Psychiatric Assessment and Evidence-Based Treatment

Reason for visit

Today is a month after John was treated for a suicide attempt, John has been brought to the clinic by his parents. According to his parents, John is not; eating well, experiencing insomnia, deteriorating hygiene, talking to himself, and losing weight. He feels that someone is out to harm him and that his food is poisoned. He is aggressive towards his dog, he beats the dog repeatedly during the day. He says life has lost meaning and he wants to end his misery, his parents believe he will hurt himself again.

History of Present Illness/Interval History

The patient is a 19-year-old male (John), a high school dropout, been struggling with mental health issues since he was 17 years. John had a smooth childhood, however, at 13 years he lost his younger brother in an accident. Around 17 years, his demeanor began to change, he became less involved in activities he used to love, withdrew from friends, and became isolated. At 17 years he became more detached from friends and family, and his girlfriend, and began to experiment with marijuana and alcohol.

At 18 years John became paranoid and thought that everyone was against him. He also began to hear voices, see things, and experience feelings that were not real. His parents took him to a therapist who diagnosed him with depression, he was then put on antidepressants. He took the antidepressants and went for a few counseling sessions, however, the medication did not seem to work so he stopped taking it. His condition worsened, and he attempted to take his life by overdosing on sleeping pills. The suicide episode led to hospitalization for one week, he was again put on antidepressants. During this period, since he could not concentrate, he dropped out of school.

Psychiatric Review of Systems

• Depression: John is depressed because he is angry with everyone and has lost interest in things, activities, and people. He keeps to himself and stays in his room all day, and this has been persistent for quite a while.
• Anxiety: He is anxious most times because he thinks people are watching or after him. The hallucinations and delusions make him irritable, restless, and uneasy all the time.
• Mania: John has lost the ability to interact with people, he finds it irritating to be in the company of others. He also experiences racing thoughts and he is not able to engage in normal conversations.
• Psychosis: John has been experiencing things that are not real, he feels, sees, and hears things that other people cannot.
• ADHD: John is not been able to pay attention and this led him to quit school. He currently cannot do anything constructive as he is out of touch with reality.
• OCD: John is currently occupied with persistent imaginary thoughts, imaginations, and impulses that consistently disturb him.
• Trauma: John, lost his brother through an accident, an incident that was never addressed emotionally.
• Sleep Disorder: John has insomnia, he has not been sleeping well, and he is afraid to fall asleep.
• Eating Disorders: John has not been eating well, he has been skipping meals and sometimes going for days without eating.

Past Psychiatric History

Chronology of past episodes

• Prior diagnoses, treatments, and response: Depression, treated with antidepressants and a few counseling sessions. Suicide attempt which was associated with depression and so another antidepressant was prescribed.
• Past medications: First-time medication for depression was Fluoxetine capsules, 20 milligrams (mg) once daily in the morning. The second time after suicide John was prescribed the Paroxetine 7.5 mg capsule to be taken once daily at bedtime. He stopped taking the Paroxetine just within one week.
• Past outpatient treatment: December 2021 treated for depression.
• Psychiatric hospitalizations/residential treatments: Hospitalized after a suicide for a week.
• Past suicide attempts: John planned and overdosed on sleeping pills. However, he was found unconscious and taken to the hospital where he recovered after a week. If John was not found and rushed to the hospital on time, he would have died.
• Prior aggressive episodes: John has been beating his dog, though his aggression is not on people, his parents fear that the aggression might escalate with time.
• Prior aggressive behaviors: none.
• Self-harm/injury: The major harm John poses to himself is drug use, he has been using alcohol and marijuana which is greatly affecting his health.

Medical

Current medical issues: Not under any medication currently.

Past medical issues and surgeries and procedures: prescribe with an antidepressant, Fluoxetine capsules, 20 milligrams (mg) once daily in the morning. However, John took the medication only for five days and stopped citing adverse effects like nausea, headaches, insomnia, and tiredness. The second time after suicide John was prescribed the Paroxetine 7.5 mg capsule to be taken once daily at bedtime which he never adhered to.

Risk Assessment

Suicide: John is a risk to himself because he is suicidal, has attempted suicide before and has recently been talking about ending his miseries. His suicidal risk is very high, if he does not get help, he might attempt suicide again.

