Psychopharmocology: Psychotic Disorders
Psychopharmacology: Psychotic disorders
Accepted psychological and biological theories regarding the causes of each disorder
Psychosis is an undefined syndrome that manifests in delusions, bizarre behavior, hallucinations, losing touch with reality. The condition is attributed to a variety of conditions including primary psychiatric complications and medical complications such as dementia, central lobe epilepsy, Schizophrenia and related disorders, medical complications, abnormalities in metabolism, endocrine and neurologic disease. It also includes drug and substance abuse complications. Common among the substances abused are hallucinogens and amphetamines. The most common primary psychosis is schizophrenia. This disorder is a severe one. It begins sometime around adolescence or in the early stage of adulthood. Although the onset tends to manifest a later among women, the occurrence of the condition seems evenly spread across the gender divide. Surveys in epidemiology demonstrate that 0.4% of the disorder is characterized by critical disorders in thinking patterns and perception. Inappropriate emotions are also prevalent. The disorder affects primary functions that serve to endow one with the feeling of uniqueness, self-direction and individuality (Werbeloff, Dohrenwend, Yoffe, Davidson, & Weiser 2015). There is likely to be a serious change of behavior in some stages of the disorder. Such interference often triggers undesirable social effects. Delusions and hallucinations are common features of psychotic disorder. Schizophrenic people are well-oriented to places, time and people. The disorder pursues a variable trend and about one third of its cases recover fully from the disorder. The condition can also follow a recurrent course and may leave residual symptoms and incomplete recovery on the social front. In the past, schizophrenic patients formed a significant portion of patients in mental institutions in the past. Actually, they are still many in places where such institutions still exist. Owing to the advances in medical health, drug therapy practices and psychosocial care, nearly half of all patients that develop schizophrenia recover from the condition fully. In the other half only one fifth of victims still face serious limitations in running their daily routines (Solem et al., 2015).
It should be noted that even after the externally obvious symptoms of the disorder have subsided, residual symptoms continue to exist in the background. Such symptoms include lack of interest in work or initiative in daily activities. Others include remaining socially incompetent and being unable to participate in pleasurable, normative activities. Such reaction leads to a poor quality of life and sustained disability. This is obviously a burden to the family and friends of the victim. Therefore, workers in health care should, consider the role of culture and spirituality in the occurrence of schizophrenia in provision of primary health care. Psychiatric symptoms are expressed differently in different cultures. Some even use metaphors. There is need in such circumstances where the health care professional is limited in the language of the victim to use interpreters to explain the symptoms. Additionally, some symptoms of psychiatric disorder-like symptoms may be considered normal in some cultures. Hearing voices is an example of such symptoms. There should be careful evaluation not to avoid misinterpretation (WHO, 2009).
Medications used in treatment of psychiatric disorders and their mode of action
Modern practice recommends the use of a single antipsychotic at a time. Simultaneous use of antipsychotics may complicate a patient’s condition and has no benefit. High doses of these medications should be avoided because they are known to trigger adverse reactions and still provide no substantial benefits. It is a standard recommended practice to begin with small doses and increase as you go. There should be a clear definition of the minimum prescribed dosage. Long-term psychotics should be used only if the problem is critical and persistent. Normally there is need to administer a test dose of a long acting formula such as 12.5mg of fluphenazine decanoate given as an intramuscular prescribed dosage. Following the first administration, the dosage is titrated after 4 to 10 days to sustain effective maintenance therapy. The health expert could give between 12.5 to 5.0mg of intramuscular fluphenazine decanoate after every 2-4 weeks.
Moving from the use of one psychotic drug to the next one should be done with utmost care. The first dose should be systematically reduced in a gradual manner as the dose of the second one is increased. Patients that do not show progress; even after using sufficient doses of two psychotics are normally given Clozapine . Prior to the administration of Clozapine, several classes of antipsychotics are prescribed. Once the use of Clozapine has commenced, the effectiveness of treatment should be scrutinized for six months. Prescription of this medication without monitoring white blood cells may heighten the risk of fatal agranulocytosis (Stroup et al., 2015).
