The symptoms of schizophrenia at an early stage and treatment can be provided to the patien - Research Paper Example

? Capstone Overview Allen Sutton Duke General Overview Schizophrenia is a brain disorder where a person is unable to think in a normal wayrather the thoughts are distorted, actions as well as emotions are abnormal. The perception of the person is unclear and the individual displays massive amount of behavioral as well as biological perturbation and therefore schizophrenia is regarded as split personality disorder. Schizophrenia is a condition of intricacy of devastating illness, a pathophysiological phenotypic observation is required and thus a thorough understanding of the condition is imperative for the timely cure. Innovative methods must be implemented to enhance the pace of diagnosis of the condition. The present research proposal encompasses innovative methods to diagnose the condition of schizophrenia and implementation of appropriate and timely measures. The proposed study is based on the symptom rating scale scores, although redundancy is observed in the rating scales but a association is essential to highlight the positive and negative characteristics of schizophrenia on the PANS scale. Relevance to the Study Considering the condition of paramount significance, it is essential to devise means to understand the symptoms of schizophrenia at an early stage and treatment can be provided to the patient. The condition is complex to understand and a complete understanding is therefore essential to delineate between the schizophrenia and other mental disorder and also to establish a clear line of demarcation between positive and negative symptoms of the disease. After a thorough understanding, the characteristics are measured on the PANSS (Positive and Negative Symptom Syndrome) scale. When the patient is subjected to the program called PROS, usually patients come up with severe symptoms of schizophrenia. This situation is disturbing and troublesome as well as a risk to the safety of patient as well as those associated with the patient. If the symptoms are discovered at later stages there is an augmentation in the cost of the healthcare and in certain cases the patient may not be able to afford the cost and hence remains untreated. Further, such cases are hospitalized at a frequent interval. The present proposal aims at identifying the cases of schizophrenia at an early stage and expedite them to the Psychiatrist. One of the drawbacks of PROS encompasses the non-addressed symptoms within the first three visits. If the patient sees Associate Chief Psychiatrist, an evidence based practitioner and a social worker who will be performing the administration of the test. It is essential to procure the opinion of these three individuals in order to achieve success. Problem Statement One of the major problems of treatment of patients with mental illness is non adherence to psychotropic medications. Non-adherence to psychotropic medication has soared as high as 90% in the first year in patients taking psychotropic medications (Weiden, 2007). Observation reveals that patients with schizophrenia normally stop their antipsychotic medications mainly because they do not consider the requirement of the medicines to be essential for their well-being and also due to lack of understanding of the mental illness (Sajatovic, 2010). Severe symptoms cause frustration in patients making them unendurable to participate in groups. Despite extensive evidence and agreement on effective mental health practices for persons with severe mental illness, research shows that routine mental health programs do not provide evidence based practices on the great majority of their patients with such illness (Drake, 2001). Evidence based practice is not always used in the program setting, however the present proposal aims at developing and implementing evidence based practice in the organization. The research proposes a methodology that is able to combat problems in the implementation of the PROS ( Personal Recovery Oriented Services), protocols. Description of organization The present proposal is to be implemented in capstone, a community- based, not- for- profit mental health organization, the organization holds 26 years of existence. The Institute of Community Living (ICL) has multiple sites with one mission: to assist individuals and families affected by or at risk for mental and developmental disabilities. The organization possesses a good reputation for delivering mental health services to people with mental illness and intellectual and developmental disorders. ICL is dedicated to delivering, residential, clinical and rehabilitative services to approximately 8,000 persons per year. Implementation of research will serve as an aid to those who are mentally challenged and require attention. Working as a clinical provider for a program within ICL, initially a community day- treatment program (CDTP) which was converted to the personal recovery orientation service (PROS, 2010). PROS, programs are designed for the integrated treatment of patients with multiple mental health and medical diagnoses (according to criteria of the DSM IV). Mental illness is a criterion but not required to be the primary