NURS 6630 Assignment: Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

NURS 6630 Assignment: Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

Zyprexa (Olanzapine)

Description and FDA Indication Uses

Olanzapine is an atypical antipsychotic principally prescribed to treat schizophrenia and bipolar disorder (it is also marketed under the brand name Zyprexa (Image 1)). FDA-approved indications related to the medication are presented in Table 1.

Table 1. FDA-Approved Indications – Olanzapine (Oral Formulation) (Guzman, n.d.)

Image 1. Olanzapine Tablets (Wellona Pharma, n.d.)

Non-FDA Uses

Olanzapine has the research supporting it for the off-label uses of dementia, anxiety, and OCD (Thomas & Saadabadi, 2022).


Olanzapine belongs to the group of drugs known as atypical antipsychotics. It functions by altering the way that a few organic brain chemicals behave.

The Medication Mechanism of Action

The drug mainly affects dopaminergic receptors in order to function. It functions as an inhibitor of the mesolimbic pathway’s d2 Receptors, preventing dopamine from potentially acting at the post-synaptic receptor.

The medication pharmacokinetics

Within the permitted dose spectrum, the pharmacokinetics of the medication is simple and dosimetric. In healthy people, it had a mean half-life of 33 hours and a range of 21 to 54 hours. The observed plasma clearance ranged from 12 to 47 L/h, with a mean of 26 L/h (Thomas & Saadabadi, 2022).

The Medication Pharmacodynamics

The medication is a second-generation antipsychotic that exhibits a variety of receptors’ sensitivities for neurotransmitter systems HTR2A and HTR2C, dopamine receptors (DRD1-DRD4)

NURS 6630 Assignment Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

NURS 6630 Assignment Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

, H1 Receptor, alpha1 transactivation, and neuromuscular junction receptors (CHRM1- CHRM5) (Thomas & Saadabadi, 2022).

Appropriate Dosing

Once daily, without regard to meals, the medication should be provided; the usual starting dose is 5 to 10 mg, with a goal dose of 10 mg/day in a few days. Given that a steady state for olanzapine would not be reached in the average patient for about one week, any more dose changes should typically take place at intervals of no less than one week. It is advised to increase or decrease the dosage by 5 mg QD as needed (Guzman, n.d.).

Considerations of Use and Dosing

In people who are elderly, have a history of hypotensive responses, are debilitated, display other characteristics that

NURS 6630 Assignment Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

NURS 6630 Assignment Study Guide for Medication Treatment Schizophrenia Spectrum and Other Psychosis Disorders

may impede the absorption of olanzapine, such as non-smoking women, or who are more pharmacodynamically responsive to olanzapine, the suggested beginning dose is 5 mg (Guzman, n.d.). The suggested beginning dose of oral olanzapine for teenagers is 2.5 or 5 mg, with a goal dose of 10 mg/day, and it should be given once daily without regard to meals. The drug is not recommended for children and during pregnancy.


For any particular medication, understanding the idea of half-life is helpful in calculating steady-state levels and excretion rates. The half-life of olanzapine ranges from 21 to 54 hours, with a typical of 30 hours. The stable plasma levels of olanzapine are reached after roughly a week of daily treatment. Olanzapine thus exhibits linear pharmacokinetics within the FDA-approved dosing range (Thomas & Saadabadi, 2022).

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Side Effects

Possible side effects include increased hunger, constipation, sore throat, dizziness, lightheadedness, stomach discomfort, and weight gain. The likelihood of falling might rise if one feels lightheaded or dizzy.


Patients who have a known sensitivity to olanzapine or drugs in its class should not use it. Olanzapine carries a black box warning for dementia-related psychosis. Due to a higher risk of death, olanzapine should not be administered to elderly dementia sufferers who also exhibit psychotic symptoms (Thomas & Saadabadi, 2022). Additionally, doctors should prescribe this drug cautiously in patients who are obese or even have diabetes owing to the negative consequences of gaining weight and metabolic disorders.


CNS depression with drowsiness, impaired vision, hypotension, respiratory depression, neuroanatomical and antispasmodic effects, as well as unusually high temperature are the most typical symptoms that come from olanzapine overdose.

Diagnostics and labs monitoring

The concentration of olanzapine in the blood is dose-dependent, but many other factors can have a significant impact on its level in the blood. For this reason, when prescribing olanzapine, it is advisable to conduct drug monitoring. Diagnostics and lab monitoring of olanzapine are of particular importance in the absence of response to therapy with this drug. In such a situation, a low concentration of the drug in the blood may indicate non-compliance of the patient with the drug regimen. Drug monitoring allows one to timely adjust the dose of the drug and prevent the occurrence of side effects. This is of particular importance, given that the development of side effects often leads to the patient’s reluctance to follow the drug regimen and self-withdrawal of the drug.

