Kootu Bulambo is a 34-year-old African female admitted to your psychiatric inpatient unit with worsening social withdrawal, apathy, and poor independent functioning over the past year.
Two years ago, she had a brief admission when she displayed aggression and persecutory delusions believing that male and female police officers were frequently having sex with her and that she was being recorded through cameras. She was not treated with psychotropic medications at the time. From the records, her symptoms appear to have remitted spontaneously and she was discharged. She was lost to follow-up thereafter.
Kootu is from Zimbabwe and was granted asylum status approximately 10 years ago. She was employed with good social functioning for about eight years. Following her first admission, she lost her job and her apartment due to not paying rent.
For the past six months, she has been living at a homeless shelter and has become increasingly reliant on staff for her basic needs. Her self-care is poor, and apathy is felt to be the prominent feature. She has very limited funds and has not claimed federal or state benefits. Her interaction is very limited. Shelter staff have not witnessed any behavior indicative of positive psychotic symptoms and there were no incidences of aggression or violence.
On this second admission, Kootu was noted to have poor self-care, weight loss, and poor motivation. There were no objective symptoms of clinical depression and she denied ongoing low mood. She did not engage with staff and refused physical examination, blood tests, and oral medication. Positive and Negative Syndrome Scale (PANSS) scoring was completed, yielding 18, 36, and 64 on the positive scale, the negative scale, and the general psychopathology scale, respectively. Prior, she had had two doses of aripiprazole short acting intramuscular injections without any adverse effects.
From your perspective as Kootu’s psychiatric nurse practitioner, answer the following questions in your initial post.
What diagnosis would you consider for Kootu?
You decide to start a long-acting injection. What are the pros and cons of starting a long-acting injection? What barriers are you going to run into with her being homeless?
Pick an appropriate long-acting injection and explain the mechanism of action, starting dose, patient education, baseline labs that need to be done, and possible food/drug interactions that you must be aware of while you have her on this injection.
What additional challenges will you face with Kootu due to her being homeless and without an income or financial support? Call a local lab and ask about what it costs for the blood tests you want her to have. Call a local pharmacy and ask how much the medication would be out of pocket.
Kootu Bulambo Case Study
- What diagnosis would you consider for Kootu?
Kootu is suffering from Schizophrenia. Schizophrenia is a chronic and at the same time severe well known mental disorder, which is currently rated to be affecting approximately 20 million people in the worldwide population (Atkinson et al., 2014). This disorder is usually characterized by several symptoms which are distortion in perception, language, thinking, emotions and self-sense, and behavior (Atkinson et al., 2014).
An individual with Schizophrenia usually shows commons signs of hallucinations which entails hearing or seeing voices or things that are not there, and delusions which are false or even fixed believes. The disorder is also associated with a kind of disability that usually in most cases affects the person’s occupational and educational performance (Atkinson et al., 2014). In the case study, Kootu portrayed high negative symptoms of the disorder with poor functional outcomes and also poor life quality or lifestyle.
Increased negative symptoms of the disability tend to lead to a huge burden to the caregivers which was the case of Kootu. The patient had lost her house due to lack of rent after she lost her job in her first admission which landed her in the shelter. The patient also experienced hallucinations and delusions which are evident in her first brief admission where she believed male and female officers were having sex with her frequently and she was also being recorded on cameras. From the positive Negative Syndrome Scale, the results showed a high scale of the negative symptoms.
- You decide to start a long-acting injection. What are the pros and
cons of starting a long-acting injection? What barriers are you going
to run into with her being homeless?
According to the case study “the patient had already been given two doses of the aripiprazole short-acting intramuscular injection without showing any adverse effects”. Since the patient had refused to take any oral medication of the aripiprazole, a long-acting injection should be commenced excluding the two-week oral drug recommended period.
Advantages of long-acting injection of antipsychotics medication include;
- Increased adherence to medication
- Decreased need for daily oral doses
- The clinic visits for the patient’s injections creates a good opportunity for monitoring by the clinician and for building consistent relationship with the patient (Chung et al., 2012).