Homicidal Ideations and/or Aggression: He is exhibiting a level of aggression that he never had before towards his dog and without treatment, his aggression might move toward people. He is also having suicidal ideation. His level of acute risk of homicide is high while his level of chronic homicide is low.

Objective Assessment

Vital signs

• Height: John is 5 ft 4 in (64 in) tall.
• Weight: His weight is 90 lbs, and his normal weight should range from 110–140 lbs.
• Waist circumference: His waist circumference is 85cm, while the average waist for men is 102cm.
• Blood pressure: His blood pressure is high at 140/95 mm Hg, the normal should be 120/80 mmHg.
• Heart rate: He has a high heart rate at 110 beats per minute (BPM), the normal is 60-100 BPM.
• Respiratory rate: His respiratory rate is high at 18 breaths per minute, the normal 12-16 breaths per minute.
• Sp02: His SpO2 was 92%, a healthy individual has SpO2 from 96% to 99%.
• BMI: John’s BMI is 15.4., which is severely underweight because the normal BMI is 18.5- 24.9 for adults 18-65 years.
• Laboratory/ radiology results: The lab technician tested John’s blood and urine and the results came out positive for Alcohol and marijuana.

Clinical Impression/Formulation/Medical Decision Making (25 Points)

Diagnosis

John’s assessment shows that his symptoms meet the DSM-V criteria for schizophrenia. Schizophrenia is a mental health condition and a spectrum of disorders that all comprise a detachment from reality, including hallucinations and delusions. The condition also negatively influences an individual’s capability to identify the symptoms they are experiencing.

As per the DSM-5, for a person to be diagnosed as schizophrenic it requires that: 1. A person has to experience at least two of five main symptoms; delusions, hallucinations, disorganized or incoherent speaking, disorganized or unusual movements, and negative symptoms. John has experienced delusions, hallucinations, and disorganization. 2. Duration of symptoms and effects: The key symptoms one exhibits must last for at least one month and the condition’s effects must last for at least six months. John has been battling this condition for almost two years just and he had been misdiagnosed. 3. Social or occupational dysfunction: This means the condition disrupts either one’s capacity to work or maintain relationships. John has dropped out of school and also lost his friendships and romantic relationship.

Making this diagnosis is very important for John because he has been struggling with this illness for a long. He needs to immediately start taking schizophrenic medication to reduce the risks and curb the negative symptoms he exhibits. John will be admitted to the clinic for some days for close observation. He will be discharged when he responds well to medication.

Plan of Treatment

For all medications: John’s treatment will include three methods, medications, and therapy (individual, family, and group). For medication, we will combine Olanzapine orally takes tablets, 10 milligrams (mg) once a day, and Risperidone 2 mg per day. Olanzapine has been used regularly to treat schizophrenia and bipolar disorder. The combination of risperidone with olanzapine in the treatment of schizophrenia can effectively reduce the symptoms and induce fewer adverse reactions.

For all psychotherapy: John requires therapy to help him get in touch with his feeling. He will need continuous counseling sessions to manage his condition. Particularly, he requires cognitive behavioral therapy, family, and group therapy. Going through CBT ensures that John gets rid of his unrealistic imagination and feelings. Additionally, John needs family therapy, to help his parents have insights into what he is going through. We will refer John to group therapy where he will meet with other people with the same condition.

For all diagnostic tests and labs: Laboratory analysis on blood and urine was conducted, and the results came out positive for Alcohol and marijuana

For all referrals: John will be referred to group therapy where he will meet with other people with the same condition. After he is done with the schizophrenic treatment, he will be referred to the clinic’s drug rehabilitation section for drug intervention.

Treatment Goal(s)

1. The two types of medication (Olanzapine and Risperidone) will aim at reducing schizophrenia symptoms including hallucinations, delusions, depression, anxiety, and aggression.
2. Cognitive behavioral therapy’s purpose at handling distorted thoughts and imaginations and this will lessen the rates of suicidal ideations.
3. Family therapy will focus on reducing John’s level of aggression, loneliness, and isolation and help him become more open about his feelings toward his parents and friends.
4. The group therapy is intended to help john meet people who share the same experiences as him, this might assist him to open up.

Prognosis: Good/Fair/Poor

Olanzapine and Risperidone have been proven to be effective in managing schizophrenia. I believe that the medications have a high probability of helping John, however, if the medication fails, we will refer John to ECT. ECT is a practice, done under general anesthesia, electric currents are passed through the brain, intentionally triggering a brief seizure (Grover et al. 2019). ECT causes alteration in brain chemistry that might speedily change symptoms of particular mental health diseases (Sanghani et al. 2018). However, it is a trial because it does not work for some people.

