An Overview of Risperdal and Counseling Emily Ramos Monmouth University An Overview of Risperdal and Counseling It is conceptualized that counselors only focus on talk therapy

An Overview of Risperdal and Counseling
Emily Ramos
Monmouth University
An Overview of Risperdal and Counseling
It is conceptualized that counselors only focus on talk therapy, psychoeducation, and the wellness model. Although these are areas of considerable focus in counseling, things such as neuroscience and the pharmaceutical industry cannot be ignored. It is essential for counselors to recognize where the intersection in counseling and pharmaceuticals is and how each depends and interacts with the other. Psychopharmacology is the scientific study of the effects of drugs on the mind and behavior. To be a competent practitioner, counselors must include pharmacological interventions in their case conceptualizations to get a full overview of a client’s mental health. It is also essential to be well versed in the medications available in the field to advocate for clients who are unaware of the options which are available to them, and to those who are currently using those interventions.

Psychopharmacology includes both medications for mental illness and drugs of abuse. Both medications and drugs affect an individual’s ability to focus, their behavior, affect and cognition. For this reason, it is imperative that a counselor has extensive general knowledge about the history, dosages, physical and cognitive effects of both medications and drugs. One of the most prescribed antipsychotics in today’s society is Risperdal (History of Risperdal, 2014) data). Risperidone is classified as one of the most commonly prescribed atypical antipsychotics in the United States. While there has been debate and legal action taken surrounding what exactly risperidone is approved for, it has been used in the treatment of schizophrenia, and mania in bipolar disorder (Davis ; Chen, 2002). Risperidone is also known to be useful in the treatment of psychosis, schizoaffective disorder, psychosis secondary to medical conditions, and depression with psychotic features (Jesner, Arif-Adib, ; Coren 2007). While the span of treatment is vast, the one thing which stands out about this medication is that it has been advertised to be useful for a range of ages. Risperidone has medication has been used for children, adolescents, adults, and the elderly in the past. Usually, medications are used for a specific age range, but the ability of this medication to be used with many individuals is the significant factor in how it gained its popularity.
I. Basic Information
Risperidone is the first antipsychotic marketed in the United States since clozapine (Umbricht ; Kane, 1995). Risperidone is the brand name of the medication is sold under the generic name of Risperdal. The forms of the medication which are currently available on the market are Risperdal, Risperdal M-tab, and Risperdal Consta. The medication is mainly used to treat Schizophrenia, Bipolar Disorder, and anger with Autism. Although there have been claims that this medication can help with diagnoses such as Mania, Tourette syndrome, Oppositional Defiant Disorder, and Delirium, there has not been research on the efficacy of its use concerning these treatments. The medication is considered to be a Serotonin-Dopamine Antagonist (SDA), an atypical antipsychotic. Risperdal is a second-generation antipsychotic which was developed by Janssen Pharmaceutica Inc., a division of Johnson ; Johnson (J;J). Antipsychotic drugs have been used as a treatment for maladaptive behaviors since the 1950s, when first generation, also known as typical antipsychotic drugs, were first prescribed to children and young adults (Ben Amor, 2012). Some examples of typical antipsychotic drugs include haloperidol and clozapine.

The United States Drug Enforcement Administration (DEA) created a system to monitor and warn for controlled substances. The drug schedules are classified as I through V to serve as a classification system for all classes of drugs. This includes both licit and illicit substances. The schedules outlined are organized on a scale of most dangerous to lowest abuse potential. The schedules also include the ability of each drug to be used for medical purposes. Risperdal is not a controlled substance but does have a severe black box warning. The black box warning on prescribing information for Risperdal was required by the FDA to be added in 2006. The warning was placed after a review of 17 placebo-controlled studies with 5,106 elderly patients on antipsychotics over a period of about ten weeks (Kales, Kim, Zivin, Valenstein, Seyfried, Chiang, ; Cunningham, 2012). Study results showed that elderly patients who took Risperdal had a risk of death that was 1.7 times higher than those who took a placebo. The specific causes of death varied from patient to patient but were primarily related to cardiovascular causes such as heart failure or heart attack and infections such as pneumonia.