Disadvantages of long-acting injections of antipsychotics medication are;
- Slow titration periods- the dose has to be started slow and increased gradually.
- Pain during injection
- Long lasting side effects of the injection
- A must clinic visits for the injection.
- Stigma associated with the long-acting injection for psychotic medication (Chung et al., 2012).
Barriers due to homeless state of the patient
The major barrier that will be encountered during this treatment is the patient may miss the clinic injection appointments eventually causing disengagement from the treatment (Parellada & Bioque, 2016).
Additionally, the medication is linked to some adverse effects which can cause serious medical effects hence affecting the attitude of the patient concerning the treatment (Parellada & Bioque, 2016). In the state of being homeless, it would be difficult for Kootu to deal will the side effects without close monitoring by any close family or caregivers.
- Pick an appropriate long-acting injection and explain the mechanism of
action, starting dose, patient education, baseline labs that need to
be done, and possible food/drug interactions that you must be aware of
while you have her on this injection
Aripiprazole is an antipsychotic medication in the second generation which is licensed to treat schizophrenia disorder. The use of aripiprazole long-acting injection to the Schizophrenia adverse negative effects has proved to be effective (Miyamoto & Fleischhacker, 2017). Aripiprazole has a unique mechanism of action following the “partial agonism at dopamine D2 receptors when compared to all other second-generation antipsychotics medication”. Aripiprazole usually rebalances dopamine and serotonin in a Schizophrenia patient to improve their thinking, behavior, and also mood. The efficiency of the drug has been well established (Miyamoto & Fleischhacker, 2017).
Approved by the US Food and Drug administration aripiprazole long-acting injection should be administered 40mg dose once a month intramuscularly for treatment initiating and maintenance Schizophrenia treatment (Miyamoto & Fleischhacker, 2017). The dose should be administered concurrently with oral aripiprazole during the medication first fourteen dosage days. The nurse practitioner is supposed to discuss with the patient first the side effects of the injection which may be very severe as well as the benefits and the mode of administration.
Caution must be taken before administering the injection like checking if the patient may have an allergy to the drug ingredients, any ongoing medication, or self-prescribed drugs, to avoid alcohol or any illegal drugs (Atkinson et al., 2014). Concerning the diet, the medication calls for a normal diet but ensure they are feeding properly to deal with the strong effects of the medication.
- What additional challenges will you face with Kootu due to her being
homeless and without an income or financial support? Call a local lab
and ask about what it costs for the blood tests you want her to have.
Call a local pharmacy and ask how much the medication would be out of
It will be difficult for Kootu to get the needed medication due to her financial constraints. Secondly being homeless and living at the shelter she cannot get proper care especially in terms of feeding properly or where to get support for the medication in terms of finance.
WHO’s Mental Health Gap Action Programme (mhGAP), which was launched back in 2008 makes use of tools and also training packages in expanding mental services across the world in poor-settings like the case of Kootu (Thornicroft et al., 2018).
WHO Quality Rights project helps to improve the quality of patient care and the conditions of human rights in social care and mental health facilities (Thornicroft et al., 2018). The program recommends healthcare providers shift the mental services from the institutions and carry them down to the community where they are most needed like in the case of Kootu who is unable to afford medication. Kootu can benefit from WHO Mental Health Gap Action Programme (mhGAP).
Keynejad, R. C., Dua, T., Barbui, C., & Thornicroft, G. (2018). WHO Mental Health Gap Action Programme (mhGAP) Intervention Guide: a systematic review of evidence from low and middle-income countries. Evidence-based mental health, 21(1), 30-34.
Kim, B., Lee, S. H., Yang, Y. K., Park, J. I., & Chung, Y. C. (2012). Long-acting injectable antipsychotics for first-episode schizophrenia: the pros and cons. Schizophrenia research and treatment, 2012.
Miyamoto, S., & Fleischhacker, W. W. (2017). The use of long-acting injectable antipsychotics in schizophrenia. Current treatment options in psychiatry, 4(2), 117-126.
Parellada, E., & Bioque, M. (2016). Barriers to the use of long-acting injectable antipsychotics in the management of schizophrenia. CNS drugs, 30(8), 689-701.