Comorbidities Considerations

Olanzapine has cardiometabolic side effects and is linked to weight gain. Weight gain brought on by antipsychotics is connected to treatment pauses, thus raising the likelihood of recurrence and hospitalization (Meftah et al., 2020).

Legal and Ethical Considerations

No legal considerations are associated with the medication – except the apparent fact that this drug can be sold only with the necessary prescription from the physician. From an ethical perspective, it is debatable whether antipsychotics should be used to treat dementia’s behavioral and psychological symptoms. Antipsychotics have negative effects, and evidence-based recommendations discourage their usage. It is argued that the palliative paradigm may be used to justify the use of antipsychotics by lowering severe suffering in people with short life expectancies.

Patient Education

Olanzapine should be taken every day at about the same time. One should ask their physician or pharmacist to clarify any instructions on the prescription label that one is unsure about. The patients should never take it in larger or fewer amounts or more frequently than directed by the doctor. Moreover, it is essential for patients to monitor their weight, given that the drug is associated with weight gain (Citrome et al., 2019). The latter indicates that the organism cannot manage the medication appropriately, and alternative treatment or drug is needed.


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(1), 2559–2569.

Guzman, F. (n.d.). Olanzapine indications: FDA-approved-uses. Psychopharmacology Institute. Retrieved 18 July, 2022, from

Meftah, A. M., Deckler, E., Citrome, L., & Kantrowitz, J. T. (2020). New discoveries for an old drug: a review of recent olanzapine research. Postgraduate medicine, 132(1), 80–90.

Thomas, K., & Saadabadi, A. (2022). Olanzapine. StatPearls.

Wellona Pharma. (n.d.). Olanzapine Tablets. Retrieved 18 July, 2022, from

Generic Name: Haloperidol

Brand Name:  Haldol

Forms: Oral, Parenteral (IM, IV)


  1. Manifestation of psychotic disorders*
  2. Tics and vocal utterances in Tourette’s Syndrome*
  3. Second-line and short-term treatment of hyperactive children*
  4. Schizophrenia with prolonged anti-psychotic treatment (i.e., monthly IM) *
  5. Bipolar disorder
  6. Behavioral problems in dementia
  7. Delirium

(Note: Those with * are FDA Approved indications)



  1. Allergy to medication
  2. Allergy to soy for decanoate solution
  3. Patients with Parkinson’s Disease
  4. Patients with Diffuse Lewy Body dementi


Blocks dopamine (D2) receptors reducing psychotic symptoms and possibly combative behaviors in the meso-limbic system within a week (6-7 days). Dopamine blockers also block dopamine in other pathways in the CNS.

Management for Side Adverse effects:

  1. Negative Symptoms: Switch to atypical antipsychotics (weaker dopamine antagonist)
  2. Extra-Pyramidal Symptoms
  3. Akathisia: Beta-blocker (1st line); Benzodiazepine (2nd line)
  4. Acute Dystonia: Amantadine, Benztropine (Cogentin) or other anticholinergics
  5. Pseudo parkinsonism: Amantadine, Benztropine (Cogentin) or other anticholinergics
  6. Neuroleptic Malignant Syndrome: Stopping the drug; Giving Bromocriptine (Parlodel), which is dopamine agonist; and Dantrolene sodium (muscle relaxant)
  7. Tardive Dyskinesia: Tapering the medication, giving Valbenazine or Deutetrabenazine
  8. Hyperprolactinemia: supportive measures, education that some effects cannot be treated


  1. Sedation: taking the medication during H.S and educating the patient about avoidance
  2. Anticholinergic effects: d/t to blocking of parasympathetic nervous response (BUCO PD)

Blurring of Vision- provide artificial tears

Urinary Retention- Increase OFI

Constipation-Increase OFI; High fiber diet

Orthostatic Hypotension- Rise slowly, monitor BP; midodrine may help

Photosensitivity- Wear protective clothing, sunblock

Dry Mouth- sugarless candy

  1. Hyperglycemia: dietary adjustment
  2. Prolonged QT interval: EKG every 6 months
  3. Acute closed-angle glaucoma: Eye check up every 6 months
  4. Hepatotoxicity: Check liver enzymes every 6 months
  5. Agranulocytosis: Monitor WBC as needed


  1. Absorption: Absorbed in the GI and Blood stream (parenteral)
  2. Distribution: Distributed in the blood stream
  3. Metabolized: Metabolized by CYP 450 in the liver
  4. Excretion: Mostly excreted through hepatic clearance
  5. Half-life:
  6. Oral: 12-38 hours
  7. Decanoate: 3 weeks


Usual Dosage range

  1. 1-40 mg/day orally
  2. Immediate release injection: 2-5 mg each dose
  3. Decanoate preparation: 10- 20 times the previous daily dose

How to Dose

  1. Oral: 1-15 mg/day; can give once daily or in divided doses at the beginning of treatment during rapid escalation. Increase as needed. Can be dosed up to 100 mg/day
  2. Immediate release injection: Initial 2-5 mg; subsequent doses may be given as every hour, but patient must be switched to oral preparation as possible.
  3. Children and elderly should be given lower dosage

How to Stop

  1. Slow titration of oral formulation over 6-8 weeks

Dosing in Children

  1. Safety and efficacy have not been established; not intended for use under the age of 3
  2. Oral: initial 0.5 mg/day; target dose 0.05-0.15 mg/kg per day for psychotic disorder; 0.05-0.075 mg/kg per day nonpsychotic disorder.

