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In patients with schizophrenia, how does early detection and treatment compared with later

recognition and treatment affect patient outcomes?

An Evidence-Based Practice Analysis

Mary Grace Gee, Sarah Jiminez, Enjoli Wasden

School of Nursing, Nevada State College

NURS 451: Scholarly Inquiry of Nursing

Dr. Ludy Llasus

April 28, 2021

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Introduction to Case Study and Practice Issue

Justin Martin is a 19-year-old college student, who has been having difficulty adjusting

to the social and academic demands of school. Growing up, Mr. Martin got along well with his

siblings but had very few friends and did not participate in any after school activities. Most of

the kids in his class thought Mr. Martin was weird but he was never teased or bullied.

Academically, Mr. Martin was a good student in high school (3.6 GPA).

In college, Mr. Martin lived in a dormitory and got along with his roommate Jeff, but he

did not develop any close relationships. Halfway into his freshman year, Mr. Martin told Jeff

that he had been receiving secret messages from the television and radio about a conspiracy

occurring on campus. One day, Jeff returns to the dorm to find Mr. Martin hiding under a desk

and talking gibberish. Mr. Martin was admitted to an inpatient psychiatric unit for 5 days with a

diagnosis of schizophrenia. Mr. Martin was started on olanzapine 5 mg once a day. By discharge

his dose is increased to 10 mg per day. After four weeks, Mr. Martin stopped taking his

medication as he perceived voices from the television telling him that the medication was

poisonous. Off medication, Mr. Martin is unsuccessful in returning to classes.

A new diagnosis of schizophrenia in a college student led the students to pose the

question, “In patients with schizophrenia, how does early detection and treatment compared

with later recognition and treatment affect patient outcomes?” Christianson reported,

“Retrospective research from patients with schizophrenia suggests that remission becomes

increasingly less likely the longer psychosis goes untreated. Yet symptoms of schizophrenia are

insidious and disease evolution varies between patients, requiring an ongoing diagnostic

process” (2017, p. 1). The main goal of effective treatment is to improve the quality of life and

functional outcomes of the patient. The proposed question explores treatment interventions

suitable for Mr. Martin that may potentially allow him to return to school and improve his

quality of life and functional outcomes.

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Evidence-Based Practice Guideline Grids

Guideline # 1

Barnes, T. R., Drake, R., Paton, C., Cooper, S. J., Deakin, B., Ferrier, I. N.,
APA Citation for
EBP Guideline Gregory, C. J., Haddad, P. M., Howes, O. D., Jones, I., Joyce, E. M., Lewis,

S., Lingford-Hughes, A., MacCabe, J. H., Owens, D. C., Patel, M. X.,

Sinclair, J. M., Stone, J. M., Talbot, P. S., & Upthegrove, R. (2019).

Evidence-based guidelines for the pharmacological treatment of

schizophrenia: Updated recommendations from the British Association

for Psychopharmacology. Journal of Psychopharmacology, 34(1), 3–78.

https://doi.org/10.1177/0269881119889296

URL of EBP https://journals.sagepub.com/doi/10.1177/0269881119889296#

Guideline

Target Practitioners, clients with schizophrenia, caregivers

Population

The objective of the article was to address the scope and targets of
Purpose / pharmacological treatment for schizophrenia.
Objective

First episode schizophrenia- Where the diagnosis of psychotic

Summary of disorder is suspected in primary care, patients should be referred to
Recommendatio secondary services as soon as practicable, with a delay of no more than a
ns week if possible.
Treatment delay and refusal- When patients decline assessment and
treatment despite efforts at engagement, given the risks of untreated
illness it may be necessary to detain them to enable assessment.
Medication adherence- When prescribing medication take into account
the known adverse effect. It should be kept as simple as possible with
respect to both the number of medications to be taken and the number of
times each day.
Maintenance treatment and discontinuation- When remission is
maintained for more than 2 years after a single episode whether the
medication should be continued or withdrawn should be reviewed.

