RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 1

The Difficulties in Ensuring Compliance in Schizophrenic Patients

Angela Babcock

Teresa Peck

Youngstown State University

RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 2

Abstract

The issue with medication compliance in those with mental illness is well known. This

case study examines R.S., who is a paranoid schizophrenic patient with bipolar. Her issues with

medication compliance are explained as well as the issues of maintaining relationships due to her

delusions of religion, persecution, and grandeur. Her issues with noncompliance lead to her

hospitalizations and cause exacerbation of her schizophrenic symptoms.

RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 3

Objective Data

R.S. is a 50-year-old female with no known allergies, full code, admitted on Oct. 30.

During her admission she was on self-harm precautions, elopement risk, and high and low risk

protocols. These are measures used keep the patient safe. The elopement risk is given when a

patient is at risk for trying to leave the lock down unit. Self-harm protocols are measures taken to

prevent suicide while on the psych unit, such as beds low to the floor, paper bags instead of

plastic in the trash cans, unbreakable bathroom mirrors, windows with screws that can’t be used

for self-harm, plastic silverware, and short dull pencils. Patients are visually checked every 15

minutes to prevent self harm. R.S. was diagnosed with bipolar, paranoid schizophrenia, diabetes,

fibromyalgia, and hypothyroidism. On admission she arrived to the ER, pink slipped, following

an argument with her ex-husband of wanting to get her gun from him. When he refused, she

became very irritable and homicidal. During ER admission patient stated, “I want to light the ER

physician on fire with my lighter.” She denies suicidal ideation but not homicidal ideation.

On Nov.8, I observed and talked to her before dinner. We had a nursing group therapy

about dealing problem solving, which she participated in. She described what it was like having

auditory hallucinations and how the first step to dealing with them is realizing that they aren’t

real and that others aren’t seeing them. During this group, I witnessed her being very labile. She

would laugh one minute and started crying when talking about the mental health stigma in our

society. During my interview with her after group, she was relaxed and neatly dressed.

Whenever talking about her doctor or family, she became very tensed and irritable. She said her

reason for being admitted was the she was admitted under false pretenses because someone

claimed she missed an appointment.

RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 4

She was having persecutory delusions, that her doctor is out to get her and trying to mess

with her medications. She stated, “he is pumping me full of meds, enough to tranquilize a horse.”

She stated, “I want to snap his neck in half like a pencil.” She also believes that her parents are

stealing food from her apartment. R.S. was also having religious delusions. These including her

stating that she was married to the antichrist and that he was going to come for her parents. She

also stated that she used to be prostitute in New York City. I believe this to be religious delusion

because her parents are Christian, and she is very against their religion. Having a delusion that

she was a prostitute would be a stab at her parents. She also stated that Chick Publications, which

is a Christian book company, are protestant right wing horror tracts that show exorcisms. She

also stated that she wants to be like Joan of Arc.

During my interview with her on Nov. 8, she had inappropriate affect. When talking

about how her ex husband raped her, she laughed and said he was an asshole. She also had

unpleasant affects in showing agitation and aggression towards her ex. husband and family. In

her thinking, she showed some circumstantiality. She would get off topic and pause. I had to

remind her what she was talking about and then she would get to the point. She was oriented in

her memory but impaired in her judgment. When the nurses tried to explain that the doctor was

titrating her medication, she only believed that titration means going from a high to low dose.

She became very irritable because the doctor is slowly increasing her medications and she

doesn’t believe that is titration. She was dictating her medications, refusing certain ones and if

two doses were required each day, she would only take the one dose.

I also interviewed her on Nov. 15, a week after my first interview. The night before she

had only slept 1.5 hours and was angry that they were keeping her over the weekend. She didn’t

recognize me from the week prior. Her reason for admission this time was that she was playing
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 5

her music too loud, so the cops came and took her here. When she talked about her parents and

ex-husband, she was still agitated and angry. She stated, “As soon as I get out of here, I’m

getting a retraining order for all of them.” She believes that her ex-husband lied to her about

everything but his name. She stated that he called pretending to be her father. Since my last visit,

she had court hearing. The court ordered that she could only be held here for 90 days and was

OPC per probate court to take long acting aristada injections every 30 days and follow treatments

and medications. OPC is court ordered treatment (including medication) for individuals who

need ongoing behavioral health care to prevent relapse, rehospitalization, and/or dangerous

behavior and who have difficulty following treatment. This can help increase patient’s long-term

compliance and reduce caregiver stress. She was having grandiose delusions. She told me that

she can’t take Zyprexa because she received a 90,000 settlement the she can’t talk about and has

a class action lawsuit against Zyprexa. She was still having persecutory delusions about her

parents stealing her food and her doctor being out of get her. Her speech was very slow that day

and she kept zoning out in the middle of our conversation. She would stop talking and stare off

into the distance. Compared to the week before, she looked exhausted. She had difficulty

carrying out conversation. When asked if she was having hallucinations, she denied ever having

them, even though the week before she described hers and said that voices told her to eat a bowl

full of pills. The nurses on shift reported that they observed her talking to unseen others in her

room on 11/15.