Once the serious episode has subsided, it is recommended that the treatment continues for at least a year. If that is not done, two thirds of patients regress back to chronic condition within a year. So far, no reliable strategy has been evolved to know the minimum dose that should be used to avoid relapse. In the course of long-term treatment, health care providers may either maintain or decrease the dose used during the acute phase moderately; depending on the condition and the prevailing clinical status. Sticking to treatment may be a long-term problem. In such circumstances, the heath care experts should consult with the patient and their family on the option of using long acting psychotics. Other strategies include patient education, educating the family about psychotherapy and some specified interventions in psychotherapy. A weekly white cell blood count is done for 18 weeks in some countries in cases where Clozapine is in use. This happens at least every two weeks through the year. If such checks are not possible, Clozapine should never be administered (Carpenter & Buchanan, 2015).
The side effects of antipsychotics are classified in two groups. There are the anticholinergic side effects and neurologic ones. The latter include parkinsoan symptoms which entail akinesia, rigidity and resting tremor. They also involve acute dystonias, akathisia, neuroleptic malignant syndrome, tardive dyskinesia and even convulsions. Anticholinergic side effects include blurred vision, dry mouth, urine retention and constipation. They also include severe agitation and frequent confusion. In case the patient develops parkinson effects, the expert should reduce the antipsychotic dose. If these effects persist, the health provider should consider administering using antiparkinsoan agents, e.g. 2-4 mg of biperiden per day. The side effects that are known to be a result of the use of second generation antipsychotics include, ketoacidosis, diabetes, hyperglycaemia and lipid dysregulation. Olanzapine and Clozapine are associated with the highest risk of weigh gain, dyslipidaemia and diabetes mellitus. The antipsychotic metabolic complications are a major cause of worry because they are risk factors in the occurrence of cardiovascular mortality and morbidity. More side effects associated with the use of antipsychotics include weight gain, orthostatic hypothension, electrocardiogram abnormalities, sedation, increased prolactin leading to galactorrhea, impotence, jaundice, elevated liver enzymes, agranulocytosis, photosensitivity, leukopenia, skin eruptions, amenorrhea, gynecomastia, retinal pigmentation. The use of Clozaoine causes significant life endangering effects; agranulocytosis is the best known among them. Clozapine use poses 10 times higher risk of Agranulocytosis than other drugs do. Monitoring blood count can help manage the use of Clozapine. The drug is also linked to, cardio-myopathy and myocarditis and pulmunary embolism (Maciukiewicz, Sriretnakumar, & Muller, 2016).
Process you would go through when seeing a patient with one of these disorders, including how you would make a differential diagnosis, conditions you would want to rule out, and how you would make decisions about treatment
The healthcare experts should investigate the possibility that the psychotic disorder could have been a result of substance abuse or organic illness. A detailed background check and assessment of the patients’ psychiatric history should be done. In situations where psychosis is a result of a medical problem, the underlying condition should be treated. Attention should also be paid to the adjunctive management of behavioral problems. If substance abuse is cited, detoxification should be prioritized. This should be accompanied with adjustment of medication. Acute schizophrenia needs o be evaluated at the earliest opportunity. Family members are useful in cases of uncooperativeness, a common tendency among this group. Health care experts should extract as much information as possible from credible sources. Trends in sleeping patterns, daily routine, and speech should be probed. The possibility of self-injury as a patients considerations should be checked too (Miller, Mednick, McGlashan, Libiger, & Johannessen, 2012).
Although patients may attempt suicide at any point as an outcome of experiencing psychotic complications, there is a higher possibility of such an eventuality when there are acute psychotic exacerbations. This is the time when the patient responds to delusions or hallucinations. The risk is also heightened during the weeks or after acute exacerbations. It is essential to intervene early in schizophrenia illness because of the positive relationship between the untreated period and the long-term treatment results. Some of the specific interventions include educating the family about psychosis, employment support, awareness about the management of illness, training in social skills, integrated handling of substance abuse issues and cognitive behavioral therapy practices. Schizophrenic patients should be provided with psychosocial intervention to complement pharmacological intervention (Chuanyue, 2015).
The objective of the above practices is to reduce severe symptoms. Antipsychotic agents should be used in the management of schizophrenia and similar disorders. The agents have a proven effectiveness against schizophrenia symptoms. Their effect on residual symptoms is disappointingly low or even absent.