Type of Meta-analyses, systematic reviews, randomized controlled trials

Evidence Used
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Guideline # 2

APA Citation for Addington, D., Anderson, E., Kelly, M., Lesage, A., & Summerville, C.
EBP Guideline
(2017). Canadian Practice Guidelines for Comprehensive

Community Treatment for Schizophrenia and Schizophrenia

Spectrum Disorders. The Canadian Journal of Psychiatry, 62(9),

662–672. https://doi.org/10.1177/0706743717719900

URL of EBP https://journals.sagepub.com/doi/10.1177/0706743717719900

Guideline

Target The target audience is all practitioners caring for patients with
Population schizophrenia. The target patient population is adults and caregivers of
patients with schizophrenia.

Purpose / The objective is to identify the features and components of a

Objective comprehensive system of services that serve patients with schizophrenia
and was designed with consideration of the incidence and prevalence of
schizophrenia.

Summary of The Canadian Schizophrenia Guidelines was facilitated through the

Recommendatio Canadian Journal of Psychiatry and the Schizophrenia Society of Canada.
ns The Canadian Psychiatric Association Clinical Practice Guidelines
Committee reviewed and approved the guideline methodological process
(Addington et al., 2017).

● First-onset Psychosis Models of Care: Treatment within an

evidence-based practice (EBP) specialty care.
● Early intervention: Early intervention should be accessible to all.
● Full range of interventions: Offer a full range of treatment with
culturally safe interventions.
● Comprehensive care across all phases: All mental health services
(MHS) should offer a range of interventions.
● Return to Primary Care: For stable patients, offer the option to
return back to their primary care provider for further management.
● Service User Experience: Improve experience of care for the
patient.

Type of Meta-analysis, systematic reviews, and randomized controlled trials

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Evidence Used

Guideline # 3

APA Citation for Scottish Intercollegiate Guidelines Network. (2013). Management of

EBP Guideline
schizophrenia. https://www.sign.ac.uk/media/1069/sign131.pdf

URL of EBP https://www.sign.ac.uk/media/1069/sign131.pdf

Guideline

Target Mental health specialists, psychiatrists, psychologists, specialist mental

Population health nurses. It will also be of relevance to general practitioners and
pharmacists.

Purpose / This guideline provides evidence-based recommendations for care and

Objective treatment of adults with schizophrenia.

Access and Engagement: Individuals in the first episode of psychosis

Summary of should receive treatment within the context of a specialist Early
Recommendatio intervention model of care.
ns Pharmacological and Related Approaches: Minimum effective dose
of either first- or second-generation antipsychotics should be used in
individuals in the first episode of schizophrenia. Acute exacerbation or
recurrence of schizophrenia prescribers should consider amisulpride,
olanzapine or risperidone as the preferred medications.
Psychological Therapies: Individual CBTp should be offered to those
with symptoms who have not adequately responded to antipsychotic
medication. A Family intervention should be offered to all individuals
diagnosed with schizophrenia.

Type of Evidence Meta-analysis, systematic reviews, randomized controlled trials.

Used
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Guidelines Similarity and Differences

Upon review of the clinical guidelines, it was evident that the guidelines had many

similarities and differences. The first and second guidelines had a similar target audience

including healthcare professionals caring for schizophrenia patients and a target audience of

caregivers of schizophrenia patients and clients with schizophrenia. The third guideline was

intended to be used by mental health specialists, nurses, psychiatrists, psychologists, general

practitioners, as well as pharmacists. The third guideline did not explicitly state a target

population. The first guideline’s purpose was to address the scope and target of pharmacological

treatment for schizophrenia. The second and third guidelines had a similar purpose that was to

provide evidence-based recommendations for care and treatment of adults with schizophrenia.

All guidelines used meta-analyses, systematic reviews, and randomized controlled trials.