Dosing in Elderly

  1. Low doses
  2. Close monitoring with dementia


  1. Decreases the effects of Dopaminergic and Dopamine-agonist drugs (levodopa)
  2. Increases the hypotensive effects of anti-hypertensive drugs
  3. Decreases the effects of pressors (epinephrine, norepinephrine, etc.)
  4. Increases the anticholinergic effect of other drugs
  5. When taken with lithium, can cause encephalopathy, which is almost similar with NM


  1. Use with caution for patients with renal and liver dysfunction
  2. Do not use with pregnant in the first trimester
  3. May cross the breast ducts


Food and Drug Administration (2005). Haldol: Brand of Haloperidol. https://,018701s057lbl.pdf

Rahman, S. & Marwaha, R. (2021). Haloperidol Stat Pearls.                                                                                               

Stahl, S. (2021). Stahl’s Essential Psychopharmacology: Neuroscientific Basis and Practical Applications. 5th ed. Cambridge

Stahl, S. (2021). Stahl’s Essential Pharmacology: Prescriber’s Guide. 7th ed. Cambridge

Stern, T., et. al. (2016). Massachusetts General Hospital Psychopharmacology and Neurotherapeutics. 1st ed. Elsevier

  1. Description of the Psychopharmacological medication agent including brand and generic names and appropriate FDA indication uses.
  2. Risperdal is the psychotropic medication of choice.
  1. Risperdal works in the brain to treat schizophrenia.
  2. It is also known as a second-generation antipsychotic (SGA) or atypical antipsychotic.
  3.  Risperidone rebalances dopamine and serotonin to improve thinking, mood, and behavior.
  4. Risperdal / Perseris are the brand names for the generic medication, Risperidone.


  1. Risperdal appropriate FDA indication uses


  1. Risperdal®

Tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Orally disintegrating tablet: 0.25 mg, 0.5 mg, 1 mg, 2 mg, 3 mg, 4 mg

Solution: 1 mg/ml

  1. Risperdal Consta®

Extended-release injectable suspension: 12.5 mg, 25 mg, 37.5 mg, 50 mg



                                                                                       (National Alliance on Mental Health Illness,2020).


  1. Any supporting, valid and reliable research for non-FDA uses.


  1. Risperdal (an antipsychotic/neuroleptic drug) is unsafe for use in children.
  1. Causing diabetes, male breast growth, obesity, brain shrinkage, and other alarming ill effects.
  2. Support attorney Stephen Sheller’s petition to the FDA to revoke approval of its use in children.
  3. The FDA’s own Pediatric Advisory Committee acknowledged these finding in 2008.


(Gorsky, 2012).


  1. Drug classification
  1. Risperidone is in a class of medications called atypical antipsychotics.
  2. It works by changing the activity of certain natural substances in the brain.


National Alliance on Mental Health Illness, (2020).


  1. The medication mechanism of action.
  1. The primary action of risperidone is to decrease dopaminergic and serotonergic pathway activity in the brain.
  2. Therefore decreasing symptoms of schizophrenia and mood disorders.
  3.        Risperidone has a high binding affinity for serotonergic 5-HT2A receptors when compared to dopaminergic D2 receptors in the brain.

(Drugbank, 2022).


  1. The medication pharmacokinetics
  1. Risperidone is rapidly and completely absorbed after oral administration.
  2. Less than 1% is excreted unchanged in the feces.
  3. The principal metabolite was found to be 9-hydroxyrisperidone.
  4. Hydroxylation of risperidone is subject to the same genetic polymorphism as debrisoquine and dextromethorphan.



  1. The medication pharmacodynamics
  1. Risperidone has a high binding affinity for serotonergic 5-HT2A receptors when compared to dopaminergic D2 receptors in the brain.2
  2.  Risperidone binds to D2 receptors with a lower affinity than first-generation antipsychotic drugs, which bind with very high affinity.
  3. A reduction in extrapyramidal symptoms with risperidone, when compared to its predecessors, is likely a result of its moderate affinity for dopaminergic D2 receptors.7,5.


(Drugbank, 2022).

  1. Mechanism of Action.
  1. The primary action of risperidone is to decrease dopaminergic and serotonergic pathway activity in the brain.
  2. Therefore, decreasing symptoms of schizophrenia and mood disorders.


