Analysis of Treatment Guidelines Paper for Schizophrenia
The analysis of treatment guidelines has been selected on the topic focusing on Schizophrenia. This paper aims to examine the disease’s impact, its characteristics, effects on the brain, and how the disorder is treated. According to Dixon et al., 2018, exuberant health care costs of Schizophrenia and unforeseeable losses to the job market were estimated at $155.7 billion. Individuals with the disorder have a high mortality rate, multiple comorbidities due to psychotropic side effects, and a shortened lifespan (Keepers et al., 2021). During the initial course of the disease, 4-10% of male individuals with Schizophrenia die by suicide (Keepers et al., 2021). In this paper, I will describe a patient that has been seen in my clinical rotation at La Mente Behavioral Health with Schizophrenia, treatment in his symptomology, therapy, and how it has impacted his daily living.
Characteristics of Schizophrenia
For patients diagnosed with Schizophrenia, some of the symptoms displayed are positive, including hallucinations and delusion during acute periods of psychosis (Kesby et al., 2018). The Schizophrenic patient may also have cognitive symptoms with impairments in memory, focus, attention, multitasking, and learning. Other characteristics of Schizophrenia are the negative symptoms of social withdrawal, lack of emotional expression, and avolition (Kesby et al., 2018). Earlier notions viewed negative symptoms as a burden for the patient with the disorder, and these symptoms added to the continuing difficulty related to the disorder (Kesby et al., 2018).
Schizophrenia Disorder
According to The Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM–5; American Psychiatric Association, 2013), to meet diagnostic criteria for Schizophrenia, the patient needs to have two or more symptoms present for a significant time during one month. For the patient to be diagnosed with Schizophrenia, they must meet symptoms in criteria A. which includes delusions, hallucinations, or disorganized speech. The patient can also display grossly disorganized, catatonic behavior and negative symptoms (5th ed.; DSM-5; American Psychiatric Association, 2013). The disturbance should be seen for at least six months and disrupt at least one or more levels of functioning like self-care, interpersonal relations, or work (5th ed.; DSM-5; American Psychiatric Association, 2013). Symptoms continue for at least six months and must consist of at least one month of symptoms, including delusions, hallucinations, or disorganized speech (5th ed.; DSM-5; American Psychiatric Association, 2013).
According to Abidi et al., 2017, the onset of childhood schizophrenia before 12 years is rare, affecting 1.6 to 1.9 per 100,000 in the child population. Most of these cases increase after 14 years of age, mainly in males, and account for 25% of all psychiatric hospital admissions in people ages 10 to 18 (Abidi et al., 2017). Approximately 90% of the individuals treated for Schizophrenia are between the ages of 15 and 55 years old, with the peak ages of onset being 10 to 25 years old for men and 25 to 35 years for women (Sadock & Sadock, 2015). According to Sadock & Sadock, 2015, the onset of the disease is rare before ten years of age and after 60; late-onset Schizophrenia occurs after 45 years.
How the Disorder Affects the Brain
Multiple theories have determined that Schizophrenia can be caused by genetic factors, perinatal complications, and altered synaptogenesis (McCutcheon, 2020). Studies report that Schizophrenia or related symptoms are at a greater rate among biological relatives and the kinship of the relationship to the individual (Sadock & Sadock, 2015). It is reported that Schizophrenia results from too much dopaminergic activity with a concentration in the amygdala, decreased density of dopamine transporter, and an elevated amount of dopamine type 4 receptors in the entorhinal cortex, causing positive psychotic symptoms (Sadock & Sadock, 2015).
Another biochemical factor affecting the patient with Schizophrenia is elevated levels of serotonin, norepinephrine, and lower amino acid neurotransmitter r-aminobutyric acid (GABA), which decrease GABAergic neurons in the hippocampus (Sadock & Sadock, 2015). Alterations in neuropeptides and excess glutamate may cause the development of psychosis. Acetylcholine and nicotine in postmortem studies show a decrease in muscarinic and nicotine receptors in the hippocampus, select areas in the prefrontal cortex, and the caudate-putamen, all involved in cognition (Sadock & Sadock, 2015).