Antipsychotic therapy should only be stated after checking blood pressure and weight. More monitoring strategies include electrocardiogram, liver function test, full blood count, creatinine phosphokinase, lipid pattern and prolactin, urea electrolytes and blood glucose checks. Clozapine patients should be checked for blood count.
Clinical practice classifies antipsychotic agents into first generation antipsychotics and second generation antipsychotics. Antipsychotics in the first generation are grouped into phenothiazines; a class that includes a host of antipsychotic formulas such as pipotiazine, promazine, levomepromazine, pericyazine among others.
Second generation types include sertindole, risperidone, ziprasidone, olanzapine, quetiapine and zotepine; to mention a few. Both classes of drugs are effective in treating psychotic symptoms (Lutgens et al., 2015).
The two classes mentioned above differ remarkably when it comes to the side effects. WHO EML recommends essential drugs for the treatment of schizophrenia and similar psychotic disorders as haloperidol, fluphenazine chlorpromazine, fluphenazine decanoate or enantate. They are clearly proven effective drugs in the treatment of the disorders and safety. Health care experts should consider oral administration of antipsychotics in acute schizophrenia cases. If there is a choice to make among several available antipsychotics, the decision should be based on 1. Whether it is included in the WHO EML;
2.The patient’s history of responsiveness to antipsychotics. If the response has been positive to a specific agent, then the agent should be the choice. If the response was bad, a different agent should be used;
3. Adherence to treatment. If it was poor, long-term acting agents should be considered;
4. Cormobidities; if there is evidence of a patient suffering from medical problems of a specific type, some of the agents may not be appropriate. For instance, thioridazine should be ruled out in cases of elederly patients suffering from electrocardiogram complications. If a patient has glucose issues, clozapine and olanzapine should only be used cautiously;
5. Subjecte effect of adverse reactions should be checked. Providers should explore such effects with the patient and family members. For instance, the effect of weight gain and its relevance may vary between males and females; depending on the culture of each;
6.Cost effects. This aspect may vary according to the facility in which the antipsychotics and service are provided;
7. Old/New agent. It is a wise thing to prescribe medications that are well-known. This is a general rule in the practice of health care. The side effects of drugs only manifest after some time. Some take years to manifest (Solem et al., 2015).
The treatment must be monitored and the effect assessed within a period of 6-8 weeks. If no meaningful improvement is noticed, the patient, the health care provider must sit, discuss, and decide whether to switch to another oral antipsychotic. If adhering to the treatment is a major issue, then the health care provider, the family members and the patient must look into the possibility of switching to a long- acting preparation.
If the patient reacts to the treatment, the health care provider should discuss with the patient and the family members and decrease the dose. If after reducing the dosage, the adverse reaction persists, it may be necessary to switch to a different antipsychotic because it could lead to life threatening effects associated with agranulocytosis. To control the acute psychotic symptoms, the provider should resort to intramuscular treatment if the oral treatment is not practicable. WHO, EML essential medicines are haloperidol injection (e.g. 5 mg intramuscular) or chlorpromazine injection (e.g. 25 mg intramuscular). After administering the intramuscular antipsychotic, the provider should monitor the blood pressure, the body temperature, the respiratory rate, and the pulse. In addition, other than pharmacological and non-pharmacological intervention, the health care provider must provide information to both the patient and the family members after listening and give a psychological support and reassurance. This is important since it helps to develop a good relationship and offer a therapeutic alliance that may positively influence the patient’s well-being and a lasting solution to the problem of the disorder.
Psychotic symptoms may include hallucination, delusion, illogical ideas, bizarre behavior, and deficiencies in speech, thought blocking, incoherence in thought association, neologisms. This may effectively be treated using antipsychotic medicine. The effectiveness of the treatment should be assessed after 6- 8 weeks to determine whether the acute episode has been resolved or not. Health care providers may need to prolong the treatment for at least a year. (Miller etal, 2012).
Psychopharmacological interventions that are commonly used for major DSM classifications.