(Drugbank, 2022).


  1. Appropriate dosing, administration route, and any considerations for dosing alterations.
  1. PO (Risperdal or Risperidal M-Tabs)

2 mg/day initially; may increase in increments of 1-2 mg/day at intervals ≥24 hr.

Recommended target dosage: 2-8 mg/day once daily or divided q12hr (efficacy follows bell-shaped curve; 4-8 mg/day more effective than 12-16 mg/day).

  1. IM (Risperdal Consta)

12.5-50 mg injected into deltoid or gluteal muscle every 2 weeks; dosage should not be adjusted more frequently than every 4 weeks.

  1. Recommended to establish tolerability of PO risperidone before initiating treatment with IM risperidone.
  2. SC (Perseris)

90 mg or 120 mg SC once monthly initially

Supplementation with oral risperidone is not recommended

  1. Based on average plasma concentration of risperidone and total active moiety, 90-mg dose corresponds to 3 mg/day oral risperidone and 120-mg dose corresponds to 4 mg/day oral risperidone.
  2. Patients who are on stable oral risperidone doses <3 mg/day or >4 mg/day may not be candidates for risperidone ER suspension.

(Medscape, 2022).

  1.  Considerations of use and dosing in specific specialty populations to consider children, adolescents, elderly, pregnancy, suicidal behaviors, etc.
  1. Risperdal (an antipsychotic/neuroleptic drug) is unsafe for use in children.
  2. Causing diabetes, male breast growth, obesity, brain shrinkage, and other alarming ill effects.

(Gorsky, 2012).


  1. Definition of Half-life, why half-life is important, and the half-life for your assigned medication.
  1. The duration of action of a drug is known as its half life. This is the period of time required for the concentration or amount of drug in the body to be reduced by one-half.                                                          (School of Health Sciences, 2015).


  1. The apparent half-life of risperidone was 3 hours (CV=30%) in extensive metabolizers and 20 hours (CV=40%) in poor metabolizers.


(Ansse Pharmaceutica, n.d).


  1. Side effects/adverse reaction potentials.
  1. Risperidone oral tablet may cause drowsiness and the feeling of being unstable.
  2. This may lead to falling, which can cause broken bones or other health problems.
  3. parkinsonism (trouble moving)
  4. akathisia (restlessness and urge to move)
  5. dystonia (muscle contractions that cause twisting and repetitive movements that you can’t control)
  6. tremors (uncontrollable rhythmic movement in one part of your body)
  7. sleepiness and fatigue
  8. dizziness
  9. anxiety
  10. blurred vision
  11. abdominal pain or discomfort
  12. drooling
  13. dry mouth
  14. increased appetite or weight gain
  15. rash
  16. stuffy nose, upper respiratory tract infections, and inflammation of your nose and throat.


The University of Illino, (2021)

  1. a.  Contraindications for use including significant drug-to-drug interactions.
  1. The potential for risperidone to participate in drug interactions was evaluated by considering the drug’s pharmacokinetic properties.
  2. Controlled studies and case reports indicate that risperidone has a low potential for metabolic drug interactions.
  3.  Drugs that inhibit cytochrome P450 (CYP) 2D6 or induce or inhibit CYP3A4 may alter risperidone plasma concentrations, but the clinical significance of such interactions seems to be minimal.
  4. Adherence to a few guidelines for the design of dosage regimens should limit the effect of drug-drug interactions on patient status and contribute to optimal pharmacotherapy with risperidone.

(Journal of clinical Psychology,2001).

  1. Overdose Consideration
  1. You take too much: You could have dangerous levels of the drug in your body. Symptoms of an overdose of this drug can can cause side effect as listed above.
  1. Diagnostics and labs monitoring.
  1. Recommended monitoring SGA safety was made according to a classification scheme based on the GRADE system.

(Psychiatry, J. Can, 2011).

  1. Legal and ethical considerations
  1. All psychiatrists commonly confront ethical dilemmas when considering psychopharmacologic indications, benefits, and risks, as well as those of alternative management strategies.
  2. To the experienced clinician, balancing these factors may come to feel like second nature, particularly when the treatment context includes a solid rapport with the patient. Furthermore, patients with intact cognition, insight, and judgment are typically able to engage meaningfully in shared decision making, which then unfolds naturally over the course of treatment.
  3. However, in many other cases, psychopharmacologic management raises a host of ethical issues with no easy or optimal solutions. Three cases, presented below, illustrate a few of these challenges.

(The Journal of Lifelong Psychiatry, 2021).