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The black box warning on Risperdal outlines the increased risk of death in elderly patients with dementia and states that Risperdal is not approved to treat these patients.  Risperdal’s black box warning states:
“WARNING: INCREASED MORTALITY IN ELDERLY PATIENTS WITH DEMENTIA-RELATED PSYCHOSIS: Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Risperdal is not approved for use in patients with dementia-related psychosis” (Kales et al., 2012).
II. Drug Development
Although Johnson & Johnson is best known for their line of baby products, they also have a reputation for pharmaceuticals. Johnson & Johnson has created a respected name for its company in the health and personal care industries. The company was founded by the Johnson brother in New Jersey, in 1886 (Johnson & Johnson, 2012). The company intended to create safe products for consumers. In 1961, Johnson and Johnson expanded their products by entering more deeply into the pharmaceutical industry by purchasing Janssen Pharmaceutica. This purchase became a significant advantage for the Johnson and Johnson Pharmaceutical Research and development branch. This branch’s primary focus was to research human developmental disorders, neurological disorders, mental illness, and various other medical diagnoses.

In this new venture which Johnson and Johnson created, the development of Risperdal was made. Risperdal is a lab synthesized medication. This medication was initially created with the intention to treat Schizophrenia, Bipolar Disorder, and irritability with individuals who have autism (NAMI). This was a significant break-through because, at this time, the first generation of antipsychotics had been associated with an extensive range of side effects. The side effects ranged from death to chemical dependence. To lower the patient’s risk when taking these, second-generation antipsychotics were introduced in the 1980’s. These new antipsychotics were classified as safer than the first generation antipsychotics because they minimized the risk posed to the patients.

It is important to note that while this new generation minimized risks, it did not eliminate side effects. The drug Risperdal was first approved by the Food and Drug Administration (FDA) in 1993 for the treatment of schizophrenia in adults. Later in 2003, it also gained approval for treatment of adults with Bipolar I disorder. In 2006, Risperdal gained approval as a treatment for the younger population and was approved for use with autistic children and teenagers (Risperidone: Medline Plus). With this change in approval, Risperdal became the “go to” medication for children aged 13-17 who were thought to exhibit symptoms of schizophrenia, as well as children aged 10-17 who exhibited bipolar symptomology (William ; Shelton, 2010). This was a pivotal point in both mental illness treatment and the history of Risperdal because it was the first time an antipsychotic was believed to be safe enough to use for younger populations.

While this was a massive step for antipsychotics in the pharmaceutical industry, the marketing of the drug caused issues for its users and placed Johnson and Johnson in a compromising position. Once the FDA had given its approval, Johnson and Johnson placed maximum efforts on advertising and marketing the drug using direct-to-consumer advertising. This led Risperdal to become one of the most highly sought out and prescribed antipsychotic medications. This led to Risperdal having off-label uses such as treating conditions like attention deficit hyperactivity disorder (ADHD) which did not have approval by the FDA. In 2013, Johnson and Johnson paid a $2.2 billion settlement for the unethical and improper promotion of Risperdal which marketed to patients who were suffering from conditions which it did not have the approval to treat (Johnson ; Johnson 2012).
It is essential to know the history of approval of Risperdal to see how it evolved and the steps which were taken for it to be marketed to the population which it is used for today. Between 1999 and 2005, the FDA had issued Johnson and Johnson various warnings about marketing to the younger population. The Justice Department stated that there were various risks which the company was aware of but ignored (Johnson ; Johnson, 2012). The company had tried to expand its approval to treat symptoms of dementia in the older population but was unsuccessful. The FDA repeatedly rejected efforts of Johnson and Johnson to expand the treatment of Risperdal. Johnson and Johnson proceeded to promote the drug to doctors and other physicians who treated elderly patients through ElderCare. During this promotion, the company made assertions that Risperdal could help simplify the care of the elderly by treating unwanted symptoms which posed difficult for caretakers. These symptoms included things such as irritability and confusion. It is claimed that the company acted unethically because they understood that there were severe risks which this medication posed to older populations, but they did not make this transparent to the people they were advertising to. As stated previously, a black box warning was issued to warn adults with dementia of the severe risks which this medication can have.

While the actions of Johnson and Johnson were unethical, they were not the only company advertising to the dementia population in this way. Other medications which were given similar labels were Zyprexa, Seroquel, and Depakote (Johnson ; Johnson, 2012). Johnson and Johnson were also reprimanded for advertising to children with mental disabilities before they had gotten FDA approval in 2006. Janssen Pharmaceutica was accused of having their representatives advertise to child psychologists and mental health facilities promoting Risperdal as a safe and effective treatment for children with ADHD, and OCD. The company was aware of risks and did not inform the public. In young boys taking this medication, there was a possibility of breast development through the increased production of the hormone prolactin.