On Nov. 8, the medications she was on were divalproex DR bid 750mg to treat bipolar,

aripiprazole 20mg to treat schizophrenia, duloxetine 60mg to treat fibromyalgia, haloperidol 5mg

to treat agitation, hydroxyzine 50mg for anxiety, trazodone 150mg for sleep, and Aripiprazole

lauroxil (aristada) 662 mg IM q30 days.

RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 6

On Nov.15, R.S. was on Haldol 5mg for agitation, hydroxyzine 50mg for anxiety,

duloxetine 90mg for fibromyalgia, aripiprazole 20mg to treat schizophrenia, divalproex DR

1000mg bid for bipolar, and zolpidem tartrate 10mg for insomnia.

Her lab values on admission were WBC 10.8H, RBC 4.69, Hgb 13.4, Hct 39.9, MCV

85.1, MCH 28.6, MCHC 33.6, RDW 14.5H, PLT count 366, MPV 8.0, TSH 2.00, T4 0.99, both

her alcohol level and toxicology were negative on admission.

Summarize

To be diagnosed with schizophrenia, patient must exhibit two or more of following: delusions,

hallucinations, disorganized speech, grossly disorganized or catatonic behavior, negative

symptoms during a 1-month period. For a significant portion of time since onset of disturbance,

level of functioning in on or more major areas is markedly below level achieved the level

achieved prior to onset. Patient must have continuous signs of the disturbance persist for at least

6 months. Schizoaffective disorder and depressive or bipolar disorder with psychotic features

have been ruled out. The disturbance must not be attributable to physiological effects of

substance (Townsend, M.C., Morgan, K.I. 2017 p.342-343). Some positive symptoms that you

may see with schizophrenia are delusions of persecution, delusions of grandeur, delusions of

reference, delusions of control, somatic delusions, nihilistic delusions, paranoia, magical

thinking, associative looseness, neologisms, concrete thinking, clang associations, word salad,

circumstantiality, tangentiality, mutism, preservation, hallucinations (auditory, visual, tactile),

illusions, echolalia, echopraxia, depersonalization ( Townsend, M.C., Morgan, K.I. 2017 p.350-

352). Some negative symptoms that may be present include inappropriate affect, flat affect,

apathy, volition, deteriorated appearance, impaired social interaction, social isolation, lack of
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 7

insight, anergia, waxy flexibility, pacing and rocking, anhedonia, and regression (Townsend,

M.C., Morgan, K.I. 2017 p.352-353).

Bipolar disorder is mood disorders characterized by mood swings from profound

depression to extreme euphoria, with intervening periods of normalcy (Townsend, M.C.,

Morgan, K.I. 2017 p.419). During the manic episode, mood is elevated, expansive or irritable.

Mood is subject to change from irritable and anger or even sadness and crying. Patient may

exhibit flight of ideas, pressured speech, disorganized speech, distractibility, impulsive spending

(Townsend, M.C., Morgan, K.I. 2017 p. 425).

Identify

The stressors and behaviors that precipitated the current hospitalization of R.S. include recent

separation with husband, disturbed relationship with parents, pattern of schizophrenia, and non-

compliance with medications.

Parashos, I.A., Xiromeritis, K., Zombau, V., Stamouli, S., & Theodotou, R. (2000)

examined the reason behind noncompliance in patients with schizophrenia and their relatives.

According to their study, the most important cause for non-compliance, according to patients’

and relatives’ opinions, was the lack of knowledge concerning the illness (natural course and

importance of pharmacotherapy). This finding is supported indirectly by the existing literature.

