Exploring Nursing Management of Patients with Psychosis in the United Kingdom - Literature review Example

Case study by Andrea Flores, BA (PharmD candi of Florida College of Pharmacy A 27-year-old female was brought to the psychiatry emergency department by her family because of increasingly disturbing psychotic symptoms, which started about three days ago. The patient was found to be sexually preoccupied, aggressive, intrusive, suspicious and highly delusional. She was also experiencing auditory and visual hallucinations and had intense feelings of persecution. Upon hospital admission, her blood pressure, pulse and temperature were 145/82 mmHg, 83 bpm and 36.5 °C respectively. Complete blood count, liver and renal function tests and serum electrolytes were within normal ranges. A standard urine toxicology screen for controlled-substance abuse was negative.  Both the patient and family members denied any relevant history of medical or psychiatric disorders. Upon direct interviewing, the patient denied taking any prescription medications. When asked about over the counter medications, she admitted taking ibuprofen for occasional headaches, and stated that over the past three weeks she had been taking some Chinese herbal diet pills daily, that she had recently purchased over the internet, but could not remember exactly how many she had taken every day. She stated that the diet pills were recommended by a friend who was able to lose 27 pounds over a period of 8 weeks. She also noted that just a few days after initiating the diet pills she started feeling anxious and had difficulty falling sleep at night. The patient was started on risperidone 1 mg orally twice daily, was not permitted to take her herbal diet pills, and showed significant mental improvement over a period of just four days. The herbal diet pills she had been taking were subsequently identified as a brand that had previously been recognized as possibly containing a synthetic chemical stimulant. Discussion Herbal medicines are gaining increasing popularity as both dietary supplements and complementary remedies. They are generally perceived as safe and effective because of their presumed natural origin. However, common problems seriously affecting the integrity of herbal medicines include adulteration, contamination, lack of standardization and inappropriate or purposefully misleading labeling. Dietary supplements for weight control should be safe. However, prescription drugs have been found to be added to some herbal formulations in significant concentrations, which are then marketed as dietary supplements or natural nutritional products. One prominent example is sibutramine, a drug that is currently approved in the US for treating obesity.1 This agent or its active metabolites have recently been found to be a component of several Chinese or other "herbal" weight loss products; added to enhance the weight-reducing properties of these products that are easily available over the internet.2-7  The current FDA-approved indication for sibutramine is for the treatment of obese patients with a BMI ≥ 30 kg/m2 or a BMI ≥ 27 kg/m2 with other risk factors and this agent should only be used under the supervision of a licensed health care practitioner.1 Sibutramine is a serotonin, dopamine and norepinephrine reuptake inhibitor that is rapidly absorbed and metabolized (mostly in the liver via cytochrome P450 3A4 [CYP3A4]) into two active desmethyl metabolites M1 and M2.  Sibutramine concentrations may increase in combination with other medications which augment the serotonin or norepinephrine concentrations at the synaptic cleft, or which act as serotonin agonists due to the structural similarities. Therefore, this agent should not be combined with serotonergic drugs such as triptans or medications that alter serotonin metabolism such as SSRIs, MAO inhibitors, or antipsychotics due to the likelihood of experiencing severe side effects. Adverse events commonly associated with sibutramine are dry mouth, constipation, tachycardia, headache, insomnia, hypertension, and anxiety.1,7 In the recently published SCOUT trial that evaluated the long-term effects of sibutramine compared with placebo on the incidence of cardiovascular events among high risk patients with a history of cardiovascular disease, patients lost a mean of 2.2 kg during the lead-in phase, and patients subsequently randomized to sibutramine lost an additional 1.7 kg. However, sibutramine was associated with an increased risk of nonfatal myocardial infarction and stroke.8   Psychiatric complications have also been associated with sibutramine and are thought to be related to the additional mechanism of dopamine reuptake inhibition. Due to the increase of dopamine load at the synapse, dopamine can theoretically have potential psychomimetic effects and induce psychotic symptoms in vulnerable patients, especially at high doses of sibutramine.9 Several case studies have been published describing psychotic disorders developing in otherwise healthy patients using sibutramine for weight loss at approved doses.10,11 Some of the adulterated weight loss supplements that have been identified provide more than three times the recommended daily dose of sibutramine.12   Sibutramine has also been found in counterfeit versions of Alli, an FDA-approved agent that normally contains orlistat 60 mg and is available as an over the counter weight loss aid. Recently, the FDA issued a consumer warning regarding counterfeit, sibutramine adultered Alli being sold over the internet.13 In view of the potential cardiac, psychiatric and other side effects associated with prescription sibutramine, and the reports on adulteration of some herbal supplements and other products for weight loss, in January 2010, the European Medicines Agency (EMEA) recommended that sibutramine be removed from markets in Europe.9 The FDA will hold a public hearing on September 15-16, 