III. Use Information.

The inner workings of Risperdal occur through the alteration of the dopamine and serotonin levels in the brain (Welch, 2014). The liver breaks down Risperdal into metabolites, which in turn, block serotonin dopamine. This helps make sure that the chemicals in the brain are balanced which decrease psychosis and aggression. Although Risperdal is designed for isolated use, it can be combined with other medications. For example, in the treatment of bipolar disorder, other medications such as antidepressants may be used in combination with Risperdal
Risperdal is available by prescription only. It is available in various doses which are determined by the physician as well as the severity of the illness which it is treating. This medication is available in many forms which include orally disintegrating tablets, a solution, and also an injectable form known as Risperdal Consta (Welch, 2014). The tablet for the medication is available in 0.25 milligrams, 0.5 milligrams, 1 milligram, 2 milligrams, and 4 milligrams (Procyshyn, Bezchlibnyk-Butler, ; Jeffries, 2015). The orally disintegrating form is available in the same dosages as the tablet form of the medication. The oral solution which is on the market is available in a 1 milligram per milliliter dose. The Risperdal Consta extended-release injection suspension is available in four different dosages. It is available in 12.5 milligrams, 25 milligrams, 37.5 milligrams, and 50 milligrams (Procyshyn et al., 2015). There are specific dosage guidelines and oral formulations of approved doses of Risperidone.
Schizophrenia/Psychosis: Adults
The symptoms which an individual experienced in schizophrenia vary and are not generalized to all diagnosed with this disease. Some of the symptoms which can be present are hallucinations, delusions, and lack of feelings, social withdrawal, and an inability to focus. The initial dose recommended for adults with Schizophrenia/Psychosis is 1mg/day in 2 divided doses. The titration is 1mg daily, and the target dose is 4-8mg daily. It has been shown that the effective dose is 4-16 mg daily (Welch, 2014).

The medication can be administered once or twice daily. Initial dosing is 2 milligrams per day. The client may increase the dose at intervals of 24 hours or higher, in increments of 1 to 2 milligrams per day, as tolerated, to dose of 4 to 8 milligrams per day. It is important to recognize that this dosage may not work for everyone and slower titration may be more beneficial for some clients. The dosage which has been found to have the most significant effect is 4 to 16 milligrams per day. However, 6 milligrams per day for twice-daily dosing (BID) was not shown to be more effective than lower doses (Welch, 2014). It was however associated with more symptoms and other adverse effects, so it is not recommended.
Schizophrenia/Psychosis: Adolescents
The symptoms for adolescents are the same as those for adults, but the dosages for these populations do vary. The initial dose is .5mg/day, the titration dose is 0.5-1mg daily, the target dose is 3mg/day, and the effective dose is 1-6mg/day (Procyshyn et al., 2015).
The initial dose for adolescence is 0.5 milligrams once daily, and it is given to the client once per day, either in the morning or evening. The dose may be adjusted at intervals of 24 hours or higher, in increments of 0.5 milligrams or 1 milligram per day, as tolerated, to a recommended dose of 3 milligrams per day. Although there is speculation that the medication is most beneficial to adolescents at dosages of 1 milligram to 6 milligrams per day, there are no studies which support that there is a difference once a client exceeds 3milligrams per day. Higher dosages of the medication had a positive correlation with adverse effects. Clients who experience extreme drowsiness have been seen to benefit from taking only half of the recommended daily dose if twice a day.
Bipolar Mania: Adults
Bipolar disorder, specifically mania, can cause various symptoms in clients. Some symptoms which are consistently described are increased energy, racing thoughts, increased risk-taking, and higher intensity of senses (William et al., 2010). While these are common symptoms, some individuals become psychotic when they are in manic stages of bipolar disorder. This includes hallucinations, false beliefs, extreme fear that everyone is conspiring against them. It is important to note that in these instances, the client may not be conscious of these things but their family members may be the ones that point them out.

The initial dose range is 2 milligrams to 3 milligrams per day. The dose can be adjusted at intervals of 24 hours or higher, in increments of 1 milligram per day. The effective dose range is 1 milligram to 6 milligrams per day. In these trials, short-term (3 weeks) anti-manic efficacy was demonstrated in a flexible dosage range of 1 mg to 6 mg per day (Procyshyn et al., 2015). The dosages which were seen to be most useful to combat mania were 1 milligram to 6 milligrams per day.

