Managing Clozapine Treatment In Psychiatric Patients: Risks And Precautions Essay.

Case Study - Therapeutic Relationships

Read the following article:

Dziopa, F., & Ahern, K. (2009). What makes a quality therapeutic relationship in psychiatric/mental health nursing: a review of the research literature. The Internet Journal of Advanced Nursing Practice, 10(1). doi:10.5580/1060

• The investigators found that a therapeutic relationship in advanced psychiatric/mental health nursing could be deconstructed into nine main constructs: conveying understanding and empathy, accepting individuality, providing support, being there/ being available, being genuine, promoting equality, demonstrating respect, maintaining clear boundaries and having self-awareness.

• Using the Case Study“I am Anne” and reflecting on examples from your own clinical experience, as well as utilising academic sources, explore each of the nine constructs found by Dziopa and Ahern (2009) in a written paper.

Therapeutic Relationship in Psychiatric/Mental Health Nursing

Clozapine is an “atypical” antipsychotic that is used to treat patients who present with schizophrenia (Lally & MacCabe, 2015). However, clozapine is not used in a great subset of the patients but rather for those few patients with an advanced or progressed type of schizophrenia due to its side effects that are rather profound (Winckel & Siskind, 2017; Bastiampillai et al., 2016). The amount of dosage of clozapine is dependent upon the age, the nutritional status and factors inherent to its metabolism and interactions with other drugs. Clozapine has been available in the market since the 1960s where it was assumed that it was the best drug to use because of the inherent extrapyramidal effects that are associated with the typical antipsychotics such as chlorpromazine and haloperidol that bear significant extrapyramidal effects (Crilly, 2007).

It is important, therefore, to consider the associated side effects that are inherent to clozapine when administering the drug. These effects include the association of clozapine and heart problems or dysfunction (Barry et al., 2015). An increase in patient’s temperature, chest pain, and dyspnea is highly indicative of an adverse effect after the administration of clozapine. It is essential to perform laboratory investigations to identify any significant increase in BNP levels (which is a marker for cardiovascular problems in patients who are using clozapine to manage illnesses) (Caforio et al., 2013). Frequent measuring of the patient’s temperature and blood pressure is also crucial. The collecting of patients’ vital signs is highly necessary as it aids the early identification and management of cardiovascular problems.

Maintaining the environment and personal safety of patients who are receiving clozapine as a treatment modality is yet another essential factor to consider. The consumption of clozapine significantly increases the risks of infection to the patients in question (Correll et al., 2015) . Considering that the CYP450 is used in the metabolism of clozapine, a hindrance of the activity of the CYP450 system significantly compromises the patient’s immune system activities (Sriretnakumar, et al., 2015). The patient is likely to face more infection in such cases. It is, therefore, crucial to ensure that the patient’s environment is clean and that the patient is not exposed to any causative agent of disease. Seclusion of psychiatric patients with diseases such as tuberculosis from those receiving clozapine is thus crucial.

The risk of physical injury is also high in patients who are receiving clozapine. The fact that the patient may experience seizures is very high in many cases.  In case the environment is not safe, the patient may fall and get hurt. Seizures are very common prior to the use of clozapine. For these patients, drugs for the management of epilepsy may be necessary as they may help to control or get rid of the epileptic fits. In most instances, tonic-clonic seizures are the most common in these type of patients. During a seizure, the nurse or medical personnel should ensure that the environment is safe and that the risk of injury from the external environment and from self is minimal (Varma et al., 2011)

Clozapine Usage in Psychiatric/Mental Health Nursing

Clozapine has the potential to lead to the development of OCD (Obsessive Compulsive Disorder). The overuse of clozapine has been linked to the development of OCD in wide subset of patients. The reduction in the dose of clozapine being administered and the combination of drugs used in the management of OCD with clozapine administration, significantly aids in reducing the likelihood for development of OCD. It is crucial for the nurse or medical personnel to assess patients under his or her care for signs of compulsion and obsession that are evident in patients with OCD (Schirmbeck et al., 2013).