  1. Pertinent patient education considerations.
  1. Schizophrenia requires long-term treatment. Do not stop taking risperidone, even when you feel better.
  2. With input from you, your health care provider will assess how long you will need to take the medicine.
  3. Missing doses of risperidone may increase your risk for a relapse in your symptoms.
  4. Do not stop taking risperidone or change your dose without talking to with your healthcare provider first.
  5. For risperidone to work properly, the tablet form should be taken every day as ordered by your healthcare provider.
  6. One of the long-acting injectable forms, known as Risperdal Consta®, should be received every 2 weeks as ordered by your healthcare provider.
  7. The other long-acting injectable form, known as Perseris®, should be received every month. Both of the long-acting injections are the same medication as in the tablet form.


(National Alliance on Mental Health Illness,2020).


Ansse Ppharmaceutica, (n.d). Risperidone) tablets/oral solution Risperdal.from        .fda.gov

Drugbank, (2022). Resperidone. Retrieved from

The Journal of Lifelong Psychiatry, (2021). Ethical Issues in Psychopharmacology. Retrieved from

Gorsky Alex, (2012). Makers of RISPERDAL. Retrieved from


Journal of clinical Psychology, (2001). An Evaluation of Risperidone Drug Interactions. Retrieved


Medscape, (2022). Risperidone. Retrieved from


National Alliance on Mental Health Illness, (2020). Risperdal (Risperidone). Retrieved from




Psychiatry, J. Can, (2011).  Evidence-Based Recommendations for Monitoring Safety of Second

Generation Antipsychotics in Children and Youth. Retrieved from


Psychiatry, J.  Clin, (1994). The pharmacokinetics of risperidone in humans: a summary. Retrieved



School of Health Sciences, (2015). Pharmacology: Half-life of Drugs. Retrieved from


University of Illino, (2021). Risperidone, Oral Tablet. Retrieved from

Psychosis and Schizophrenia Assessment and Treatment


Psychosis is defined as an illness characterized by the presence of hallucinations and delusions that can cause distress or a marked change in an individual’s behavior that is out of normal function of daily living (Puntis, S et al n.d). It is describing as conditions affecting the mind, in which people have trouble distinguishing what is real from what is not real. This might involve patient telling you that he is seeing or hearing things that other people cannot see or hear (hallucinations) or believing things that are not true (delusions) (Puntis, S et al n.d). The combination of hallucinations and delusional thinking can cause severe distress and a change in behavior (Puntis, S et al n.d). Psychosis episode and symptom can start with anyone at any age, but the condition is most occurred frequently in late adolescence and early adulthood. Psychosis and schizophrenia can also be defined as a major mental disorder where the affected individual’s cognition, insight, beliefs, thoughts, and conduct are essentially altered with unreal thinking and ideas. Patient who has been diagnosed with psychosis or schizophrenia will make up his or her own special blend of values and encounters, which is different based on their condition. Schizophrenia is one of the most commonly known psychosis disorders which involves schizoaffective, delusional, non-affective psychoses and schizophreniform disorder.  To evaluate  a patient with this diagnosis the PMHNP have to follow exclusive guidelines which includes collecting details of symptoms present, the impact of these symptoms on the patient, how it affecting the patient and ways the patient has created to adapt to them (Puntis, S et al n.d).

The treatment for psychosis and schizophrenia remain exclusively antipsychotic medication in home, at the hospital and  clinics where patient received treatment. Most of the treatment has been proven to be very effective in the treatment of psychosis when patient is following medication as plan.  Patients with a diagnosis psychosis and schizophrenia frequently encounter stigmatization due to health regulation prevailing of mental health which involves necessary treatment in the facility where treatment is received ((Puntis, S et al n.d). It in termed, will exacerbate their feelings of exclusion.

The adverse effective or undesirable side effects of the medication can sometimes be unmanageable. This adverse effect includes sedation, hypersalivation, weight gain and involuntary movements. They can also add to patient feeling of being excluded in patient with schizophrenia (Puntis, S et al n.d).  Psychosis and schizophrenia have a significant impact on a patient’s life experiences and expectations. Patients need assistance and care to manage their diagnosis and cope with the reality of what had happen to them (Puntis, S et al n.d).

This  case study is a Pakistani woman who has delusional thought processes. The instruction in this assign case study is to make three decisions regarding the medications that will be prescribed for the patient this treatment for her psychosis disorder. In this assignment we will address factors that will affect the patient’s pharmacokinetic and pharmacodynamics.  Also, we will discuss ethical considerations that might have an effect on the patient psychiatric mental health and the nurse practitioner’s treatment plan as well as communication with the patient (Gotra, al 2020).

As mentioned in the description above psychosis and schizophrenia are identified mainly by the presenting symptoms of delusions and hallucinations.  This assignment is marked by subjective and objective information of mental status exam. A schizophrenia will have symptom such as auditory hallucination plus delusional thought processes and beliefs. The patient will have symptoms such as the believe that people are planning to plot and conspire against him.