Bipolar/Mania: Children/Adolescents
The symptoms are similar to those described for adults with bipolar disorder, but the dosages for each age group vary. The initial dose given to clients is 0.5 milligrams once a day, taken either in the morning or evening. The dose can be adjusted at intervals of 24 hours or greater, in increments of 0.5 milligrams or 1 milligram per day, as tolerated, until the client reaches the target dose of 1milligram to 2.5 milligrams per day (Procyshyn et al., 2015). The dosages which have been seen to have the most effect on adolescents with bipolar disorder are 0.5 milligrams and 6 milligrams per day. There was no evidence of dosages of 2.5 milligrams daily or more to be more effective. It was found that there was a greater risk of adverse effects once the dosage of 2.5 milligrams was exceeded.

Irritability Associated with Autism: Children and Adolescents
It is important to recognize that the dosages chosen are different for each client due to the severity of their symptoms, as well as their ability to tolerate the medication. Although the use of Risperidone in autism is considered “off-label” treatment, it is still used. The total daily dose of Risperidone can be given to clients one time a day or half of the daily dose can be given twice a day. The dosage is also dependent on the weight of the client. If a client weighs less than 40lbs, they should start with the 0.25 milligrams a day (Jesner et al., 2007). If clients weigh more than 44lbs, then they should start with the .50 milligram tablet once a day.

After taking the medication for four days, the dose can be increased to the recommended dose of 0.5 milligrams a day for those on the original dose of 0.25 milligrams. For those on the 0.50-milligram dose, they can increase to 1 mg a day after four days. This medication should be continued for at least 14 days. If the physician does not believe that the medication is benefiting the client sufficiently, they can increase the dosage by 0.25 milligrams every 2 or more weeks. For patients who weigh more than 44 lbs, the dosage can be increased in increments of 0.5 milligrams per day. The dosage range which has been seen as most useful is 0.5 milligrams to 3 milligrams per day (Procyshyn et al., 2015). Once the client has been placed on the medication and it their symptoms have been controlled, the prescribing physician should re-evaluate if the client should continue taking the medication and make sure that the dosage is correct. The physician should also continue to go over the risks and benefits associated with the medication.
Risperdal Consta
The long-acting risperidone (Risperdal Consta) has an initial dose of a 12mg intramuscular gluteal injection every two weeks, the titration is ; 4 weeks, the target dose is 25-50mg IM every two weeks, and the effective dose is 25-50mg IM every two weeks (Bhanji, Chouninard ; Margolese, 2004). The extended formula release is an off-white powder that is available in various dosages. It is available in 12 milligrams, 25 milligrams, 37.5 milligrams, or 50 milligrams per vial (Procyshyn, 2015). Risperdal Consta is given to clients in what is known as a dose pack which contains a pre-filled syringe with the diluent, a SmartSite Needle-Free Vial Access Device, and one Needle-Pro 20 G TW safety needle (Bhanji et al., 2004).
IV. Counselor considerations I
Although the individuals in the United States who have Schizophrenia only total about 2%, it is a chronic illness which must be treated. While one of the goals for this population is to increase their quality of life, not every individual will benefit from taking Risperidone. Each reacts differently to medication, and there are factors which must be taken into consideration. When looking to use pharmaceutical interventions an individual’s medical history, mental state, and lifestyle must be taken into consideration. Some of the most beneficial therapies for Schizophrenia are psychotherapy and family support groups. The symptoms which can be helped with Risperidone are hearing voices, detailed hallucinations, and disorganized thinking (Hunter, Joy, Kennedy, Gilbody, & Song, 2003). Clients with schizophrenia are unable to make decisions for themselves at times when they are in deep psychosis. They can be reliant on their family members who can add stress to those in their support system.
The symptoms which are exhibited in bipolar clients are being overly sensitive, racing thoughts, and impulsive behavior (William et al., 2010). The treatment for bipolar disorder is usually a combination of medication and psychotherapy. Mindful based interventions, family intervention, and cognitive behavioral therapy (CBT) are also useful in the treatment of bipolar disorder. Clients seeking treatment may many times be non-compliant with medication which is a challenge which the physician must be aware of and try to overcome. These individuals are usually able to make decisions for themselves but are not very likely to attend therapy or other interventions without the influence of family and friends.
The counseling techniques that will be useful in gathering information from my client are building a trusting relationship with rapport, interviewing, and doing an in-depth biopsychosocial. The most beneficial thing in a counseling relationship is trust. The client must feel that they are in a safe environment where they can share without the fear of being judged. The client must also feel that their counselor is genuinely listening to them. It is essential that counselors understand that a client’s decision to attend counseling is not one that should be taken lightly. With this medication, a majority of clients have schizophrenia and bipolar disorder which bring up the issue of compliance to taking medications as well as who is the primary person asking for the medication as an intervention. There is also a strong stigma associated with both of the diagnoses mentioned which the counselor must be sensitive to. To make sure the client feels comfortable, confidentiality must be ensured. This can be done in the initial session by ensuring the client that anything they say in their sessions will not be shared with others. This information should be included in the informed consent. The informed consent should also continue to be revised and looked over as the sessions continue.
When working with a client with Schizophrenia, it can be hard to determine which medications can be beneficial especially when it comes to determining the level of psychosis. It is also essential to determine who is requesting the medication. Is the client in the right state of mind to fully understand what the side effects of the medication are, or is the medication being requested by a loved one who is taking care of their mentally ill family member? If a family member or legal guardian is requesting the medication, then the physician should keep in mind what will best serve the client. It may be difficult for the physician and family members to agree while choosing something that the client also agrees on.