diagnosis, but a participant must have a functional disability that rises to the level of impairment. The program has a census of 230 persons who are admitted in a graduated step process that gives the participant the choice whether to participate after which an initial assessment by the clinical providers. There are 20 clinical providers and 10 case managers with various levels of education. The program is designed to offer comprehensive patient centered treatment that help the patient recover from barriers that have kept them from acquiring the necessary skills of self care. Introduction Schizophrenia has a worldwide prevalence of 1% and is considered the prototypic disorder for understanding the phenomenology of psychosis and the impact of antipsychotic treatment, but with patients with schizophrenia exhibit features that extend beyond those seen in other psychotic illnesses. Hallucinations, delusions, disorganized speech and confused or agitated behaviour comprise the types of psychotic symptoms found individually or rarely together in all psychotic disorders and are typically responsive to pharmacotherapy. These are referred as positive symptoms while the schizophrenia patient also suffer with the negative symptoms encompassing apathy, avolition, alogia and cognitive deficits particularly deficits in working memory, processing speed, social cognition and problem solving abilities that test 1.5-2 standard deviations below population norms (Green et al, 2004). Cognitive dysfunction is the strongest predictor of functional impairment among schizophrenia patients, yet negative symptoms and cognitive deficits show limited improvement with antipsychotic treatment (Buchanan et al, 2007). Schizophrenia is not identical to other psychoses is imperative for appreciating the differential impact of antipsychotic medications on psychotic symtomatology and for understanding the rationale for non-dopaminergic antipsychotic drugs based on the underlying pathophysiology of schizophrenia (Carpenter & Koenig, 2008). The dopamine (DA) overactivity hypothesis has led to the development of the first therapeutic class of antipsychotic agents, now referred to as typical or first generation antipsychotic drugs. these medication differed in potency but shared the common mechanism of significant DA D2 blockade and associated risk for extrapyramidal side effects. In the past, the term "neuroleptic" was also employed to refer to typical antipsychotic drugs, literally meaning to "take hold of the nerves" in Greek, but this has been dropped from contemporary usage in favor of "antipsychotic drug", a term that more accurately reflects the primary clinical use of these agents. While the DA hypothesis is an advance over earlier conceptualization of psychosis, it has limitations and does not account for the cognitive deficits associated with schizophrenia that appear to be related to the decreased DA signalling in the prefrontal cortex. Advances in treatment have emerged from exploration of alternative mechanisms for psychosis and from experience from atypical antipsychotics potently antagonize the 5-HT2 receptor, while blocking D2 receptors less potently than older typical antipsychotic agents resulting in the atypical clinical profile of antipsychotic efficacy with limited extrapyramidal side effects. Also promising the medications that target glutamate and 5-HT7 receptor subtypes, receptors for GABA and acetylcholine, and even peptide hormone receptors such as oxytocin (Carpenter & Koenig, 2008). Schizophrenia is a neurodegenerative disorder with complex genetics and incompletely understood pathophysiology. Certain environmental exposures confer an increased risk of developing schizophrenia, including fetal second-trimester viral and nutritional insults, birth complications and substance abuse in the late teen or early adult years (Fanous & Kendler, 2008). Rather than being the result of single gene defect, mutations or polymorphism of many genes appear to contribute to the risk of schizophrenia. Implicated are genes that regulate neuronal migration and synaptogenesis (neuregulin 1), synaptic dopamine availability (Val{108/158} Met polymorphism of catechol-O-methyltransferase which enhances dopamine catabolism), glutamate and DA transmission (dystrobrevin binding protein 1 or dysbindin, particularly with schizophrenia patients with prominent negative symptoms), nicotinic neurotransmission (?7-receptor polymorphism) and cognition (disrupted in schizophrenia-1) (Porteous, 2008). Schizophrenia patients also have increased rates of genome-wide DNA microduplications termed copy number variants (Need et al, 2009) as well as epigenetic changes including disruptions in DNA methylation patterns in various brain regions (Porteous, 2008). This genetic variability is consistent with the clinical disease heterogeneity and suggests that any one specific mechanism is unlikely to account for large amounts of disease risk. In addition to increased mesolimbic DA activity related to positive symptoms, schizophrenia patients have decreased DA D1 activity in the dorsolateral and ventromedial prefrontal cortex (PFC) that is associated with cognitive deficits and negative symptoms (Buchanan et al, 2007). Cognitive dysfunction