Create a power point presentation (10-15 slides) or a poster to present to healthcare providers (50 points; 35% of total assignment grade)
•Provide evidence-based information that is significant to advanced practice.
*10-11 pages content, 1 title page, 1 reference page
Preventative Intervention in Schizophrenia
Samuel Leslie
University of Arkansas for Medical Sciences
March 11, 2016
Evidence-based Literature Review
Title: Preventative Intervention in Schizophrenia
Authors: Samuel Leslie, BSN
Author Affiliations: University of Arkansas for Medical Sciences
Clinical Significance: Schizophrenia is a devastating, life-long, often progressive mental illness that yields a high cost to both individuals and their loved ones. Therefore, early detection followed by appropriate interventions is important in current clinical practice.
Statement of the Problem (or Purpose): The purpose of this work was to explore evidence from literature to identify strategies that allow risk factors of schizophrenia to be identified leading to early interventions prior to the onset of the condition. Early intervention may prevent or reduce the severity of schizophrenia after onset. Those with specific clinical antecedents of schizophrenia can receive preemptive treatment.
PICO Format Question: In children and adolescents, can preemptive treatment of schizophrenia based on identified specific clinical antecedents, as compared to no early intervention, prevent the development of the illness?
Literature Search Strategy: The literature search process used Pubmed. Search terms used to locate the appropriate literature were schizophrenia, adolescence, and intervention.
Literature Search Results & Evidence: The literature search produced an initial total of 4c09 studies. The two studies most relevant to the desired topic were selected. Early identification of the triad of psychological, cognitive, and biological functioning in at-risk children may help to identify those at risk for developing schizophrenia. The focus is on community-based screening of 9-11 year olds. Interventions prior to the onset of schizophrenia might help to prevent the illness with treatment. Additionally, certain phenotypes are associated with schizophrenia. These phenotypes can be used to create risk scores in adolescents who have not developed schizophrenia. They correlate strongly with positive and negative symptoms, and may be used to ascertain genetic risk that could indicate an individual might develop schizophrenia.
Comparison and Synthesis of Evidence: The evidence from these articles indicates that early risk factors can be identified and used to predict those who will develop schizophrenia, aiding in early, preventative interventions.
Conclusions and Implications for Nursing Practice: The combined evidence from these two studies indicates that improved clinical outcomes can be obtained by identifying those who are at risk for developing schizophrenia and implementing early treatments. The treatment plan will address all phases of schizophrenia, however, with the expectation that some will go on to develop schizophrenia despite preventative interventions. These preventative interventions may help to reduce the severity of the acute phase of schizophrenia and contribute to a longer, more stable residual phase.
Preventative Intervention in Schizophrenia
Evidence and Information Synthesis
Psychotic diseases such as schizophrenia are generally associated with irreversible effects on an individual’s life or on the life of the family members. Therefore, early detection followed by appropriate interventions is important in the current clinical practice. These disorders can be prevented through identification, tracking and treatment of clinical antecedents to the specific psychotic disorder.
Laurens & Cullen (2015) identified three aspects (triad) of schizophrenia. One of them was psychotic symptoms reported by at-risk children, also known as psychotic-like experiences (PLEs). There was also the emotional symptoms or behavioral/social problems reported by children and caregivers respectively. Delay in motor and/or speech development reported by caregivers was the third aspect of schizophrenia antecedents. The researchers worked with two high risk groups in the form of children with antecedents of schizophrenia (ASz) and children with family history of illness (FHx). A third, low risk group made of children exhibiting none of the characteristics in the high risk groups (TD group) was also identified.