In decision #1

The first medication to choose by PMHNP is Invega Sustenna 234 mg intramuscular times one. Next will be 156 mg intramuscular once a month. This decision is taken because Invega Sustenna is an atypical antipsychotic drug that is recommended for the treatment of paranoid schizophrenia (Gotra, al 2020). The mechanism of action is by blocking the dopamine and serotonin receptors. This medication work by helping to decrease hallucinations and delusional thoughts and help maintain focus.

The patient in this case study presented with a diagnosis of disorganized, paranoid, and delusional thought process. The patient report that she stopped taking her Risperdal about a week ago after she got out of the hospital (Gotra, al 2020).. This will give the PMHNP idea that oral medication clearly will not be effective because, with the diagnoses will effectively be treated with long-term injections that could eradicate the problems of a patient not taking their medication regularly as plan.  medication noncompliance patient is a widespread worry in schizophrenia treatment because of the symptom of anosognosia. Anosognosia is the lack of comprehension and an unawareness of the presence of a disorder (Gotra, al 2020).

Patient with schizophrenia may not recognize that their behavior, hallucinations, or that delusions are unusual or unfounded. Relapses happen when a person stop taking antipsychotic medication, stop participating in therapy, or both, relapse into active phase psychosis (Gotra, al 2020).

The main reason for decision #1 is for the patient to have a reduction in patient’s symptoms of paranoia. Also, a reduction in her PANSS score by 25% which may be achieved by patient’s adherence to medication. The administration of the Invega Sustenna once monthly is the best choice for this patient because of patient history of non-adherence to medication as schedule. Also knowing that Invega Sustenna was endorsed by the FDA following a study that showed a significant break in the cycle of hospitalization in patients taking this once-monthly schizophrenia treatment (Gotra, al 2020). Following a 4 week visit, patient PANSS score was at 25 %, compliance with treatment with treatment appointment with the support of her husband and tolerating medication with expected side effect complaint of 2 pounds weight gain/ pain at injection site (Gotra, al 2020).

Decision # 2

I will choose to maintain the current dosage Invega Sustenna. the patient will continue to the same doses as in decision #1.  the reason is that paliperidone dosage of 39-234 mg is usually well tolerated in adult patients with schizophrenia (nordholm et al 2013). Patients with schizophrenia have less relapsed and are proven to have at least one relapse within five- six years of diagnosis. Patients are at risk for relapse due   increase of non-adherence to treatment plans. Research shows that many patients treated with an oral atypical (nordholm et al 2013). In this decision #2 the expected achievement was achieved as evident by patient follow up visit and a reduction in PANSS score and tolerating treatment with major adverse effect. Paliperidone palmitate has been shown to be effective in reducing PANSS total scores in both acute and maintenance treatment. patient reports weight gain total of 4.5 pounds in a 2-month period and pain at the injection site. (Nordholm et al 2013).  At this stage, PMHNP needs to educate the patient on the importance of remaining compliant. Also, medication can be alternated on different sites as well as given on the deltoid to reduce injection site discomfort (nordholm et al 2013).

Changing medication from Invega Sustenna to Haldol Decanoate or Abilify is not necessary at this stage. Firstly, there oral which will defeat the whole purpose of wanting the patient to be compliant.

Decision # 3

In this decision 3, at this stage I will continue the patient on the same dosage monthly of Invega Sustenna. The explanation of this is that long-term maintenance examination of have shown remarkable progress from baseline to the termination which was tracked on PANSS with the patient on Invega Sustenna.   intramuscular paliperidone has been proven to be effective in the treatment of adult patients over a long-term period (Jenkins, et al 2018).

The anticipated attainment and the result of decision # 3 is continued maintenance level for the patient on medication and continue the decrease in symptoms and educate to follow up an appointment as schedule to avoid relapse (Jenkins, et al 2018). At the current decision, it is important that prior to prescribing medication PMHNP will educated the patient about side effect of the medication and prevention. Educate about ng weight loss, diet and exercising while taking Invega Sustenna.

The decision remains the same, because there is no difference between what I expected to achieve with decision #3. the complaint is still the same, as weight gain is expected and to counter this weight gain issue, education should be reinforced. Other medications like Abilify is not appropriate for this patient.  Invega Susitna proven to have more success rate in the treatment of schizophrenic.  Abilify has lots of adverse effects like akathisia (Jenkins, et al 2018). furthermore, patient is not considered overweight, changing medication is not recommended due to potentially exposing the patient to cardiovascular complications with prescription. the main goal of psychotic treatment to keep treatment simple to encourage adherence of patient to plan (Jenkins, et al 2018).