Compliance is found to be improved by 30% after a series of psychoeducation sessions and also

by the provision of knowledge specifically about medication (Parashos, I.A. et al. 2000). Lack

of insight, social pressure and side-effects are also mentioned in the literature as reasons for non-

compliance. Of special interest is our finding that 50% (10/20) of the reasons mentioned in our

study were related directly (side-effects) or indirectly (lack of knowledge about treatment

methods, including efficacy and safety of drugs) to the use of drugs for treatment. This relatively
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 8

high percentage shows the importance of accurate and extensive discussion of the issue of

pharmacotherapy with the patients ( Parashos, I.A. et al 2000). On Nov. 3, R.S. Depakote level

was 28.6. This proves that there was noncompliance in her medication adherence. On Nov. 13,

her valproic acid level 57.7, which is within the therapeutic range.

Due to disturbed family relationship, no one was there to ensure that R.S. was taking her

medications. With the pattern of schizophrenia and the periods of remission and exacerbation, it

is important to have a strong support system. According to R.S., she didn’t have a strong family

relationship for a while, so her husband appeared to be her support system. With the recent

separation, she lost that support system.

Discuss

Family has no history of mental illness. Patient has minimal contact with brothers and

parents. R.S. was admitted in 1992 to Weston State Hospital in Washington, where she was

diagnosed with schizophrenia at age 24. She spent 5 years there. Was going to counseling at

Genesis Counseling for 11 years and seeing Dr. Fikter there, but per collateral hasn’t been there

for a year. Last fall, R.S. was at Highland Springs. She was at Mercy Health Toledo 1 week prior

to admission and was discharged.

Describe

I sat next to R.S. in a group therapy about problem solving. When hallucinations were

bought up, she participated in the discussion, describing what her auditory hallucinations were

like and that she had to realize they weren’t real. She stated that in the past voices told her to eat

a bowl full of pills. Nursing care for this patient would be providing a safe and therapeutic

environment. Pinho, Lara Guedes de, et al. (2017) states “when caring for a patient with
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 9

delusions, it is important not to discuss or deny belief so as not to risk compromising trust.

Reasonable doubt must therefore be used as a therapeutic technique. For example, “I understand

that you believe this to be true, but I do not think the same.” The nurse should also be attentive

during feeding and taking medication, since the delirium of poisoning may be present, and the

patient may believe that the food or medication is to poison him. Thus, it may be necessary to

confirm whether the patient has taken the medication (Pinho, Lara Guedes de, et al. 2017).

Nurses should also monitor the patient for symptoms of schizophrenia. The nurses witnessed

R.S. talking to unseen others in her room on 11/15.

Analyze

R.S. stated that she recently converted to Catholic 6 years ago. Her parents are Christian,

and she was raised Christian. Patient stated that her priest came to visit her, which was very

important to her. Her and her parents’ religious differences seem to be the main cause for her

religious delusions about her being married to the antichrist and her delusions about Christian

faith and her seeing exorcisms as a child. In a way, it seems as though she is showing a bit of

regression. When interviewing her it seemed she was regressing back to her teenage years and

being rebellious towards her parents. She kept claiming that they are always in her business and

wouldn’t get off her back, even though they are around 80 years old. The chart also stated that

she has minimal contact with them, however she claims they are always butting in her life.

Evaluate

R.S. is a very intelligent individual. She is well read on psychology and medications.

When attempting to be educated on her medications and titration, she became very agitated with

the nurses. They tried explaining to her that they were titrating her from low to high doses and in
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 10

her mind, titration only means high to low. An issue that affects her care are also her delusions.

She believes that her doctor is out to get her and purposefully messing with her medications and

delaying her disability process. Her persecutory delusions make it hard to treat her. A study done

by Kilicaslan, E. E., Acar, G., Eksioglu, S., Kesebir, S., & Tezcan, E. 2016, examined the

relationship between the type of delusion and the treatment in patients with schizophrenia. In our

study, the analysis of the correlation between delusion types and response to therapy showed that

in patients with religious and grandiose delusions, the duration of hospitalization was statistically

significantly longer than in other patients (p=0.013, p=0.008). A study assessing first-episode

schizophrenia patients came to a result consistent with our study, finding that sexual, religious,

and grandiose delusions are strong determinants for poor response (Kilicaslan, E. E. et al 2016).

Summarize

R.S. was previously followed by Coleman. She will be discharge back to Coleman.

Coleman offers behavioral health services, family, individual, and group counseling, and

community housing. Social work will do a duty to warn ex-husband and family. OPC per probate

court mandated that R.S. take medications and follow treatment. Patient will be starting long-

acting aristada injections at the end of the month. Hopefully she will be able to get housing at

Coleman so that she can be monitored for medication compliance.