The results indicate that about 3.4% of psychotic children aged between 9 and 11 years are associated with a family history of schizophrenia. Moreover, it is clear that males in United Kingdom (UK) are more susceptible to schizophrenia than females, as indicated by the prevalence of antecedent triad in the two genders. In addition to gender, race is another factor affecting susceptibility to schizophrenia. For example, antecedents in this study were more reported in African-Caribbean children than in British children. Almost 75% of children involved in the study were found to have experienced at least one of the PLE’s, indicating that the PLE’s may be part of a range of common experiences in middle childhood. Although PLE’s have been found to act as possible markers for early detection of schizophrenia, their use is limited by the fact that most children fail to report them to their caregivers. As the results indicate that PLEs identified in early childhood persist to adolescent stage, interventions targeting PLEs are important in reducing adolescent psychopathology in addition to alleviating risks for the development of schizophrenia.
Social withdrawal acts as a good indicator of schizophrenia. According to Laurens & Cullen (2015), ASz children and FHx children demonstrated a high level of social withdrawal, as reported by their parents. Since the ASz group had a higher level of social withdrawal, it can be concluded that children at a high risk of schizophrenia are more affected by psychosis. Prodromal ymptoms such as paranoid beliefs, anxiety, and negative symptoms may present during adolescence, with full psychotic experiences developing later in life (Jones et al., 2016). This can be attributed to the fact that non-genetic factors such as cannabis use or childhood trauma affect the genetic factors. It is worth noting that more exposure to such non-genetic factors increases as age increases. Also, increased exposure to negative events in life and daily hassles was found to influence development of schizophrenia. Schizophrenia is an easily inherited condition caused by a combination of many factors. Schizophrenic individuals exhibit diverse phenotypes as well as frequent comorbid conditions. There is a great need to develop more evidence on how schizophrenia is genetically determined in the general population.
As stated by Jones et al. (2016), negative symptoms form an important phenotype that can be used with anxiety disorders to indicate schizophrenia in adolescents. Particular susceptibility to schizophrenia is identified by incorporating the genetic factors through the use of genome wide association studies (GWAs). Although negative symptoms and anxiety can act as effective markers to signal a high genetic risk for schizophrenia when general populations are involved, the variance of the genetic risk for schizophrenia is small, making it difficult to completely capture the negative symptoms evident in schizophrenia
With regard to cognitive impairment, important early schizophrenic indicators include impairments in executive functioning, working memory, verbal memory and general intelligence. Impairments in social cognition should also be an area of interest, such as diminished ability to recognize facial expressions. Jones et al. (2016) argued that impairments in the childhood performance IQ may be associated with genetic risk for schizophrenia. However, it is not clear whether individuals acting through various brain pathways have different relationships with these phenotypes. Although neurobiological abnormalities associated with onset and progression of schizophrenia have been investigated in previous studies, the studies have been limited by two major confounding factors in the form of neurodegenerative processes and antipsychotic medication. However, (Laurens & Cullen, 2015) avowed that structural abnormalities in the brain, including both brain increases and decreases, are associated with the prodromal phase of schizophrenia. Additionally, functional brain abnormalities such as abnormal levels of dopamine influence progression of this disorder.
It is not clear whether there is genetic overlap between major depressive disorder and schizophrenia in adults. This in an indication that a higher level of analysis is needed in future studies. This should include a measure of depression in a way that makes it possible to capture more short-lived disorders in adolescents that make it difficult for an overlap between schizophrenia and chronic depression to be observed. The combined results of these two studies can lead to important insights in clinical practice. Combining neurobiological, cognitive and psychological factors along with genetic factors associated with the onset of schizophrenia could be a great step. This could reveal how genetic factors are affected by the environment in the onset and development of schizophrenia.
Therapeutic Treatment Plan
Using the two studies alone, it is difficult to provide a treatment plan for schizophrenia. Additional information was needed. According to Lehman et al. (2010), an effective therapeutic treatment plan for an individual and his or her family affected by schizophrenia can be developed. The treatment plan is developed with the knowledge that schizophrenia is a chronic disorder that affects all aspects of life of an individual or family members. As a result, the plan will be developed to meet three goals: reducing or eliminating symptoms, maximizing quality of life, and promoting and maintaining recovery from debilitating impacts of the disorder to the highest level possible. The plan is also meant to make the diagnosis of schizophrenia a process and not a one-time event. In this way, there will be room to reevaluate and even change the treatment plan when new information is identified (Lehman et al, 2010).