Ethical Considerations

The PMHNP should have knowledge of dealing with schizophrenia and psychosis.  PMHNP should be mindful that the patient may have the feeling that their medical and physical health problems may not be taking totally serious by healthcare professionals.  Ethical consideration also include specific patient involves finding a support system. This will assist in forming trust and relationship which will allow joint care planning over time (Garfield, D., & Steinman, I. 2015). Also, establishment of a therapeutic relationship is vital to evaluating the nature of a patient’s problems and provides the groundwork of any following management plan. Lastly, , it is always important to obtain informed consent for treatment  from the patient before starting any form of treatment (Garfield, D., & Steinman, I. 2015).


It is very important for PMHNP who is treating a patient with schizophrenia to be aware and have knowledge of medications that promote adherence to treatment plans. PMHNP should listen to patient concern. It is very essential to carry the patient and their support system along to enable them to be part of plan of care, this will   promote adherence and commitment to treatment. The PMHNP is required to communicate treatment plan, medication adherence, adverse effects to the patient. Lastly, the patient needs to know that there are undesirable side effects like weight gain and sexual dysfunction (Garfield, D., & Steinman, I. 2015). The PMHNP should be empathetic toward patients need and concern, provide information about financial help.


Nordholm, D., Krogh, J., Mondelli, V., Dazzan, P., Pariante, C., & Nordentoft, M. (2013). Pituitary gland volume in patients with schizophrenia, subjects at ultra high-risk of developing psychosis and healthy controls: A systematic review and meta-analysis. Psychoneuroendocrinology38(11), 2394–2404.

Puntis, S., Puntis, S., Minichino, A., De Crescenzo, F., Harrison, R., Cipriani, A., & Lennox, B. (n.d.). Specialized early intervention teams (extended time) for recent‐onset psychosis. Cochrane Database of Systematic Reviews11.

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Antipsychotic agents, also called neuroleptic or major tranquilizers, are used primarily to treat schizophrenia. Schizophrenia is characterized primarily by a clear sensory but marked thinking disturbance. Second-generation/ Atypical antipsychotics are widely used due to their broad spectrum of receptor activity since they affect Serotonin, dopamine, and GABA neurotransmitters (de Miranda et al., 2020). Besides, they are better at alleviating negative symptoms and cognitive dysfunction than typical antipsychotics. The purpose of this assignment is to develop a study guide for an antipsychotic agent.

Drug Description

Quetiapine, whose brand name goes by Seroquel, is used in treating schizophrenia. It is FDA-approved for treating schizophrenia, Bipolar disorder, and major depressive disorder (MDD) as an adjunctive treatment (de Miranda et al., 2020).

Non-FDA uses

The non-FDA uses of Seroquel include the treatment of generalized anxiety disorder (GAD), Alcohol Dependence, and Insomnia.

  • According to Ansara (2020), Seroquel exhibits efficacy in managing treatment-resistant-GAD as an adjunctive agent. In this case, smaller doses than those prescribed for schizophrenia and bipolar disorder are usually needed for symptom improvement.
  • Seroquel has been found to reduce alcohol consumption in heavy drinkers and has the potential for treatment for alcohol dependence, particularly among heavy drinkers (Vatsalya et al., 2020).
  • Low doses of quetiapine are usually prescribed for insomnia, although this is a non-FDA use due to potential adverse effects like weight gain and akathisia (Boafo et al., 2020).

Drug classification

Seroquel is an antipsychotic under second-generation antipsychotics.

MOA Pharmacokinetics Pharmacodynamics
An antagonist for D2 receptors and serotonin receptors. Absorption: Bioavailability: 100%

Peak plasma time: Immediate release-1.5 hr; extended release-6 hrs

Reduces the hallucinations and delusions associated with schizophrenia by blocking dopamine receptors in the mesolimbic system of the brain.
Acts on dopaminergic D1 and D2 receptors. Metabolism: Metabolized in the liver by CYP3A4


Excretion: Urine (73%), feces (20%).


Appropriate dosing: 150-750 mg/day (Immediate release); 400-800 mg/day (extended release).

Children <12 years: safety not established.

Children >12 years: Dose range 400-800 mg/day (de Miranda et al., 2020).

Geriatrics: 50-200 mg/day (Immediate); 50 mg/day (Extended)

Pregnant and breastfeeding women: Not recommended.

Route of Administration:  Orally.

Considerations for dosing alterations: Elderly and patients predisposed to hypotensive reactions.

Half-life:  The time it takes for the concentration of a drug to decrease to half of its initial dose in the body.

  • Understanding half-life is important because it determines a drug’s excretion rates and steady-state concentrations. After one half-life has passed, half of the starting drug amount is eliminated from the body (Smith et al., 2018).
  • Seroquel has a half-life of 6 hours for immediate release formulation and 7 hours for extended-release formulation.

Side effects/adverse reaction potentials

Seroquel is associated with various adverse effects, including somnolence fatigue, dry mouth, constipation, increased appetite, weight gain, orthostatic hypertension, and dizziness (de Miranda et al., 2020). Neuroleptic malignant syndrome is a possible adverse effect due to the drug’s D2 receptor blockage.