In Schizophrenia, Computed Tomography (CT) shows lateral and third ventricular enlargement, reduced volumes of cortical gray matter, and reduced symmetry in multiple brain areas, including occipital, temporal, and frontal lobes (Sadock & Sadock, 2015). Within the limbic system, the hippocampus is smaller, and there is a disruption in the glutamate transmission in Schizophrenic patients (Sadock & Sadock, 2015). The thalamus shows volume shrinkages, particularly in the subnuclei, there is a dysfunction in the prefrontal cortex, a decrease in the basal ganglia, and a decrease in blood flow in the cerebellum helps with memory, attention, emotion, and social cognition.
Spectrum of the Disorder
Symptomology
Symptomology in Schizophrenia can be present in other psychiatric and neurological disorders. The clinician needs to thoroughly review the symptoms during a period and evaluate the patient’s intellect, educational level, and cultural and subcultural factors (Sadock & Sadock, 2015). Beginning signs and symptoms of the disorder may have specific attributes that patients with schizotypal or schizoid personality disorders possess. They may be submissive, reserved, and withdrawn, not having many friends. A patient may initially become somatic, complaining of headaches and weakness. The patient may not be active in social, occupational, or personal activities. They may undergo a curiosity for philosophy, religious, or occult inquiries, leading them to have bizarre emotional experiences, unique behaviors, and abnormal affect (Sadock & Sadock, 2015).
A patient with Schizophrenia may present with agitated, combative, or violence depending on their response to their hallucinations. These hallucinations can be visual, auditory, olfactory, tactile, and gustatory. The patient may be disheveled, poorly groomed, and dressed in multiple layers. A schizophrenic patient may be talkative, have odd tics or behaviors, mannerisms, or catatonic, which can seem lifeless- unable to speak with waxy flexibility (Sadock & Sadock, 2015). Some patients with Schizophrenia may become impulsive, agitated, suicidal, or homicidal due to their command hallucinations, and the untreated patient can become violent and may need emergency medications to prevent hurting themselves or others (Sadock & Sadock, 2015).
According to DSM-V 2013, after a year of Schizophrenia, the first episode, which is currently an acute episode, is the first indication describing the symptoms and time criteria(American Psychiatric Associations, 2013). The first episode, currently in partial remission, is when an improvement after a prior episode is sustained, and only a portion of the criteria has been fulfilled (American Psychiatric Associations, 2013). In the first episode, currently in complete remission, the individual prior to the previous episode in which the patient has no symptoms (American Psychiatric Associations, 2013). In order for the patient to fall under the criteria of multiple episodes currently in acute episodes, multiple episodes of symptoms may be determined after an initial episode, remission, and which includes at least one relapse (American Psychiatric Associations, 2013). After that, the DSM-V explains further multiple episodes in total, partial remission, continuous, unspecified, and specified with the diagnosis of catatonia (American Psychiatric Associations, 2013). The DSM-V also explains how to specify the severity of the symptoms rated for current severity considered severe in the last seven days on a five-point scale ranging from zero to four present or severe (American Psychiatric Associations, 2013).
Type of Disorders
Catatonic
According to DSM-V, 2013, patients with catatonia have at least three or more of twelve psychomotor features, which may show decreased motor activity, reduced engagement during a psychiatric evaluation, or extreme and unique motor activity (American Psychiatric Associations, 2013). The patient may display some psychomotor activities and unresponsiveness to agitation (American Psychiatric Associations,2013). The patient’s motor activity may be severe (stupor) to moderate (catalepsy and waxy flexibility) with mutism or negativism (American Psychiatric Associations, 2013). In the diagnosis of catatonia, the patient may need to be observed for self-harm or harming others, hyperpyrexia, exhaustion, self-injurious behavior, and self-inflicted injury (American Psychiatric Associations, 2013).
Disorganized
The patient with a disorganized type of Schizophrenia may be described as noticeably disinhibited, unorganized, and with marked regression. Disorganized patients are disheveled, with the bizarre behavior of grinning and grimacing, with social and behavioral responses that are irrational at times. Eye contact is poor, their association with reality is low, and they have an aimless, nonconstructive demeanor (Sadock & Sadock, 2015).