When working with a client who has bipolar disorder it is beneficial to get an in-depth biopsychosocial to see if the client has either been in a psychiatric facility or treatment program in the past and what medication if any, they are on. This will help narrow down what has worked for the client in the past and what dosage they had received. Biopsychosocial interviews are a useful resource because it not only gives pertinent information to the counselor before they meet their client, but it also gives an opportunity for the counselor to clarify things with the client. The intake asks questions about past treatment facilities attended, medical history, and symptoms.
There are many barriers which will be faced when trying to select a successful treatment for the client. This in part has to do with the population which gets prescribed risperidone. Schizophrenia and Bipolar disorder are challenging to treat because many times they are sent to counseling or to get medical assistance from family members. These clients can also be facing moments of psychosis and mania respectively which can cause them to be either non-compliant with medication, or in a state of confusion. They may also suffer from other medical conditions and the interactions between Risperidone, and those medications are crucial to understand to suggest the best treatment possible. In order to overcome this barrier, a relationship should be made between all physicians so that all medical information is up to date, and so that the counselor is aware of any antipsychotics which may have previously been taking.
Another barrier to the treatment of all individuals is family members. This is especially true for this population because they can be very reliant on family members throughout their day to day lives. This causes the family members to feel entitled to contribute to the decision-making process because they will be affected by changes as well. They are affected by changes in the medication because it may affect how their family member acts, their health, and the amount of dependence the client will have on them. For this reason, additional means of support can be suggested to both the client and the family members. This support consists of psychoeducation for the client and group therapy for family members. The psychoeducation can benefit the clients by helping them understand what their diagnosis means as well as validate some of the clients feelings.

Medications can significantly decrease symptoms and can help a person get to a functional level. While this is the goal of using medication, each individual may react differently to the medication. Going on medication is a trial and error period which may include many adjustments before the correct dosage is found. It is also essential for the physicians to explain to the clients that the medications can take time to work, so patience is necessary. In patients with Schizophrenia, benefits such as lessening of voices can be an indicator that the medication is working. This is helpful to clients because it can allow them to have a better quality of life by not having voices or at least lessening the volume of the voices which distract them from doing everyday things.
Documentation in counseling must be done in a specific way in order to protect the confidentiality of the client. Documents can be kept in either paper form or electronically. If the notes are kept electronically, they must be password protected and placed on a computer with secured hardware. In order to make sure that notes are kept and secure to the best of the counselors’ ability, the rules set into place by the American Counseling Association Code of Ethics (2014). This code of ethics specifies that counselors must obtain documentation such as informed consent, consent to record, and signed authorization of a records release. The codes are enforced in order to make sure that the client is always protected and that there is a general set of best conduct rules which all counselors can reference.