is the greatest predictor of poor functional outcome in schizophrenia and shows limited response to antipsychotic treatment. Experimental studies have provided new insights into the mechanisms of cognitive dysfunction. Glutamate NMDA receptor stimulation is involved in tonic inhibition of mesolimbic DA release, but facilitates mesocortical DA release (Sodhi et al, 2008). Thus, it has been established that schizophrenia is a complex mental illness that is caused due to environmental implications as well as genetic predisposition. Genetically at risk individuals may witness the symptoms of schizophrenia and if it runs in genes then chances of procuring the condition augments. The onset is usually in adulthood or at the later stages of life, women display the condition at the later stages of their lives while males represent this earlier and with higher intensity as compared to the females (Schizophrenia, Pub Med). The present proposal is based on identification of the symptoms of schizophrenia and such individuals display difficulty in working as well as keeping friends together with the thoughts like anxiety, depression as well as suicidal tendency and thoughts (Schizophrenia, Pub Med). The proposal is based on the analysis of the symptoms such as irritable or tense feeling, sleeplessness and poor concentration. With the gradual enhanced intensity of the schizophrenia condition and problems related with thoughts, sentiments and behaviour may be observed. Besides these other features encompasses lack of emotions, delusions, hallucinations, jumping thoughts without relevance as well as social isolation may be observed in individuals. Considering these symptoms, schizophrenia is categorized as- 1. Paranoid schizophrenia encompassing anxious temperament, an individual may display angry or argumentative predisposition, a feeling of false belief that others are trying to harm either the person himself/ herself or to their dear ones (Schizophrenia, Pub Med). 2. Disorganized schizophrenia encompasses lack of clarity of thoughts and expressions, kid-like behaviour, lack of emotions are few features linked with disorganized schizophrenia (Schizophrenia, Pub Med). 3. Catatonic schizophrenia encompasses lethargy and inactiveness, rigid muscles and posture, grimaced facial expressions, no response to others (Schizophrenia, Pub Med). Taking these in consideration the protocol has been devised that will aid in directing the individual to seek psychiatric help. Innovative Implications ICL is committed to new innovative ways to enhance treatment adherence in patients with mental illness. Initiatives to educate provider and direct-care staff are of paramount significance. The innovations presented in the present research proposal comprise a strategic plan in the way new patients are admitted to the PROS program. Evidence reveals that a large percentage of patients with schizophrenia are non adherent to psychotropic medications mainly because of past experiences. Patients complain about adverse drug reaction, weight gain, sexual side effects and many have the idea that drinking is forbidden. Under such situation psycho-education based on psychoanalysis becomes imperative and instead of asking the willingness of the patient to take the medication, the patient must be psychologically motivated to take the medication. Psychoanalysis is performed to understand the behavior and emotions of the individual. These factors remain hidden in the unconscious mind and generate gloom. These symptoms may in some cases be distinguished while in others it could result in individuality attributes, impede performance in professional as well as personal fronts. All these affects the self esteem of the individual, hence there is a need to undergo psychoanalytic treatment. Psychoanalysis determines the chronological basis of the problem, changes that took place over point in time and enables one to deal with the truth (What is Psychoanalysis?). Psychoanalysis encompasses treatment of cataleptic factors encumbering relationships, work performance, mood alterations and their impact on self esteem. The method is based on the verbal procedures. The sole motive of psychoanalysis is to resolve the issues related with psychological problems by conveying cataleptic clashes to the cognizant mind, where they may be tackled and determined. The focus is on basic approaches of practicing concerns and being judgmental on them as compared to the focus on behavior. Psychoanalysis therefore focuses on altering the personality of the individual in a complete manner in contrast to bringing alteration only in behavior (Guy, 2009). According to Freud, psychoanalysis is devised to fortify self-image, enhance attentiveness, alertness and to gain control on superego. It is a continuous process and may take years to be accomplished. A psychoanalyst plays an inert role and guide the person but unlike teacher the psychoanalyst cannot teach. It is imperative that the psychoanalyst should understand the emotional confrontation of the individual; it then becomes essential to bring the issue to the aching consciousness. A psychoanalyst reveals the derivation of the emotional confrontation. In order to make the therapy an effective method it is