Other the negating effects associated with clozapine, it is essential to note the unique mechanism of action that clozapine contains that makes it a drug of choice for the schizophrenic patients (especially with the chronic type of schizophrenia). Clozapine has a greater affinity for the D4 and D1 receptors and a lower affinity for the D5 receptors and serotonin (S2 receptors) respectively.  This ability makes clozapine the drug of choice for those clients with an exaggerated type of schizophrenia, considering it is the only drug with the ability to operate on the receptors as mentioned (Torniainen et al., 2014)

Laboratory testing for patients taking clozapine as a treatment modality should always be performed. This fact is stressed by the fact that clozapine has the ability to cause neutropenia or a decrease in the decrease in the neutrophil count in children. Blood transfusion should be performed in case a disparity is identified in these subsets of patients. Lithium carbonate is also essential in controlling the neutrophil count in these patients. Agranulocytosis is also common, it is, therefore, important to ensure that children (who are more at risk) have fool blood counts conducted and are separated from any disease-causing substance (Torniainen et al., 2014). 

Conclusion

Clozapine is the drug of choice for the management of schizophrenia. However, the risks of its use have to be closely identified and monitored. Taking patients vital signs as per institution policy and assessing the normal blood counts for any disparity is crucial for the patients. Clozapine should be used after other typical neuroleptics have failed to yield results due to its many side effects. 

• Clozapine should be used as the last alternative in most cases of treatment
• Children should have their blood count monitored continuously when they are receiving clozapine as a treatment modality
• Nurses should monitor patients receiving clozapine for any side effects such as seizures and ensure they are within a safe environment
• Nurses should ensure that infection prevention and control is performed to avoid the spread of infection to patients receiving clozapine due to its associated effects on the immune system.
• Noting and managing the signs of OCD in patients receiving clozapine is highly necessary to ensure appropriate management of these patients.
• A collaborative approach should be used in managing patients receiving clozapine in the treatment settings. 

References

Warnez, S., & Alessi-Severini, S. (2014). Clozapine: a review of clinical practice guidelines and prescribing trends. BMC psychiatry, 14(1), 102.

Kar, N., Barreto, S., & Chandavarkar, R. (2016). Clozapine monitoring in clinical practice: beyond the mandatory requirement. Clinical Psychopharmacology and Neuroscience, 14(4), 323.

Yuen, J. W., Kim, D. D., Procyshyn, R. M., White, R. F., Honer, W. G., & Barr, A. M. (2018). Clozapine-Induced Cardiovascular Side Effects and Autonomic Dysfunction: A Systematic Review. Frontiers in neuroscience, 12, 203.

Lally, J., & MacCabe, J. H. (2015). Antipsychotic medication in schizophrenia: a review. British medical bulletin, 114(1), 169-179.

Winckel, K., & Siskind, D. (2017). Clozapine in primary care. Australian prescriber, 40(6), 231.

Bastiampillai, T., Gupta, A., & Allison, S. (2016). FDA changes clozapine monitoring guidelines: Implications for worldwide practice. Asian journal of psychiatry, 21, 19-20.

Crilly, J. (2007). The history of clozapine and its emergence in the US market: a review and analysis. History of psychiatry, 18(1), 39-60.

Barry, A. R., Windram, J. D., & Graham, M. M. (2015). Clozapine-associated myocarditis: case report and literature review. The Canadian journal of hospital pharmacy, 68(5), 427.

Caforio, A. L., Pankuweit, S., Arbustini, E., Basso, C., Gimeno-Blanes, J., Felix, S. B., ... & Klingel, K. (2013). Current state of knowledge on aetiology, diagnosis, management, and therapy of myocarditis: a position statement of the European Society of Cardiology Working Group on Myocardial and Pericardial Diseases. European heart journal, 34(33), 2636-2648.

Correll, C. U., Detraux, J., De Lepeleire, J., & De Hert, M. (2015). Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World Psychiatry, 14(2), 119-136

Sriretnakumar, V., Huang, E., & Müller, D. J. (2015). Pharmacogenetics of clozapine treatment response and side-effects in schizophrenia: an update. Expert opinion on drug metabolism & toxicology, 11(11), 1709-1731.

Varma, S., Bishara, D., Besag, F. M., & Taylor, D. (2011). Clozapine-related EEG changes and seizures: dose and plasma-level relationships. Therapeutic advances in psychopharmacology, 1(2), 47-66.

Schirmbeck, F., & Zink, M. (2013). Comorbid obsessive-compulsive symptoms in schizophrenia: contributions of pharmacological and genetic factors. Frontiers in pharmacology, 4, 99.

Torniainen, M., Mittendorfer-Rutz, E., Tanskanen, A., Björkenstam, C., Suvisaari, J., Alexanderson, K., & Tiihonen, J. (2014). Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin, 41(3), 656-663.