V. Pharmacokinetics
Pharmacokinetics is the study of the movement of drugs in the body, including the processes of absorption, distribution; localization in tissues, and excretion (Bou Khalil, 2012). Risperidone is completely absorbed after oral administration and reaches peak concentration within 1 to 2 hours. Food does not affect the absorption of risperidone, so it does not have to be taken on an empty stomach. Risperidone is partly metabolized to 9-hydroxy-risperidone (CITE). Another metabolic pathway for risperidone is N-deacylation. After a client ingests the medication, Risperidone is eliminated with an estimated half-life of 3 hours (CITE). This medication is one that is quickly distributed in the body which is also why it has gained popularity. Risperidone is quickly distributed in the body. One week after taking the medication, 70% of the dose leaves the body through urine, and 14% leaves the body through feces (CITE). “In urine, 3545% of the administered dose consists of risperidone and 9-hydroxy risperidone – the rest is inactive metabolites” (CITE). Risperidone is well absorbed. The major metabolite is known as 9-hydroxyrisperidone, and risperidone plus 9-hydroxyrisperidone are doses proportional over the dosing range of 1 milligram to 16 milligrams daily; 0.5 milligrams to 8 milligrams twice a day (CITE). After taking the tablet form of Risperidone, the peak plasma concentration occurs in about 1 hour.
Risperidone is primarily metabolized in the liver. The central metabolic pathway is through hydroxylation of risperidone to 9-hydroxyrisperidone by the enzyme, CYP 2D6 (CITE). “A minor metabolic pathway is through N-dealkylation. The main metabolite, 9-hydroxyrisperidone, has similar pharmacological activity as risperidone” (CITE). Due to this reaction, the effect which takes place is caused by the combined concentrations of risperidone plus 9-hydroxyrisperidone (CITE?). CYP 2D6 is more commonly known as debrisoquin hydroxylase; it is the enzyme responsible for metabolism many other drugs. The variation in this enzyme is subject to genetic polymorphism, which means that there is a variation which occurs in different ethnicities due to the genetic variation (CITE).
Risperidone like any other drug is prone to some drug to drug interactions. This occurs with quinidine, giving virtually all recipients a risperidone pharmacokinetic profile typical of poor metabolizers. The therapeutic benefits and adverse effects of risperidone in patients receiving quinidine have not been evaluated, but observations in a modest number of poor metabolizers given risperidone do not suggest significant differences between poor and extensive metabolizers. Second, co-administration of known enzyme inducers (e.g., phenytoin, rifampin, and phenobarbital) with risperidone may cause a decrease in the combined plasma concentrations of risperidone and 9-hydroxyrisperidone (CITE). It would also be possible for risperidone to interfere with the metabolism of other drugs metabolized by CYP 2D6. Relatively weak binding of risperidone to the enzyme suggests this is unlikely.

Risperdal Consta is an injectable form of the medication. The medication is in the form of both deltoid and gluteal intramuscular injections. After the initial injection, a release of less than one percent of the actual dosage is released, and the next release of medication occurs three weeks after. On the third week following the injection, the release of medication is continuous until week 6 (Bhanji et al., 2004). The medication subsides and is no longer being released by week 7. For this reason, any supplemental oral antipsychotics a client is taking should be given during the first three weeks of being injected. After repeatedly getting the Risperdal Consta intramuscular injections every two weeks there is no accumulation of risperidone seen when an individual used this form of medication long-term in doses of 25-50 milligrams.
VI. Pharmacodynamics
Although the exact mechanism for Risperdal in the treatment of schizophrenia is unknown, it is known that the therapeutic quality of the medication occurs via a combination of dopamine and serotonin receptor antagonism. It is important to note that Risperdal acts as an antagonist at other receptors, but with lower potency. Risperdal has low to moderate affinity for the serotonin 5HT1C, 5HT1D, and 5HT1A receptors, weak affinity for the dopamine D1 and haloperidol-sensitive sigma site, and no affinity for cholinergic muscarinic or ?1 and ?2 adrenergic receptors (Assogna, Pozzi, & Lucchetti, 1992)
Risperidone is classified as an antagonist which targets serotonin and dopamine receptors. In order to cause a change in symptomology, it binds to “alpha1-adrenergic receptors, and with lower affinity, to H1-histaminergic and alpha2-adrenergic receptors” (Assogna, 1992). Central dopamine receptor antagonism is what is believed to be the mechanism which helps to relieve the symptoms of schizophrenia, but also induce extrapyramidal symptoms and release of prolactin (Assogna et al., 1992). Although risperidone antagonists dopamine receptors and causes release of prolactin, it is less potent than classical neuroleptics for depression of motor activity and for induction of catalepsy in animals. Balanced central serotonin and dopamine antagonism may reduce extrapyramidal side effect liability and extend the therapeutic activity to the negative and affective symptoms of schizophrenia (Assogna et al., 1992).

