neurophysical examination) that include measurement of patient’s waist circumference, body mass index (BMI), blood pressure and heart rate. Moreover, laboratory evaluations including but not limited to thyroid function tests, renal testing, liver functioning tests, lipid, fasting glucose, and electrolytes are also critical before risperidone administration (Sadock et al.,2015)
Stage 2: Non-Responder to Stage 1: Titration up.
Regarding risperidone titration, it can be administered twice or once daily basis at a starting dose of 2mg. An increment dosage of 1 to 2 mg is recommended up to the maximum recommendable dosage of 4 mg to 8mg daily. In our case scenario careful follow up for side effects for several days up to two weeks followed, however, the patient showed tolerance as there were no signs of sedation, postural hypotension nor akathisia after the administration of the Risperidone. According to Kreyenbuhl et al. (2011) therefore, the patient’s dosage was titrated at a dosage of 1mg after every 24 hours up to 6mg daily since she had been started on 2mg of Risperidone IM prior. It is at this point that signs of intolerance including postural hypotension, akathisia and sedation, were seen.
Stage 3: Non-Responder to Stage 2: Changing Antipsychotic
Change of antipsychotics medication may be deemed effective in cases where there is infectivity with the current antipsychotic due to many side effects. The literature outlines two basic ways of changing antipsychotics, that is cross tapering and gradual tapering. With cross tapering, there is the simultaneous tapering of the current drug within 1-2 weeks. In so doing, the replacement drug, on the other hand, is titrated in 3-4 steps in a span of days to several weeks. There is, however, the possibility of continuing a full dose of the current drug for patients who have a higher risk for relapse. At the same time, the new antipsychotic, on the other hand, is slowly tapered up until its therapeutic range. Given the many side effects associated with Risperidone, Olanzapine is the alternative, a second-generation antipsychotic like Risperidone, though with less risk for EPS symptoms. This drug’s mechanism of action results in diminishing cognitive and aggressive symptoms. Due to its possibility of weight gain and metabolic side effects, Olanzapine is not considered a first-line drug during the first stage. Hence it usually is cross tapered with Risperidone in cases where Risperidone, the first line antipsychotic is deemed ineffective. Administration of Olanzapine was done at an initial starting dosage of started at 5 mg orally daily. During the cross tapering, there was an increase in Olanzapine dose by 1.25 mg daily up to the maximum recommendable dosage of 10 mg was reached. Risperidone dosage, on the other hand, was downgraded by 1 mg daily up to 2 weeks. There is, however, side effects and withdrawal symptoms during the cross tapering hence critical patient observation as well as patient’s improvement are paramount. The possible Olanzapine’s side effects include but not limited to dizziness, light-headed feeling, or having trouble keeping your balance, restlessness, unusual behaviour, depression, insomnia, weakness, difficulty walking and constipation.
Moreover, augmentation with Divalproex is as well possible to bring synergistic effects. However, it may lead to sedation, tremor, dizziness, ataxia, headache, asthenia, abdominal pain, weight gain, polycystic ovaries, hyperandrogenism, hyperinsulinemia, or decreased bone mass, among others. In our case scenario, partial response was observed hence moving to the last stage.
Stage 4: Non-Responder to Stage 3: Treatment-Resistant Schizophrenia
Any patient whose treatment regimen reaches stage four is termed non-responders by Stock et al. (2015). In their findings, Stock and friends outlined that non-responder ought to be put on clozapine trial before a trial of antipsychotic dual therapy. In our case scenario, Clozapine is considered the drug of choice in this stage. The standard dosage for Clozapine is usually 12.5 mg once or twice daily. Titration may include the increment of 20-50 mg to the acceptable target dosage of 300 to 450 mg daily. Clozapine may, however, lead to the following potential side effects tardive dyskinesia, dyslipidemia, hyperglycemia, tachycardia, weight gain, sialorrhea and orthostasis. (Stock et al., 2015)
References.
Brunton L. L, Knollmann BrC, Hilal-Dandan R. Goodman & Gilman’s. (, 2018). the pharmacological basis of therapeutics. Thirteenth edition. Ed. New York: McGraw Hill Medical.
Kreyenbuhl, J., Slade, E. P., Medoff, D. R., Brown, C. H., Ehrenreich, B., Afful, J., & Dixon, L. B. (2011). Time to discontinuation of first-and second-generation antipsychotic medications in the treatment of Schizophrenia. Schizophrenia Research, 131(1-3), 127-132.
Patel, K. R., Cherian, J., Gohil, K., & Atkinson, D. (2014). Schizophrenia: Overview and treatment options. In P and T (Vol. 39, Issue 9, pp. 638–645). Medi Media USA Inc. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159061/
Rostama, B. May, M., & Houseknecht, K. L. (2020). Atypical antipsychotic medications disrupt the cardio-metabolic and cardio-immune axes. Intervent Cardiol, 12(2), 11-16.
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Synopsis of psychiatry: behavioural sciences, clinical psychiatry. Wolters Kluwer.
Siafis, S., Tzachanis, D., Samara, M., & Papazisis, G. (2018). Antipsychotic drugs: from receptor-binding profiles to metabolic side effects. Current Neuropharmacology, 16(8), 1210-1223.
Silverman, J. J., Galanter, M., Jackson-Triche, M., Jacobs, D. G., Lomax, J. W., Riba, M. B., … & Yager, J. (2015). The American Psychiatric Association practice guidelines for the psychiatric evaluation of adults. American Journal of Psychiatry, 172(8), 798-802.