essential for the individual to deal with the issue and resolve the pain (Guy, 2009). According to Sigmund Freud's Theory, personality of the individual is shaped by diverse factors that enable an individual to react with the situation and respond to the world. The theory states that every individual is born with an identity. The personality of the individual revolves around this identity comprising gender, annoyance and appetite. Personality of the individual facilitates growth as it expresses the congregation of basic needs and how well they are met. In case of strong identity, desires and personality satisfaction commands the individual's life; on the contrary, if superego is too burly, the individual possess highly unyielding morals, the individual is going to be critical and rigid while interacting with others. Thus, the convictions an individual possess are deep seated in the unconscious mind and it is not accessible at a conscious intensity. What an individual is responsive about is determined by the conscious mind and at this stage an individual is least aware about the personality as most of the part of the personality development is hidden and unapproachable. When the individual is prompted then only subconscious mind and emotions are activated else they remain out of the dynamic conscience (Models of Understanding Human Behavior). Psychoanalysis is therefore a constant process where the analyst is required to build a repo with the patient, a bonding, an understanding similar to parent-child relationship. This familiarity and considerable approach enables the individual to rely on the analyst and transfer the hidden painful emotions from the unconscious mind to the conscious mind. According to Freud, this act is influential and provides the access to the analyst about the relevant issue bothering the individual. It is also observed that Freud's theory works well with males as compared to females (Models of Understanding Human Behavior). The PROS admission process happens in preadmissions interviews before an initial psychiatric evaluation. Some patients are evaluated soon after pre-admission and some evaluations happen after months of contemplation on the part of the patients. Standardization is definitely a priority for the continuity of care of schizophrenia case. Patients are non adherent partly because of lack of education by clinical providers that is imperative to initiate psycho education with the comprehensive assessment from the first day of pre admission. The PANSS is one option for standardizing pre - admission process and adopting guidelines. The administration of the PANSS diagnostic scale can be incorporated in the existing EMR. The PANSS measures 30 positive, negative and cognitive symptoms of schizophrenia. Psychiatric treatment can be expedited to high scorers. The providers facilitating the administration of the scale during the pre admission visit also assess high risk behavior and thoughts. Psychoeducation about the patient’s perceptions of medication can be documented and later measured in subsequent scales. This process will decrease the amount of patients that are symptomatic without proper medication treatment. The existing scale (MMSE, Folstein 1975) is inadequate to measure the severity of the high risk symptoms, but training will be provided in association and co-ordination with EBP Director. Quality Assurance can track the outcomes that will be useful in future research. This process has trialability and observability with the potential of adoption. Stakeholder and early adopters with an outlook may prove to be instrumental in introducing a new evidence based policies adopted by end users. Complexity and communicability of the innovation are attributed to the early adopters Greenhalgh (2005). The staff within the organization has experience with diagnostic scales. The electronic medical record is an ideal outer context to incorporate a diagnostic scale to measure symptoms and predict high risk behaviors. All these features pave the way to pursue the research in the proposed field Description of Evidence Evidence based literature to date highlights that, medication adherence interventions have not been widely adopted or sustained in "real-world" practice settings (Weiden et al, 2007). Studies recommend systemic and programmatic changes to overcome treatment barriers (Ziedonis, 2005). Poor medication adherence in patients with psychotic symptoms has a high prevalence of re-hospitalization and a negative impact on clinical outcomes in patients receiving services in the outpatient setting. (Weiner, 2007) Description of Barriers and Facilitators ICL represents a hierarchy of disciplines from administration to mental health peer specialist. The Locus of power is in social work who is the decision makers, innovator and early adopters in the organization. The diffusion of an innovation in ICL would take many facets of communication. Organizational bulletins, new letters, memos, directives, word of mouth and individual communication. The present proposal is already in the design phase of the innovation of this evidence based practice and alleviate systemic barriers that lend to the high rate of non - adherence. The approval is pending, but it is expected