2010 to discuss whether further action should be taken against the drug in the US.14  In addition, both health care providers and patients need to be aware of potential adulteration of dietary supplements and lifestyle products, particularly those purchased over the internet. case study 2 my 17 yr. old son - liz - Mar 9th 2012 I had to drive my son to the hosp. a few nights ago.March 5. he was not himself. He seemed to be at times but then would say things that were totally not what was being discussed at the time. On the way he screamed something was trying to get into his head. or that something was trying to come out and he would hold his chest. He would say things like im biggy smalls and his uncle was Tupac and now i see. and so many things he said that was crazy. They diagnosed it as being drug induced pychosis. They tell me this could be permanent damage. It could last 3 to 5 days. 2 wks 2 mths or even a yr. we have no answers. The only hope i have at this moment is what a nurse told me Ive seen worse, Ive seen them come in where they cant feed themselves. And theyve pulled through.left here normal again..so after hearing this i have hope that my son will pull through. He was started on Risperidal 0.5mg. and the very next morning was increased to 1 mg. the DR. will be increasing it all the way to 2 mg..if anyone can help with advice or anything..please do case study 3 Going mental - Howard - Mar 1st 2012 Been a marijuana addict for about 12 years and im 28 years old. It seems like my drug use has changed my brain chemistry inducing stress, delusions, anger, foggy thoughts, terrible memory, paranoia, depersonilization and soicial angst and no interest in things i used to enjoy. It feels as if its getting worse and its making my drug use worse aswell. I find myself struggling to think clearly, even after a few days without it. When i was around 20 i had a gran-mal seizure and was told i developed epilepsy. the neuroligist was told of my frequent marijuana use and i was told it was do to a binge drinking issue. I think my brain was damaged in the 4 seizures ive had and to top it off they put me on a terrible drug called depekote which basically poisined me and i had to go see a specialists at the mayo clinic and was changed over to a new drug called lamotrigine. Im just wondering if anyone knows weither its from the pot smoking, or damage from the seizures and or the medication they prescribed, or a combination of both. Theres times i feel better but there few and far between. my next move will be to see a psychiatrist. Dont abuse drugs no matter what the circumstances because in the end youll pay for it. Theres no way to fix your brain once its damaged. Most marijuana smokers are in denial and suffer in silence, they defend the drug thats changing there mood and personality and way of thinking. I see it all the time, trying to defend legalizing pot comparing it to alcohol, believe me there both bad for you ive been smoking it for along time and im pretty sure i will never be the same as i was before. Drugs are for F&$king losers. believe me charlie sheen isnt WINNING. Stay strong and healthy. Thats the way to live your life   Case study 4 Energy Drinks and Psych Meds? - - Sep 21st 2012 About a month and a half ago my husband had a psychotic episode that ended him up in jail.  He has been institutionalized at least 3 times.  He is 31 years old and has a history of meth use.  Prior to us dating he told me that he was diagnosed schizophrenic and bipolar and has also been labeled 51/50.  In the 7 years that we have been together he has had 3 violent episodes.  The first one that I witnessed was in a church at a funeral.  He had not taken his meds for only 2 days and really didn’t get much sleep.  In the church he started hearing voices that another young man sitting across the church was trying to hurt his dad.  He literally got up, walked over to the young man and started hitting him.  This turned into a very bad situation as the young man he hit happened to be a gang member with a gun in his car.  To make this long story short, I had to get him home right away to pick up his meds.  He got really aggressive towards me in the car as I was driving and being that it was my first experience of that nature with him, I was afraid.  Got the meds, he took them and about 2 hours later he fell asleep.  Slept for about an entire day and a half and woke up “normal”.  The next major episode was about a month ago.  He was talking to his dad who was cursing him out and calling him a liar as he was asking for help with our car that broke down.  This is what triggered him to NOT take his meds for about 3-4 days.  He ended up roaming the streets for that time.  I found him at my parent’s house and he did not look well.  He started on me about me being the devil and how I’m hurting everyone around me.  In the next breath he’s crying asking me to make the voices stop.  I did not want him to get out of control at my parents home so I asked him to take a walk with me.  As we were walking he started to get more and more delusional and out of control.  He tried pushing me into the street with oncoming traffic.  He then hit me so hard in the back of the head and this was the first time he has ever touched me while in this state of mind.  I told him that I was going to call the police and he just started crying and took off running.  I couldn’t find him.  I did not call the police.  I felt sorry for him because what he was going through.  I went to work that night and did not hear from him so I went online and found out he had been picked up by the police for resisting arrest, assaulting a peace officer and battery on a peace officer.  At court I found out that he was picked up in a grocery store not too far from where I left him earlier that day for harassing people in the store.  