With patients experiencing an early onset of schizophrenia, all three guidelines

recommended assessment without delay with the intent to reduce the amount of time that

psychosis goes untreated. In addition, the second guideline recommended early onset

treatments including crisis resolution and home treatment teams with the participation of

multidisciplinary teams including psychiatrists, nurses, and non-professional mental health

staff. Subsequently, the third guideline recommended early treatment in which quick access to

assertive outreach programs to help reduce the duration of untreated psychosis by providing a

range of therapeutic approaches that minimize symptoms and maximize functioning, (Scottish

Intercollegiate Guidelines Network, 2013). Additionally, early treatment for guidelines one and

three suggest starting with the lowest dose of medication therapy recommended and evaluating

the patient for a decrease in signs and symptoms of schizophrenia. The second guideline did not

explicitly indicate recommended medication types or dosages for treatment.

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For patients with ongoing schizophrenia that is not stable, the first guideline

recommended the importance of medication adherence and how it should be kept as simple as

possible with respect to both the number of medications taken and the number of times each

day. The second guideline recommended the use of crisis houses, acute day facilities, assertive

community treatment, or hospitals for ongoing care for unstable patients. The third guideline

recommended maintenance of schizophrenia, patients should be prescribed first generation

antipsychotics, and continue with therapy services. However, it did not overtly state treatment

recommendations for unstable schizophrenia.

For patients with schizophrenia whose symptoms have stabilized effectively with

treatment, the second guideline recommended the return to primary care for ongoing

management and treatment. It complements the first guideline which stated that when

remission is maintained for more than two years after a single episode, medication should be

reviewed whether to be continued or withdrawn. Similarly, the third guideline mentioned that

long term treatment should include usage of antipsychotic medication for two years.

Analysis of Family Influences

Schizophrenia is a debilitating illness that has an effect not only on the patients’ lives,

but also on their families. When Mr. Martin was young, he was perceived by his parents as a

lonely, quiet and serious child. Although he was never a victim of bullying, most of his

classmates noticed that he was different. His poor social life was an indication of the negative

symptoms of schizophrenia. Hussain (2020) poor social functioning is a hallmark of

schizophrenia. Justin Martin’s parents sent him off to college thinking that he was a perfectly”

healthy teenager. His manifestations were only noticed after his first psychotic episode when his

roommate Jeff found him hiding under the desk and talking gibberish.

Mr. Martin’s diagnosis of schizophrenia affected his studies and his relationship with his

father. He was unable to go back to school and his disorder drove his father to give him an

ultimatum for not adhering to his medication. His father lack of knowledge on schizophrenia
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may have contributed to the rift between Mr. Martin and his dad. In the first guideline, it talked

about medication adherence and that practitioners should consider the known adverse effect of

medication and it should be kept simple as possible with respect to both the number and of

medications to be taken and the number of times each day (Barnes, 2019). In this case study it

did not mention as to why Mr. Martin stopped taking his medication. The increased

misunderstandings between Mr. Martin and his father ultimately led him to overdose on

olanzapine and Tylenol.

The third guideline recommended that a family intervention should be offered to all

individuals diagnosed with schizophrenia who are in close contact with or live with family

members and should be considered a priority where there are persistent symptoms or a high

risk of relapse. Family is an important influence for Mr. Martin’s recovery and management of

schizophrenia. His family dynamics and lack of their support can greatly impact his outcome,

and, “Family intervention for individuals diagnosed with schizophrenia has developed out of the

consistent finding that the emotional environment within a family was an effective predictor of

relapse” (Scottish Intercollegiate Network, 2013, p. 57).

Implementation for Practice

When working with patients who have schizophrenia, health care members could

perhaps consider the use of implementing these evidence-based practice guidelines to provide

positive outcomes. Within the first guideline recommendations when a patient is experiencing

psychosis and refusing treatment, it may be necessary for the patient to be detained and given

appropriate treatments. As nurses, it is of great importance to recognize that when a patient

with schizophrenia is refusing treatment and assessment, that crisis interventions be

implemented. Crisis interventions are “designed to provide rapid assistance for individuals or

groups who have an urgent need” (Holman, et.al, p. 173). A study on patients and families

during crisis intervention detailed that, “most patients reported feeling trapped in psychotic
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thoughts and inner confusion during a crisis whereby communication was difficult”

(Daggenvoorde et. al., 2018, p. 467). Thus, to prevent further risk, rapid intervention is needed.