In the past 25 years, DSM system and psychopharmacology has been evolving and currently have a strong influence on each other. The psychopharmacological revolution necessitated that there should be a method of systematic and reliable psychiatric diagnosis that provides the impetus for the research diagnostic criteria and development of structural assessment that were forerunners of DSM-III. The availability of well-defined psychiatric diagnoses is intended to stimulate the development of the specific treatment while the DSM-IV will influence the future revisions. The development of the DSM-IV and ways of addressing several issues in psychiatrics nosology including descriptive, reliability, diagnosis, validity, heuristic values of the current classification is important. It entails interacting with psychopharmacological research. So far, the changes in the DSM-5 classification affects the decision making process and assists in choosing the medications. It focuses on the solving the problem by differentiating schizophrenia with mood symptoms, bipolar disorder, schizoaffective disorder with psychosis. According to the Harvard South shore program, there is evidence of the derived algorithms for the schizophrenia, bipolar disorder, and pharmacotherapy.
The DSM-5 patients showing the mood symptoms will have to meet the criteria for schizophrenia as recommended by the algorithm in the use of mood stabilizers and antidepressants (David, 2013). A new version of diagnostic and Statistical manual of mental disorder was released in May 2013 (American Psychiatric Association 2013), and was presented to the annual congress of APA meeting. The publication was preceded by about 10 years of work that had brought together both Americans and international experts.
The DSM diagnostic system is therefore used in psychiatric care research in the U.S.A. Also, DSM-5 will have an important role to play in the revision of the psychiatric classification published by the WHO as well as the ICD (international classification of diseases). The system plays an important role in collecting statistics in health care and statistics in many countries of the world.
The preparation is advanced and the revised version, ICD-11 may not be featured until late in the 2017. This is because of the delay caused bureaucratic hurdles in the decision making process. The ICD — 11 will however correlate with the DSM-5 system. DSM-IV was compared with DSM-5 to help identify any changes in the psychiatric diagnosis and the consequences for psych pharmacotherapy. DSM-5 did not make changes but moved towards dimensional diagnosis and was preserved in the previous primary symptom- based descriptive and categorical system approach. The reason why the dimensional approach was adopted was that it was possible to adopt it through transnosological specifiers and gives one an opportunity to make syndrome- or symptom made assessment. The criteria such as dependence, effective and schizophrenic were changed to allow the inclusion of other new disorders (Moller 2014).
Differentiating the medical conditions and medications that stimulates psychiatric disorder
In the American psychiatric Association Diagnostic and Statistical manual of mental Disorders ( DSM-5 Fifth Edition). Many psychiatrists have identified a number of patients with a factitious disorder and have grouped them as those suffering from Munchhausen’s syndrome. Factitious disorder are among the somatic symptom related to somatic symptoms that remains dominant in both cases but often encountered in medical settings. The factitious disorder imposed is only but a falsification of illness manifestation in another person. It is done by the caregivers to their patients. The patients at times become the responsibility of the surgical or medical clinics. However, it is noted that the disorder is always a complex mental problem that is more serious than the dishonest simulation of the symptoms. It is mostly associated with emotional difficulties. Initially, the disorder used to be referred to as Munchausen syndrome or factitious disorder by proxy. The factitious disorder imposed by third parties (caregivers including the parents), one that is falsified or the one that is intentionally imposed or psychological symptoms and signs in the person who is under their care (child) rather than the one that is caused by themselves. The caregiver intentionally falsifies the history and may end up injuring the child with drugs or add bacterial contaminants to urine specimen or blood so as to simulate diseases. When this happens, the caregiver may help the child seek medical care to demonstrate that he is protective and deeply concerned. The child suffers from frequent hospitalization for no specified symptoms and no firm diagnosis. The child may become seriously ill and may eventually die.
Normally, treatment is always challenging and there is no clear, effective treatment. The patient may obtain relief if their treatment demand is met but may escalate the treatment beyond what the physicians are able to accommodate. If the treatment demands are not met, it may lead to angry reactions making the patient to move from hospital to hospital or from one physician to another (peregrination). Thus, if the disorder is identified earlier, own and psychiatric or psychological consultation is sought early, it helps to avoid the risky surgical procedure and invasive testing as well as unwarranted use of drugs. Diagnosis will normally be based on examination and history alongside other tests excluding physical disorder that exaggerates and fabricates induction, fabrication, simulation, and physical symptoms.