Calling them evil, they are the devil etc…He came out of jail and went back on his meds and everything seemed to be going just fine. Three days ago I noticed that he had not been sleeping and that he was starting to act weird again.  I assumed that he started using meth again.  He told me to walk with him to the police station so he can turn me in for hurting people.  I followed because I figured it was probably the safest place for me at that moment.  He told the police that I was the devil and that I have been sending gargoyles after people that he loves etc..They took him to a psychiatric facility.  The nurse called me to ask me questions and get a background on his situation because he has not spoken to them since he was admitted.  Apparently he is not being compliant with taking the medication they are giving him so they have been giving him Emergency Shots.  (what is that?)  Anyhow, he tested negative on a drug screening so I guess he was NOT using meth.  I did however notice that there was an empty can of Amp (energy dring) in the trashcan at home and my sister saw a full can in the fridge which was gone by the time we got home from work.  When I mentioned that to the nurse she said that the combination of the medication (Carbamazepine and Risperidone) and the energy drink may have exacerbated the psychosis.  Everyone says I’m strong for the way I’ve handled this situation with my husband for 7 years because I hold it all in and try my best to learn about his illness.  I try to educate myself to not only understand what he is going through but to also protect myself and him.  I am thankful that I believe in God and that he has carried me through these 7 years of what seems like torture.  Sorry for the long story but here goes my question: What types of food or beverages other than the obvious should I try to keep out of his diet?  He has a sweet tooth and I’m pretty sure that is probably not a good thing.  He drinks lots of soda but never has had an energy drink until a few days ago.  Help me please.  Educate me so that I don’t go crazy myself!  I want to understand and do what I can to keep him as sane as possible.  Thank you so much for reading and for any advice you may have to give.Blessings to all who suffer from this terrible disease and for those who have to live with them. CASE STUDY 5 its so hard - - Aug 14th 2012 my husband has a history of using/selling drugs but he sobered up for a really long time.Just last year, one of his old friends moved back into the neighborhood and things just started to change. J found meth in his pockets and he admitted that hes back to selling drugs.I gave him an ultimatum so then he stopped.Its been more than a month since he stopped for real (i lnow coz i make a constant sweep of his clothes,the house , even d garage..i even check his bank acct constantly) but Ive noticed a change in him. At first he just kinda got quieter, then he started to laugh&giggle out of nowhere.It bugged me so I turned to some of his friends who went thru the same thing & they said its normal if a person is withdrawing from drug use.I learned to live with it but still, its so hard to look at the person you love & you dunno whats running in his head:( We have a daughter and I always fear that he would snap or sumthin while im at work but so far hes been okay.he still goes to work but hes like a zombie almost, like he has his own world.everytime i try to talk to him hell respond with a one-liner and thats it.its so hard, im desperate..i dunno how to help him! i e been asking him to get a checkup but he insists he doesnt need it.Im crying as Im typing this coz i dont know what to do anymore. and oh, he thinks Im the one with the problem coz I get mad at him "without any reason and cry out of nowhere".no matter how I try to explain and talk to him it seems like nothing gets through his head.I cant get through him.what do I do? CASE STUDY 6 Unexplained episodes - Christian - Oct 17th 2010 Ive been having what I call episodes where I become a person incapable of functioning like I normally would. They usually last from 7 to 14 days. The most frustrating thing for me is the feeling that Im high on some drug, or like Im not really here. Its extremely hard for me to talk, people have told me that I talk slow and soft. Its a great effort for me to move, but I am still able to. I also noticed that I become numb all over. For example: one time I was outside and an ant was biting my foot, I felt something, but it didnt hurt, and I didnt care. Its hard for me to smell and taste anything. If it werent for my boyfriend I probably would eat. I stop taking care of myself, etc. brushing my teeth, hair, shower. I get dehydrated. I can still think, I know whats going on, but its almost as if Im dreaming and cant wake myself up. Ive gone to countless doctors and they have all been stumped. Ive been to psychiatrist after psychiatrist and all have different opinions. Once I had psychosis, then I had bipolar, then borderline personality, and the one I believed was the major depressive disorder. The episodes actually began after I smoked cannabis one night, but have been laced with methamphetamine. I noticed something wrong because Ive smoked pot before and I knew it was never this intense and it never lasted this long. The first time lasted about 2 weeks. A month later it happened again, only that this time I never took anything. After that it kept happening, usually with a couple of months in between, but I can never tell when. I thought I had figured out a pattern, but after this time Im starting to wonder if my brain has figured out a way to get the same exact experience I did that night without the help of any elicit drug. I know for a fact that my therapist or doctor have any clue on whats going on because they always ask me if I had been drinking or something. Im worried that somehow, one day, I wont come back from that episode. Please help me or help me find someone who knows where I can get help.  Read More