Follow-up: (timing)

We will follow up with John to know whether the medication is working or if we should result in ECT. We will follow up through calls for the first 24-48 hours. We will also set a clinic visit after every two weeks.

Evidence-based Treatment

Medication

Past investigations show that Olanzapine and Risperidone are used widely in treating schizophrenia. Barbosa et al. (2021) did a survey in Brazil and found that Olanzapine and Risperidone were used to treat schizophrenia. Cheng et al. (2019) did an investigation in China that also revealed that the two medicines were used to treat schizophrenia. Citrome et al. (2019) did a systematic review in the US and found that olanzapine was largely utilized to control schizophrenia.

Psychotherapy

Psychotherapy has equally been used to help persons with mental health issues including those with schizophrenia. Burlingame et al. (2020) did a study that indicated that group therapy was effective for schizophrenia. Jameel et al. (2020) revealed that therapies decrease the negativity and anxiety levels of patients and motivate patients to accept treatment. Vidal Gutiérrez et al. (2019) documented that family therapy is efficient in improving the social functioning of persons with schizophrenia and lessening expressed emotion among their caregivers.

Development

According to the stages of development by Erik Erikson people in their later teens and early twenties (John’s age bracket) are supported to be interacting to create intimate relationships (Gross, 2020). Otherwise, they will be isolated for the rest of their lives or will have difficulty creating and maintaining relationships.

Patient Education

Schizophrenia is a mental condition influenced by changes in the brain. The illness causes one to see, feel, and hear unrealistic things. The condition makes one moody or hyper, stressed, and anxious. For the treatment, we will start you on two types of medication that you will take as advice. Additionally, you are to attend individual, family, and group sessions that will help you with your feelings and emotions.

References

Barbosa, W. B., Gomes, R. M., Godman, B., Acurcio, F. D. A., & Guerra Júnior, A. A. (2021). Real-world effectiveness of olanzapine and risperidone in the treatment of schizophrenia in Brazil over a 16-year follow-up period; Findings and implications. Expert Review of Clinical Pharmacology, 14(2), 269-279. Web.

Burlingame, G. M., Svien, H., Hoppe, L., Hunt, I., & Rosendahl, J. (2020). Group therapy for schizophrenia: A meta-analysis. Psychotherapy, 57(2), 219–236. Web.

Cheng, Z., Yuan, Y., Han, X., Yang, L., Cai, S., Yang, F & Yu, X. (2019). An open-label randomized comparison of aripiprazole, olanzapine, and risperidone for the acute treatment of first-episode schizophrenia: Eight-week outcomes. Journal of Psychopharmacology, 33(10), 1227-1236. Web.

Citrome, L., McEvoy, J. P., Todtenkopf, M. S., McDonnell, D., & Weiden, P. J. (2019). A commentary on the efficacy of olanzapine for the treatment of schizophrenia: The past, present, and future. Neuropsychiatric Disease and Treatment, 15, 2559. Web.

Gross, Y. (2020). Erikson’s stages of psychosocial development. The Wiley Encyclopedia of Personality and Individual Differences: Models and Theories, 179-184. Web.

Grover, S., Sahoo, S., Rabha, A., & Koirala, R. (2019). ECT in schizophrenia: A review of the evidence. Acta Neuropsychiatrica, 31(3), 115-127. Web.

Jameel, H. T., Panatik, S. A., Nabeel, T., Sarwar, F., Yaseen, M., Jokerst, T., & Faiz, Z. (2020). Observed social support and willingness for the treatment of patients with schizophrenia. Psychology Research and Behavior Management, 13, 193. Web.

Sanghani, S. N., Petrides, G., & Kellner, C. H. (2018). Electroconvulsive therapy (ECT) in schizophrenia: A review of recent literature. Current Opinion in Psychiatry, 31(3), 213-222. Web.

Vidal Gutiérrez, D. A., Saldivia, S., Grandón Fernández, P., & Inostroza Rovegno, C. (2019). Effectiveness of behavioral family therapy in people with schizophrenia: A randomized, controlled clinical trial. Salud Mental, 42(2), 65-74. Web.