Non-punitive, nonaggressive, and non-confrontational approach should be used to present the diagnosis of factious disorder to all patients. To reduce guilt or reproach, the physician may present the diagnosis and seek help. In some cases, experts recommend that in such cases, mental treatment may be offered without the need of having the patient admit his role in causing illness. In either case, assuring the patient that he can cooperate with the physician to resolve the problem may be helpful.
Discriminate issues on diversity and culture which is relevant to pharmacological treatment
Several studies have established that ethnic density may affect the psychotic disorder. Ethnic minorities’ incidences may increase the disorder while the neighborhood proportional ethnic composition may actually decrease the disorder. It has been demonstrated that there is always a high rate of psychotic disorders in countries with diverse ethnic compositions such as United Kingdom, and USA. The difference could be six times as much as the majority population; hence it has been described as epidemic even though there is no evidence of genetic basis. The variation in prevalence between the ethnic group supports the socio- environment hypothesis in aetiology of psychosis. The cause of this difference has been the subject in a number of debates and it has been argued that the difference is caused by misdiagnosis of ethnic minorities due to cultural stereotypes and institutional racism. There is evidence that people from ethnic minorities are likely to access services through the justice system and may compulsorily get admitted to a hospital. However, recent evidence suggests that this may not be sufficient to account for the disparity between the ethnic majority and the ethnic minority. Research shows that there is an elevated rate of psychotic disorder in ethnic minorities despite the standardized procedures used in assessing symptoms but which ignores ethnicity (Bosqui Hoy & Shannon,2013).
This shows that the high prevalent rate does not just result from institutional racism and that the rate reflects the real phenomenon. It has been suggested that the proportion of ethnic minority is one of the factors that act as a buffer against the influences. Historically, many ethnic minorities are clustered in the neighborhoods because of the discriminatory systems that force the ethnic minorities to live in low quality housing. Other factors such as protective function from racial abuse, sharing of cultural aspects, language, religious values with the neighbors, and enhanced social support are believed to lead to this development. Where there is no association between the prevalence of the psychotic disorder and the size of the local ethnic group in relation to the total population, there is always some effect.
Therefore, the proportion of the ethnic group that lives in an area is always inversely related to number of members that suffer from psychosis disorder. This Phenomenon is referred to as ethnic density effect (Termorshuizen, Smeets, Braam, & Veling, 2014). In areas that have less ethnic density, the risk is found to be 5 times greater than that found in areas with the majority white population. This shows a considerable influence on the risk of one developing a psychotic disorder.
Research on pharmacological management of the psychiatric disorder
Maintaining antipsychotic therapy is important in preventing relapse. Depot preparation is thought to successfully prevent covert non- adherence and is believed to improve the patient’s condition. The objective is for one to evaluate how the patient adheres to medication and how it determines treatment of psychosis patients. Psychotic disorder treatment aims at obtaining a functional remission while minimizing relapse. Relapse is known to be caused by non-adherence to medication. When there is non-adherence to oral antipsychotic treatment, it makes the psychiatrists switch to injectable risperidone. Understanding the factors that leads to poor medication adherence helps the physicians to manage their patients in a better way and helps to improve their outcome (Bayle et al., 2015). Guidelines on how to apply the evidence-based practices (EBP) places emphasizes on the clinical expertise with the patient values, empirical evidence and preference in selecting and implementing the treatment. The preference of the patient becomes important and helps in guiding treatment decision in cases of psychiatric disorder especially where both psychological and pharmacological treatment shows efficacy especially where there is no evidence-based decision. This may refer to choosing treatment that is based on the patients’ socio demographic and clinical characteristics. The patients’ preference may inform the policy level decision on how the resources should be allocated. It may include funding and training on how to treat disorders without choosing between efficacy and cost. The patient preference may in a way influence the outcomes. Evidence shows that when the patient is provided with the preferred treatment, it leads to better treatment retention as well as better clinical outcome (McHugh, Whitton, Peckham, Welge, & Otto, 2013).
Evaluating, incorporating and demonstrating ethical behavior in accordance with the emerging technologies that are applicable to psychology
Psychotropics have now become the most commonly prescribed medications. There is an improved use of the agent that has helped to improve the lives of millions of people living with the mental disorders. Reliance on the psychotropic has resulted in ethical and societal concerns. Amongst the concerns are the risks associated with pharmacological interventions that includes paradoxical finding in depressed children, who are taking antidepressant drugs that may lead to increased risks of suicidal behavior relative to those receiving placebo.