After the diagnosis, the next step will involve identification of treatment goals and have the outcome measures for use when gauging the effectiveness of the treatment. It will also be important to develop realistic expectations as far as the degree or improvement that can be expected with treatment. Treatment and assessment targets in this case will involve posttraumatic stress disorder, medical comorbidities, substance use disorders, suicidal behaviors, and depression. Community adjustment problems such as social isolation, victimization, unemployment and homelessness will also be considered in this level of treatment plan (Lehman et al., 2010).
Treatment modalities and the treatment setting must also be selected. Developing a successful therapeutic alliance is of the utmost importance. This can help psychiatrist to gain important information about the patient in addition to developing a good level of trust between the two parties. This will increase the willingness of the patient to cooperate in the treatment plan. The alliance will also allow the psychiatrist to understand barriers to patient participation in the treatment plan. The practical barriers in this case may include inadequate social resources or cognitive impairments. Since family history has been linked to some cases of schizophrenia, the therapeutic plan will be made more effective through engagement of family members as well as other important support persons. It is recognized that the individual may require various forms of treatment from different clinicians. Therefore, the clinicians will use the alliance as an opportunity to coordinate their input in addition to being able to prioritize their activities. A high level of documentation will be maintained in this plan since an accurate history of current and past treatments is important (Lehman et al, 2010).
According to Lehman et al. (2010), there are three phases of schizophrenia: prodromal, acute, and residual. The treatment plan will specify all the possible phases of treatment. The acute phase is characterized by psychotic episodes, requiring the treatment plan to demonstrate the objectives of preventing harm. Additionally, efforts in this phase will be aimed at controlling disturbed behavior and reducing the severity of psychosis and symptoms related to psychosis. It will also be important to establish the factors that caused acute episode before formulating long- and short-term treatment plans. The initial evaluation will be made as thorough as possible, depending on the patient’s clinical status.
The plan will also identify the stabilization phase. The goals will include reduction of stress on the client and provision of support as a way of minimizing the probability of relapse. Service provided in this phase will also enable the patient to adapt to life in the community as well as promote the recovery process. Cases where the patient will have improved with a specific medication regimen will necessitate the continuation of the regimen in question coupled with monitoring for a period not less than 6 months (Lehman et al., 2010).
Treatment will also be provided in the residual phase with an aim of sustaining symptom control or remission. This will involve efforts aimed at ensuring that the client maintains or improves his or her level of functioning. Effective treatment of relapses or increased symptoms will be provided. The plan will also ensure that there is continued monitoring of adverse treatment effects. Comorbid conditions of patients will be continue to be addressed using adjunctive therapy. Treatment will include assertive community treatment, supported employment, and family intervention (Lehman et al., 2010).
References
Laurens, K.R. & Cullen A.E. (2015). Toward earlier identification and preventative intervention in schizophrenia: evidence from the London Child Health and Development Study. Social Psychiatry and Psychiatric Epidemiology, 5(2), 1-12.
Lehman, A., Liebman, J., Dixon, L., McGlashan, T., Miller, A., Perkins, D., & Kreyenbuhl, J. (2010). Practice Guideline for the Treatment of Patients With Schizophrenia Second Edition. APA Practice Watches. Guidelines for the Treatment of Psychiatric Disorders: Comprehensive Guidelines and Guideline
Jones, H., Stergiakouli, E., Tansey, K., Hubbard, L., Heron, J., & Cannon, M. et al. (2016). Phenotypic Manifestation of Genetic Risk for Schizophrenia During Adolescence in the General Population. JAMA Psychiatry, 3(3), 221-228.
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