that with the adoption of this innovation the rate of non-adherence will decrease and generate awareness towards schizophrenia symptoms among the staff. Innovation Administration of diagnostic scale to the existing EMR hardware/software to detect high-risk symptoms using PANSS and APA evidence based guidelines in the treatment of patients with schizophrenia during pre- admission. Attributes of innovations that influence adoption: perception of the staff on multi- levels, Compatibility - diagnostic scales to pre - admission patients. EMR- Moderate complexity for providers to administer diagnostic scale Trialability / operability - pilot study can be conducted with small sample population. Reinvention - high chance of modification of policy and procedure. Adopters Innovators, adopters, locus of control, leaders, motivators, early/late adopters, champions, ICL organization has many people in high position that influence the adoption of an innovation. Laggards are the end users that learn about innovations from interpersonal channels, peers. Institutional leadership is critical in creating a cultural context and influence innovation. Preparedness: Formal and informal communications Bulletins, newsletters, conferences, seminars, political conference, social networks, actors, opinion leaders have wide social network, CEO ,COO, CMO and CFO, journalism, spoken or written communication, websites of the organization and other related means. Antecedents involves- Readiness , usability, adaptability , observability, acceptance of change and absorption of information, values, personality traits and perception of innovation Readiness / Adaptability encompasses- Interest in piloting initiatives and diffusion of innovation, advantages and cost effectiveness of the innovation. Outer-context- Influence of adoption in terms of technological and administrative innovations. Inter-organizational networking in the public sector, political and social influences. Conclusion Ever since the inception of PROS at ICL it has been observed that the inner context of culture and clinical practices of the program have focused on rehabilitation of the participants and not much emphasis is being provided on adherence to medications or education of how to overcome the barriers triggering a high rate of non adherence. These key factors influence the need for new innovations and guidelines to promote the accurate diagnosis. New innovation should give a step by step plan encompassing education of staff to the evidence based guidelines for the treatment of patients with schizophrenia and reinforce patient centered care by using diagnostic scale to measure severity and intensity. To assess a patient using PANSS, an approximately 45-minute clinical interview is conducted. The patient is rated from 1 to 7 on 30 and patients with high scores are referred to the psychiatrist at the first interview and subsequently every three months they are observed. As per the proposal, QI reports will be generated to show increase or decrease in symptom scores. Treatment will be efficacious with measurable outcomes that mimic the APA practice guidelines and decreased high risk behaviors. Differential diagnosis and treatment with psychotropic medication along with psycho education will enhance the gradual process medication adherence and elevate global function of patients. The psychoanalytic theory although old but it provides a complete picture about the individual's likes and dislikes as it is more close to the reality as the unconscious memories really trouble the individual and reminds of the incidence that proved to be the turning points in shaping the personality and thoughts of the individual. If the treatment is accompanied with psychoanalysis, to understand the cause of worry and pain then appropriate treatment and healing could be provided, on the contrary other theories such as behavioral theory facilitates one to understand the influence of the environment which itself is changing and individual may be exposed to many different kind of environment even within the same set of conditions. In order to treat mental illness the cause of the problem is to be rectified and the problem itself evades. Thus psychoanalytical theory together with the innovative procedure could prove to be boon in treating various levels of mental illness by understanding the cause of the trouble. References 1. Buchanan, R. W., Freedman, R., Javitt, D. C., et al. (2007). Recent advances in the development of novel pharmacological agent for the treatment of cognitive impairment in schizophrenia. Schizophrenia Bull, 33, 1120-1130. 2. Carpenter, W. T., Koenig, J. I. (2008). The evolution of drug development in schizophrenia: past issues and future opportunities. Neuropsychopharmacology, 33, 2061-2079. 3. Fanous, A. H., Kendler, K. S. (2008). Genetics of clinical features and subtypes of schizophrenia: A review of recent literature. Curr. Psychiatr Rep, 10, 164-170. 4. Folstein, M.F., Folstein, S.E., McHugh, P. R. (1975). "Mini-mental state". A practical method for grading the cognitive state of patients for the clinician. J. Psychiatr. Res. 12(3), 189-98. 5. Green, M. F., Kern, R. S., Heaton, R. K. 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