In addition, there are possible metabolic effects such as diabetes, hyperglycemia diabetes that are associated with antipsychotics. The widespread application (over prescription) of the medication is also causing concern. Here too, there is a controversy because it is thought that the non-psychiatric providers are the main source of psychotropic prescriptions in the U.S. Not everyone agrees that cosmetic psychopharmacology is unethical and there are issues with cosmetic plastic surgery used for physical enhancement.
New ethical issues have arisen from the use of psychotropics (eg stimulants) used for cognitive performance enhancement of the individuals. Before any patient is put on the psychotropic medication, a careful diagnostic evaluation and review of the patient’s history with regard to how he responds to treatment and previous symptoms is done. Understanding the patient’s concerns, hopes and motivation are all important in helping to develop an appropriate therapeutic strategy that include use of psychopharmacological agents that address the specific target symptoms. The objective is to prescribe psychotropic when it is needed and when there is evidence that it will help. In many cases, combined psychological and biological intervention may be of great therapeutic benefit.
Practitioners who value ethics must therefore update themselves with the empirical findings on psychosocial treatments, keep record of adverse effects, contradictions, and indicate their findings. In addition, clinicians who prescribe medication should be ready to recommend and share data driven psychological intervention and psychotherapies and indicate the first line of treatment or any other adjunctive treatments. The ethical practitioner should be able to engage in a trusting and informed consent dialogue with their respective patients (McHugh et al., 2013)
Selection of reuptake inhibitors in psychopharmacological industry presents a serious moral problem in the world of corporate model medicine. The pharmaceutical companies are obligated morally to disclose and share the information in their possession having considered the risks and the benefits of the drug. This is the only way that the patients will be able to make informed decisions about the treatment they expect.
In addition, this is the time when the moral and scientific integrity of psychopharmacology deserve a very close scrutiny. Pharmaceutical industry has so far created corporate psychiatry together with researchers, direct consumers of the antidepressants, ghost writers of medical journals for their rightful market share. They focus more on marketing the disease and not the cure; Illness intervention that has no commitment to health care threatens the success that has been made so far. Even though, it is expected that the corporations will behave ethically, the way they are doing, given that they are all profit driven, the shareholders demand that they maximize profit and enhance the value of their shares.
The pharmaceutical companies are presenting themselves as responsible producers of the health care products. The products they deal in, require trust in science and ethical commitment to the well-being of their customers and patients. Unfortunately, this is not exactly what the pharmaceutical industry is doing (McHenry et al., 2006).
Bayle, F. J., Tessier, A., Bouju, S., & Misdrahi, D. (2015). Medication adherence in patients with psychotic disorders: an observational survey involving patients before they switch to long-acting injectable risperidone. Patient preference and adherence, 9(1), 1333-1344.
Bosqui, T. J., Hoy, K., & Shannon, C. (2013). A systematic review and meta-analysis of the ethnic density effect in psychotic disorders. Social Psychiatry and Psychiatric Epidemiology, 49(4), 519-529.
Burton, M. C., Warren, M. B., Lapid, M. I., & Bostwick, J. M. (2015). Munchausen syndrome by adult proxy: A review of the literature. Journal of Hospital Medicine, 10(1), 32-35.
Chuanyue, W. (2015). Psychopharmacological treatment for schizophrenia: less is more. Shanghai Archives of Psychiatry, 27(6), 368-370.
Carpenter, W. T., & Buchanan, R. W. (2015). Expanding Therapy With Long-Acting Antipsychotic Medication in Patients With Schizophrenia. JAMA psychiatry, 72(8), 745-746.
David, O. (2013). DSM-5: How do the changes affect decision-making in psychopharmacology. Klinik Psikofarmakoloji Bulteni, 23(1), 57-58.
Lutgens, D., Iyer, S., Joober, R., Brown, T. G., Norman, R., Latimer, E., … & Malla, A. (2015). A five-year randomized parallel and blinded clinical trial of an extended specialized early intervention vs. regular care in the early phase of psychotic disorders: study protocol. BMC psychiatry, 15(1), 1-8.