A key role of the nurse is to provide a complete and thorough assessment while also

providing a therapeutic and trusting relationship with the patient. Furthermore, as nurses,

establishing therapeutic communication includes, “(1) silence, (2) active listening, (3) clarifying

techniques, and (4) questions” (Halter, 2018, p. 141). In guideline two, specific

recommendations about the clinical encounter involve offering help, treatment, and care in an

atmosphere filled with hope, optimism, and recovery-orientation. In addition, providers should

aim to foster the patient’s autonomy, promote participation in treatment, and support the

patient’s self-management of their disease (Addington et al., 2017). It is also imperative that the

nurse have competency with the provided interventions, provide treatment and care in the least

restrictive and least stigmatizing environment possible, and offer diverse treatment options, if

available (Addington et al., 2017).

Within the third guideline, recommendations for a patient who is experiencing their first

episode of psychosis, include interventions that are multidisciplinary with an array of resources.

An assessment of the family dynamic, support, and providing education to patients and their

caregivers is vital. Halter (2018) states, “Psychoeducation promotes patient-centered care by

helping the patient to recognize and self-manage symptoms” (p.203). In Mr. Martin’s case,

education should include informing the patient and family about signs and symptoms that may

manifest with schizophrenia, as well as medications that he may be prescribed. During a first

episode, it is important the nurse educate about medications that are commonly used to treat

manifestations and their associated side effects. Additionally, the nurse should include

information about common stigmas associated with schizophrenia and also engage with the

patient and family members in a non-judgmental manner.

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References

Addington, D., Anderson, E., Kelly, M., Lesage, A., & Summerville, C. (2017). Canadian Practice

Guidelines for Comprehensive Community Treatment for Schizophrenia and

Schizophrenia Spectrum Disorders. The Canadian Journal of Psychiatry, 62(9),

662–672. https://doi.org/10.1177/0706743717719900

Barnes, T. R., Drake, R., Paton, C., Cooper, S. J., Deakin, B., Ferrier, I. N., Gregory, C. J.,

Haddad, P. M., Howes, O. D., Jones, I., Joyce, E. M., Lewis, S., Lingford-Hughes, A.,

MacCabe, J. H., Owens, D. C., Patel, M. X., Sinclair, J. M., Stone, J. M., Talbot, P. S., &

Upthegrove, R. (2019). Evidence-based guidelines for the pharmacological treatment of

schizophrenia: Updated recommendations from the British Association for

Psychopharmacology. Journal of Psychopharmacology, 34(1), 3–78.

https://doi.org/10.1177/0269881119889296

Christianson, L. (2017). Improving functional outcomes in college and university students with

schizophrenia in the Western world. Journal of American College Health, 66(1), 61–68.

https://doi.org/10.1080/07448481.2017.1360306

Daggenvoorde, T. H., Gijsman, H. J., & Goossens, P. J. J. (2018). Emergency care in case of

acute psychotic and/or manic symptoms: Lived experiences of patients and their families

with the first interventions of a mobile crisis team A phenomenological study.

Perspectives in Psychiatric Care, 54(4), 462–468. https://doi.org/10.1111/ppc.12247

Halter, M. J. (2018). Varcarolis' foundations of psychiatric-mental health nursing: A clinical

approach (8th Ed.). Elsevier.

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Holman, H.C., Williams, D., Sommer, S., Johnson, J., Ball, B. S., Wheless, L., Leehy, P., &

Lemon, T. (2019). Rn adult medical surgical nursing (11th ed.). Assessment

Technologies Institute

Hussain, S. (2020). The Impacts of Parental Schizophrenia on the Psychosocial Well-Being of

Offspring: A Systematic Review. IntechOpen.

https://www.intechopen.com/books/quality-of-life-biopsychosocial-perspectives/

the-impacts-of-parental-schizophrenia-on-the-psychosocial-well-being-of-offspring-a-

systematic-revie

Scottish Intercollegiate Guidelines Network. (2013). Management of schizophrenia.

https://www.sign.ac.uk/media/1069/sign131.pdf