Paranoid
Preoccupations portray patients with Paranoid Type Schizophrenia with one or more delusions of recurrent auditory hallucinations, which may be persecutory or grandeur (Sadock & Sadock, 2015). Patients with Paranoid Schizophrenia may have their first episode later in age and may show less of a lapse in their lucidness, emotional responses, and demeanor than other patients with another form of Schizophrenia (Sadock & Sadock, 2015). These patients usually are guarded, mistrustful, tense, cautious, and may be contentious or aggressive (Sadock & Sadock, 2015).
Residual & Undifferentiated
Patients with residual Schizophrenia may have emotional blunting, illogical thinking, social withdrawal, and bizarre behavior showing lasting confirmation of schizophrenic disorder (Sadock & Sadock, 2015). Patients who do not fit into a specific type of Schizophrenia may be diagnosed with an Undifferentiated type (Sadock & Sadock, 2015).
Schizoaffective Disorder
Schizoaffective disorder is when an individual is experiencing the symptoms of Schizophrenia like disorganized thinking, delusions, and hallucinations, along with symptoms such as depression and mania (Sadock & Sadock, 2015).
Associated Co-morbidities
Some associated comorbidities with a patient who has Schizophrenia are obesity, diabetes mellitus, and cardiovascular disease. Patients with Schizophrenia may be obese due to poor diet and the effects of antipsychotic medication. As a result, the patient will have decreased motor activity, increasing their chances of diabetes mellitus and cardiovascular disease. Patients with Schizophrenia also have 1.5 to 2 times an increased risk of HIV infection than the general population (Sadock & Sadock, 2015). Other risks for Schizophrenia patients are chronic obstructive pulmonary disease due to their increased prevalence of smoking and rheumatoid arthritis found in one-third of the population (Sadock & Sadock, 2015). According to Sadock & Sadock, 2015 the significance of rheumatoid arthritis is unknown to this population.
Treatment for Schizophrenia
The treatment of choice for individuals diagnosed with Schizophrenia is atypical antipsychotics: serotonin-dopamine antagonists like olanzapine, risperidone, ziprasidone, quetiapine, and aripiprazole (Sadock & Sadock, 2015). Atypical antipsychotics block binding to dopamine receptors to a lower extent, making it less possible to produce movement disorders (Sadock & Sadock, 2015). Atypical antipsychotics have fewer extrapyramidal side effects than first-generation drugs but may cause lipid elevation, diabetes, and weight gain (Sadock & Sadock, 2015).
Typical antipsychotic medications are dopamine receptor antagonists (DRAs), which block cholinergic, histaminergic, and noradrenergic receptors (Sadock & Sadock, 2015). Some first-generation antipsychotics are perphenazine, molindone, chlorpromazine, and haloperidol (Sadock & Sadock, 2015). Some advantages of taking DRAs are decreased risk of causing metabolic abnormalities, but unfortunately, DRAs may cause extrapyramidal syndromes (EPSs) (Sadock & Sadock, 2015). Contraindications for using DRAs include a history of a severe allergic reaction, high risk of seizure, severe cardiac abnormality, a patient who has prostatic hypertrophy or narrow-angle glaucoma, and finally, the history of tardive dyskinesia (Sadock & Sadock, 2015).
Antipsychotic medication decreases the acute phase’s positive symptoms, usually lasting from 4 to 8 weeks (Sadock & Sadock, 2015). Maintenance treatment with antipsychotics can last 1 to 2 years after the first psychotic episode and can continue for five years after the first episode (Sadock & Sadock, 2015). Treatment-resistant patients show good responses when taking Clozapine after multiple failed trials on DRAs (Sadock & Sadock, 2015).
Patient Selected with Schizophrenia
The selected patient was a 66-year-old female L.M. with a diagnosis of Schizophrenia that was in for a follow-up appointment. Her family brought her to the clinic for decompensation two months ago for psychiatric evaluation. The family stated that the patient’s Psychiatrist had retired, and she ran out of medication. L.M. presented with bizarre behavior that had been occurring for over a month. The family stated that she had not been showering for two weeks and had not been going outside of her home for one month because she believed the Federal Bureau of Investigation (FBI) was after her. The family says she would sometimes barricade herself with her youngest son inside the home. The family also reported that she has been saying for over one month that the television and radio have been telling her that the FBI is going to implant a chip in her brain.