Contraindications for use including significant drug-to-drug interactions

  • Currently, no identified FDA contraindications of quetiapine.
  • It is contraindicated in patients with documented hypersensitivity.
  • However, quetiapine is associated with an increased risk of death in elderly patients with dementia-related psychosis (Osborne et al., 2020).
  • Precaution is needed with drugs that prolong QT intervals and patients with prolonged QT intervals.

Contraindications due to drug-to-drug interactions

  • Amisulpride
  • Goserelin
  • Lefamulin
  • Leuprolide

Overdose Considerations

Seroquel can be life-threatening if taken in an overdose. Toxicity occurs with levels > 1500 ng/mL.

Supportive care is the mainstay of treatment in an overdose.

Measures for acute toxicity include: Maintaining the airway; Ensuring adequate oxygenation; Ventilation (Osborne et al., 2020).

Gastric lavage and administration of activated charcoal with a laxative can prevent more drug absorption if promptly given.

Diagnostics and labs monitoring

The prescribing clinician should monitor the patient’s metabolic panel focusing on fasting glucose, cholesterol and triglyceride levels, weight, and blood pressure (before and during treatment). Besides, patients on long-term treatment should have a lens exam every six months for cataract monitoring (Osborne et al., 2020). Leukopenia, neutropenia, and agranulocytosis can occur with Seroquel treatment, and thus a complete blood count (CBC) should be performed during the first few months of treatment (Osborne et al., 2020). In addition, orthostatic vital signs should be monitored in patients vulnerable to hypotension like geriatrics, patients with dehydration, hypovolemia, and those on antihypertensives.

Comorbidities considerations

  • Precautions should be taken in patients with hypokalemia, cardiac arrhythmia, and hypomagnesemia. Metabolic panels should be obtained before initiating the drug (Osborne et al., 2020).
  • Patients with diabetes mellitus should have their glucose monitored to avoid hyperosmolar coma.

Legal and ethical considerations

  • The clinician prescribing Seroquel should uphold beneficence by ensuring that the drug will have the maximum benefit in treating a patient’s psychotic, bipolar, or MDD symptoms. Nonmaleficence should be upheld by considering the drug’s side effects and ensuring that the benefits outweigh the risks.
  • The clinician should obtain consent from the patient before initiating treatment with Seroquel and explain the potential benefits and side effects for the patient to make an informed decision.
  • Confidentiality of the patient’s health information should be maintained to prevent legal consequences.

Pertinent patient education considerations

The patient should be educated about the drug’s indications, benefits, and side effects. Patients should be informed that the drug can be discontinued if they experience severe side effects and if they have a decrease in WBCs (de Miranda et al., 2020). Besides, they should be educated that abrupt drug discontinuation poses a risk for withdrawal symptoms.


Seroquel is a second-generation antipsychotic, FDA-approved for treating schizophrenia, Bipolar disorder, and MDD. It is also used off-label in treating insomnia, treatment-resistant GAD, and alcohol dependence. Seroquel is an antagonist for D2 receptors and serotonin receptors, which results in reduced psychotic symptoms. Patients on Seroquel should be monitored for cholesterol and triglyceride levels, weight, blood pressure, fasting glucose, cataracts, complete blood count, and orthostatic vital signs. Ethical principles of beneficence, nonmaleficence, confidentiality, and consent should be upheld when prescribing patient Seroquel.


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Boafo, A., Greenham, S., Sullivan, M., Bazaid, K., Suntharalingam, S., Silbernagel, L., Magner, K., & Robillard, R. (2020). Medications for sleep disturbance in children and adolescents with depression: a survey of Canadian child and adolescent psychiatrists. Child and adolescent psychiatry and mental health14, 10.

de Miranda, A. S., Ferreira, R. N., Teixeira, A. L., & de Miranda, A. S. (2020). Mood Stabilizers: Quetiapine. NeuroPsychopharmacotherapy, 1-23.

Osborne, V., Davies, M., Evans, A., & Shakir, S. (2020). Observational assessment of safety in Seroquel (OASIS): a specialist cohort event monitoring (SCEM) study in England. Therapeutic advances in psychopharmacology10, 2045125320954616.

Smith, D. A., Beaumont, K., Maurer, T. S., & Di, L. (2018). Relevance of Half-Life in Drug Design. Journal of medicinal chemistry61(10), 4273–4282.

Vatsalya, V., Kong, M., Marsano, L. M., Kurlawala, Z., Chandras, K. V., Schwandt, M. L., Ramchandani, V. A., & McClain, C. J. (2020). Interaction of Heavy Drinking Patterns and Depression Severity Predicts Efficacy of Quetiapine Fumarate XR in Lowering Alcohol Intake in Alcohol Use Disorder Patients. Substance abuse: research and treatment14, 1178221820955185.