Psychiatry 2008 - September 2008 - (Page 42)

Mr. X specifically remained inconsistent in taking oral antipsychotic medications at any time other than when he was in a day treatment program Monday through Friday. His inconsistent intake of medication during weekends, holidays, and evening hours created a conundrum in attempting to establish an adequate oral antipsychotic regimen. He therefore required an injectable antipsychotic treatment regimen for adequate treatment of his psychosis. In the past, when Mr. X allowed injections in his gluteal muscles, he experienced excessive pain in his hips to the degree that he could not sit comfortably or sleep at night. Mr. X would accept his long-acting biweekly injections only in the left arm (deltoid) for at least seven years and would not allow the medication to be injected at any other site. As a result of the inability to rotate sites and the clinical necessity of injecting longacting medications into the deltoid, he developed three egg-shaped, hard, painful, noninfected lumpy nodules in his left deltoid in 2007. These painful and hard lumpy nodules occupied approximately 75 percent of the deltoid. Mr. X was informed by his psychiatrist and the treatment team about the FDA-approved gluteal site for risperidone long-acting injections. He did consent to a trial of an alternative deltoid site for risperidone long-acting injections starting on August, 7, 2007. These injections were administered deeply and slowly into the deltoid. The result of this intervention was a decrease in the size, pain, and density of these nodules considerably. In June of 2008, 10 months later, they occupied approximately 12 percent of the deltoid and were significantly less dense and tender. Qualitative improvements were also seen in treatment adherence with this patient. These improvements included impressions on the part of the involved treatment personnel that the patient was more open to clinical suggestions than previously and was less resistant to considering 42 Psychiatry 2008 [ S E P T E M B E R ] alternative courses of thought and action than had previously been observed. In some of these instances, the patient permitted changes in his treatment routine and alterations in daily activities, which were deemed to be positively correlated with clinical improvements, especially given that the narrow rigidity of his previous treatment response repertoire had closed off potential avenues for improvement. The patient’s medications were titrated up to 75mg of risperidone long-acting intramuscular injections every two weeks along with risperidone 8mg and aripiprazole 15mg orally each day. His irritability and agitation decreased to an extent where the patient was able to continue to live with his family and to independently commute using public transportation to and from his day treatment program Monday through Friday. He was also able to visit his internist regularly for management of hypertension. He had significantly fewer episodes of altercations with other patients, but continued to need redirection at times. He continued to experience an appreciable level of paranoia and still only allowed the risperidone long-acting injections to be administered by his psychiatrist. with other patients, was more flexible in his behaviour, and allowed changes in his routines as a result of reduced paranoia. Prior study results and the results of this case study support the safe and effective use of the deltoid muscle as an alternative injection site. As long-acting psychotropic medications become more available, bioequivalency studies on a variety of injection sites would be clinically useful. REFERENCES 1. Downie G, MacKenzie J, Williams A. Pharmacology and Medicines Management for Nurses, Third Edition. Upper Saddle River, NJ: Elsevier Health Sciences, 2003. Trigoboff E. The science of psychopharmacology. In: Kneisl C, Trigoboff E (eds). Contemporary Psychiatric-Mental Health Nursing, Second Edition. Upper Saddle River, NJ: Prentice Hall, 2009:110–135. Thyssen A, Ning X, Herben V, et al. Pharmacokinetics of long-acting injectable risperidone injected in deltoid muscle compared to gluteal muscle in subjects with schizophrenia. Poster presented at the 161st Annual American Psychiatric Association Annual Meeting; 2008 May 3–8; Washington, DC. Ning X, Thyssen A, Quiroz J, et al. Tolerability and safety of longacting injectable risperidone in chronic schizophrenia subjects using deltoid muscle as an alternative injection site. Poster presented at the 161st Annual American Psychiatric Association Annual Meeting; 2008 May 3–8; Washington, DC. Kane J, Honigfeld G, Singer J, Meltzer H. Clozapine for the treatment-resistant schizophrenic: a double-blind comparison with chlorpromazine. Arch Gen Psychiatry. 1988;45:789–796. 2. 3. DISCUSSION Additional factors that contributed to this patient’s clinical improvement include participation in a 25-hour-perweek day treatment program, residence with his caring brother and sister-in-law, family assistance in managing his finances, and medications for extrapyramidal side effects. It should be noted that this patient had in place the day treatment program and his family involvement when he was being treated with conventional antipsychotics in long-acting formulations. Treatment outcome under these conditions was inadequate in part, as indicated by the presence of episodes of irritability and aggression, psychological rigidity, and heightened paranoia. With the present treatment regimen, the patient had fewer verbal altercations 4. 5.

Table of Contents Feed for the Digital Edition of Psychiatry 2008 - September 2008

Psychiatry 2008 - September 2008 Editor’s Message Editorial Advisory Board Contents Psych Rx Letters to the Editor Use of Benzodiazepines in the Treatment of Anxiety Functional Neurosurgery in the Treatment of Severe Obsessive Compulsive Disorder and Major Depression: Overview of Disease Circuits and Therapeutic Targeting for the Clinician Treatment of Comorbid Adolescent Cannabis Use and Major Depressive Disorder Risperidone Long-acting Injections: Successful Alternative Deltoid Muscle Injections for Refractory Schizophrenia Alcohol/Substance Misuse and Treatment Nonadherence: Fatal Attraction Transforming the Psychiatric Inpatient Unit from Short-term Pseudo-asylum Care to State-of-the-art Treatment Setting Journal Watch Classified Advertising Information for Authors

Psychiatry 2008 - September 2008

For optimal viewing of this digital publication, please enable JavaScript and then refresh the page. If you would like to try to load the digital publication without using Flash Player detection, please click here.