L.M. was started onOlanzapine 5 mg at bedtime and started Cognitive Behavioral Therapy. L.M. returned to multiple office visits, and two months later, she reported that she has been taking her medication every night and keeping up daily with activities of daily living. The patient reported that her therapy has been effective. L.M. had a bright affect, and was clean and appropriately dressed during the follow-up appointment, denying any paranoia or auditory hallucinations. L.M. said it helps her identify and change her distorted thinking that the television and the radio were sending her messages and that the FBI was trying to implant a chip in her brain. The patient also established different explanations of schizophrenia symptoms and ways to cope with feelings through role play.
Patients seen at La Mente Behavioral Health
During my clinical rotation at La Mente Behavioral Health, the percentage of patients seen with Schizophrenia is approximately 20 %. During my observation, the youngest patient with the disorder was 22 years old, and the eldest was 72 years old. There have been more males seen with this disorder than females. The treatment of choice for these patients are atypical antipsychotics and Cognitive Behavioral Therapy. With medication and therapy, these patients have minimized symptoms and functional impairments. One individual seen in the clinic with a diagnosis of Schizophrenia was hospitalized for a prolonged period due to being non-compliant with the medication regimen and using methamphetamines. The Psychiatrist is currently seeing the patient in the hospital to treat his substance use disorder and symptomology.
Clinical Guidelines for Schizophrenia
American Psychiatric Association (APA)
According to Keepers et al., 2021, the American Psychiatric Association (APA) recommends an initial assessment that includes psychiatric treatment history, suicidal history, aggressive behaviors, and physical health. Evaluation should consist of cultural and psychosocial factors when evaluated. Guidelines should also have the patient’s trauma history, physical fitness, substance abuse issues, goals, and choices for treatment needs to be assessed (Keepers et al., 2021). In pharmacotherapy with patients who have Schizophrenia, the APA recommends the individual be medicated with antipsychotics, with close monitoring of side effects and effectiveness (Keepers et al., 2021). The patient should continue on that regimen for individuals whose symptomology has improved with antipsychotics.
In patients with Schizophrenia, the psychosocial intervention that the APA recommends in their first episode of psychosis is treated in a specialty care program (Keepers et al., 2021). The patient with a diagnosis of Schizophrenia should be treated with cognitive-behavioral therapy, receive psychoeducation, and receive supported employment services (Keepers et al., 2021). Patients who have poor engagement with services and have frequent relapses need to receive assertive community treatment (Keepers et al., 2021). Family intervention programs could benefit other patients with family involvement (Keepers et al., 2021). APA also finds that the patient diagnosed with Schizophrenia receives supportive psychotherapy, therapeutic goals for social skills training, cognitive remediation, and interventions to develop person-oriented recovery and self-management skills (Keepers et al., 2021).
Korean Medication Algorithm
In 2019 the Korean Medication Algorithm for Schizophrenia released revisions to be used in clinical situations, which consists of five stages (Lee et al., 2020). Stage one guidelines suggest starting with a second-generation antipsychotic, where monotherapy is suggested. This study reported that risperidone was favored at 29.9%, aripiprazole at 28.4%, olanzapine at 16.4%, and paliperidone at 14.9% efficacy in second-generation antipsychotic monotherapy (Lee et al., 2020). At stage two, if a particular second-generation antipsychotic (SGA) is not tried in stage one or a first-generation antipsychotic (FGA) with no response to a single trial of SGA or FGA continues to stage three (Lee et al., 2020).
For patients that continue to stage three, clozapine monotherapy is the treatment of choice, with a high percentage of individuals being satisfied with this treatment (Lee et al., 2020). The only opposition during the treatment of clozapine was the resistance to testing clozapine levels at 52.2% (Lee et al., 2020). In individuals that were not successful in clozapine therapy, stage four recommends combination therapy of clozapine with a combination of SGA, mood stabilizers, electroconvulsive therapy, or long-acting injectable antipsychotics (Lee et al., 2020). Lee et al. (2020) had the highest success with a combination of clozapine with second-generation antipsychotics. Stage five is recommended for treatment-resistant patients who have no treatment to take combination therapies of SGA with FGA, different combinations of SGAs, electroconvulsive therapy with SGA and FGA, or FGA with SGA combined with a mood stabilizer or antidepressant (Lee et al., 2020).