Although antipsychotic agents are generally effective, nonadherence is recognized to be

major problem, and can lead to poorer clinical outcomes and higher treatment costs

Accordingly, long-acting injectable (LAI) intramuscular formulations of antipsychotic agents

with extended dosing intervals have been developed to provide an alternative for patients who
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 11

are nonadherent to oral preparations, as set out in US guidelines, LAI formulations of

antipsychotics are recommended for patients with recurrent relapses related to nonadherence to

oral preparations and for those who prefer this mode of administration (Frampton, J. 2017).

Aripiprazole lauroxil LAI can be administered once-monthly (q4w), every 6 weeks (q6w) or

every 2 months (q8w), depending on the dose strength . This makes compliance more likely

due to less doctor visits and need to remember to take your medication, especially with those

suffering from schizophrenia. R.S. will benefit from this type of medication administration due

to her decreased compliance.

Prioritized

Psychosis, paranoid schizophrenia, persecutory delusions, bipolar disorder

List

Risk for violence r/t suspiciousness of doctors, agitation aeb verbalization of wanting to snap

doctors neck

Impaired social interaction r/t absence of significant others, disturbed thought process aeb

minimal contact with family, agitation

Social isolation r/t altered state of wellness, inability to engage in satisfying personal

relationships aeb seen sitting alone, projects hostility, withdrawn

Insomnia r/t short periods of sleep, paranoia, preoccupation of thoughts aeb observed changes in

affect, observed lack of energy

Disturbed thought processes r/t hallucinations, inability to trust aeb hostility towards doctor,

delusional thinking
RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 12

Risk for noncompliance r/t disturbed thought process aeb refusal to take medication, persecutory

delusions

Risk for Self-neglect r/t to paranoia aeb nonadherence to health activities

Risk for suicide r/t wanting her gun aeb involuntary admission, showing up to ex-husbands

wanting gun

Disturbed sensory perception: auditory/visual r/t hallucinations aeb verbalizing hx of hearing

voices, seen talking to unseen others

Dysfunctional family processes r/t conflict with family aeb agitation, anger, and hostility towards

family

In conclusion, caring and interviewing R.S. showed me a lot about how schizophrenia

can negatively impact your life. Due to her delusions, she pushed her family and husband away.

She developed persecutory delusions about her parents and as a result is at risk for social

isolation and issues with treatment and care. She doesn’t have a support system to ensure that she

is caring for herself and following her medication treatment. I hope that after being discharged

her OPC per probate and long-acting injections will help increase her medication compliance to

prevent exacerbations. Community mental health services such as Coleman, will hopefully work

to increase her compliance and do follow ups with her. Mental illness is a challenging issue in

terms of compliance, support system, prevention of rehospitalization, and compliance.

RUNNING HEAD: The Difficulties in Ensuring Compliance in Schizophrenic Patients 13

References

Frampton, J. (2017). Aripiprazole Lauroxil: A Review in Schizophrenia. Drugs, 77(18), 2049–

2056. https://doi.org/10.1007/s40265-017-0848-4

Kilicaslan, E. E., Acar, G., Eksioglu, S., Kesebir, S., & Tezcan, E. (2016). The Effect of

Delusion and Hallucination Types on Treatment Response in Schizophrenia and Schizoaffective

Disorder. Dusunen Adam: Journal of Psychiatry & Neurological Sciences, 29(1), 29–35.

https://doi.org/10.5350/DAJPN2016290103

Parashos, I. A., Xiromeritis, K., Zoumbou, V., Stamouli, S., & Theodotou, R. (2000). The

problem of non-compliance in schizophrenia: Opinions of patients and their relatives. A pilot

study. International Journal of Psychiatry in Clinical Practice, 4(2), 147–150. Retrieved from

https://eps.cc.ysu.edu:8443/login?url=https://search.ebscohost.com/login.aspx?direct=true&Auth

Type=ip,uid&db=a9h&AN=4430519&site=ehost-live&scope=site

Pinho, Lara Guedes de, et al. (2017) “Nursing Interventions in Schizophrenia: The Importance of

Therapeutic Relationship.” Journal of Neurology & Stroke,

http://medcraveonline.com/NCOAJ/NCOAJ-03-00090

Townsend, M., Morgan, K. (2017). Essentials of Psychiatric Mental Health Nursing: Concepts of

Care in Evidence Based Practice Ed.7. Philadelphia, PA: F.A. Davis Company