For patients that were not compliant with medications or had no treatment response with stages one through five, a long-lasting injectable antipsychotic was recommended at the clinician’s discretion (Lee et al., 2020). Some of the limitations of the study were established on Korean experts instead of experimental evidence, and the sample of 69 providers was not sufficient enough for the 4,525 psychiatrists in South Korea (Lee et al., 2020).
Canadian Schizophrenia Guidelines
The Canadian Psychiatric Association’s recommendations were pulled from many sources of pharmacological interventions for children until 18 years old using evidence-based randomized control trials (Abidi et al., 2017). The guidelines were used following the first phase of the ADAPTE process consisting of three phases: set-up, adaptation, and finalization(Abidi et al., 2017). The first recommendation is that early identification of the psychotic symptoms to decrease the period of untreated psychosis is necessary for improved positive outcomes (Abidi et al., 2017).
Recommendations two thru nine provide education on starting antipsychotic medication in young people with psychotic symptoms and educate the family on the decisions the start such medication, possible side effects, health risks of the medication, and instilling a biopsychosocial management plan (Abidi et al., 2017). Recommendations for these individuals when starting antipsychotic medications simultaneously with psychological and psychosocial interventions to treat the initial episode of psychosis (Abidi et al., 2017). Education on age-appropriate information on the benefits and possible side effects; the need for an electrocardiogram before starting antipsychotics and nonprescribed therapy. The article also discusses the need to speak with the patient about using prescription, nonprescription medication, tobacco, cannabis, and alcohol and the possibility that certain drugs exacerbate psychotic symptoms (Abidi et al., 2017).
The article provided education on educating the patient and guardians by reviewing antipsychotic medications regularly, the impact of an acute episode on a young person and plans for recovery, and the risk of relapse if the mediation is stopped one to two years after an acute episode (Abidi et al., 2017). The Canadian Psychiatric Association’s recommendations are to discontinue or taper antipsychotic mediations gradually while monitoring for signs and symptoms of deterioration for at least two years(Abidi et al., 2017). In subsequent acute episodes of psychosis or Schizophrenia, antipsychotic medication and psychological interventions like cognitive behavioral therapy should be started (Abidi et al., 2017). Routine and constant monitoring practices should be implemented once prescribing antipsychotic medications (Abidi et al., 2017). Aripiprazole has been approved for patients under the age of 18 years with the diagnosis of Schizophrenia, and Clozapine is offered for those who have not responded to at least two different SGA or FGA used for 6 to 8 weeks (Abidi et al., 2017). The Canadian Psychiatric Association’s recommendations provided thorough insight into how to educate patient who is starting antipsychotics and how to educate them on medication management, side effects, titration, and psychological interventions. Unfortunately, it did not provide information on which medications worked, the rationale for using them, and how the clinician made changes, if any, during the treatment of a patient with Schizophrenia.
Treatment Guideline Selected in Clinical Practice
The treatment guideline I would use in my clinical practice is the American Psychiatric Association (APA). It provided a more complex combination of information from the other two guidelines that were lacking. As a clinician, a thorough evaluation of the patient’s history, trauma, and current symptoms is needed to evaluate to make appropriate interventions. The APA recommends that the treatment plan be developed and personalized once the patient is diagnosed for the individual’s previous treatment responses, tolerability or adherence, and any health concerns (Keepers et al., 2021). The only information I would have liked to see was what medications they recommend when treating a patient. It specifies that the FGAs and SGAs have limited clinical trial data, and depending on the medication prescribed, the clinician’s preference depends on the efficacy or the side effects on the patient. I would have like to see an algorithm like the one provided in the article Korean medication algorithm for Schizophrenia.
Multiple studies were reviewed on Cognitive Behavioral Therapy with patients with the diagnosis of Schizophrenia and the use of the ABC model on how the patient experiences visual and auditory hallucinations. The Canadian Journal of Psychiatry article provided great information for children and adolescents with Schizophrenia. Overall, all three guidelines provided different ways of caring for the patient diagnosed with Schizophrenia.
Korean Medication Algorithm for Schizophrenia 2019, Second Revision: Treatment of Psychotic Symptoms (Lee et al., 2020).
Cognitive Behavioral Therapy in Treatment of Schizophrenia (Kart et al., 2021)
References
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