VII. Adverse effects
As mentioned previously, an adverse effect which has been recognized is an increased risk of death in the elderly. The effects of Risperdal also span to Tardive Dyskinesia, Neuroleptic Malignant Syndrome, and other movement disorder. It is essential to be aware that as with all other medications, clients must be aware of the short and long-term risks associated with medications. Before taking Risperdal, all clients should consult their medical doctor in order to make sure that there are no adverse interactions with medications which they are currently being prescribed.
Tardive Dyskinesia
This is the development of abnormal facial, shoulder, and limb movements. These movements are uncontrolled by the client and often persist even when the medication is discontinued. This can be treated with other medications. The populations which are most prone to this are women and the elderly (Gwinn, & Caviness, 1997). Although medication can help suppress these symptoms, it is believed that the longer an individual is on the medication, the harder these symptoms are to reverse. In order to treat this, the medication must be discontinued immediately.

For this reason, it is imperative that physicians prescribe Risperdal Consta in a way which will minimize the likelihood that a client suffers from this syndrome. This medication should only be used in individuals with a chronic illness which is known to benefit from this intervention (Gwinn et al., 1997). Clients should also always try alternative medications which pose less of a risk prior to beginning Risperdal Consta. Drug discontinuation should be considered immediately, although there have been some instanced where clients had to continue the medication while experiencing symptoms of this syndrome.
Neuroleptic Malignant Syndrome
This is a hazardous adverse effect which can be fatal, and it is common with antipsychotics. This can cause symptoms such as rigid muscles, fevers, blood pressure irregularities, as well as heartbeat irregularities. If this occurs, it is recommended that clients seek immediate assistance by going to the emergency room. The client is asked to seek immediate help because the diagnostic process is complicated. Physicians must rule out diagnoses such as pneumonia and also identify all other symptomology. To treat this syndrome, the client must discontinue the antipsychotic as well as all other non-essential medication. It will be required to lessen the symptoms of the client while they are extensively monitored to track changes. The client must also report this syndrome to all future physicians because there can be reoccurrences if antipsychotic medications are re-introduced. Clients taking this medication can also experience side effects such as blurry vision, dizziness, fatigue, and anxiety. There are also significant risks of hyperglycemia, hypotension, cardiovascular diseases, seizures, and aspiration pneumonia.
There is data that suggests that clients with a history both familial and individual of diabetes are at risk for worsening glucose control which can, in turn, lead to hyperglycemia (Yamashita, Fujii, & Misawa, 2013). For this reason, it is recommended that clients undergo blood glucose testing prior to starting the medication. These levels should also be regularly monitored. Hypotension experienced by clients can cause symptoms of fatigue, dizziness, and tachycardia (Yamashita et al., 2013). Clients with a history of seizures should be explained that this medication can worsen their condition. It is also important to note that Dysphagia Esophageal Dysmotility and aspiration have been associated with antipsychotic drug use (Yamashita et al., 2013).
VIII. Counselor considerations II
In order to potentially avoid the severe side effects which were mentioned above, an in-depth biopsychosocial must be taken when first meeting with a client. This would allow the counselor to be privy to any past medical history, surgeries, family medical history, and current medications which the client is taking. This will be useful in weighing the benefits and risks of taking this medication because the client will be able to contribute to their treatment by making an informed decision. For example, if a client has a family or individual history with diabetes, the client should be informed of the risks of elevated glucose levels. If they do choose to continue with the medication, precautions such as repeated glucose testing can be done in order to ensure the client’s safety.

Psychoeducation can also be used to not only inform the clients, but their families as well about the potential risks associated with this medication, or lifestyle changes which must be made in order to decrease the risks associated with treatment. Psychoeducation can also be a platform to advocate for a combined treatment of medication and psychotherapy. It is also important for counselors to have extensive knowledge of the side effects so that they can explain and make clients aware of them. If a client is aware of some of the adverse side effects before taking the medication, they will be more likely to report any odd symptoms due to the severity of many of the adverse effects.

In the first session, the client will be given an informed consent to sign as well as debriefed on what a counselor is mandated to report and what stays confidential. It is beneficial to ask the client what symptoms caused them to seek therapy and have them expand on any other symptoms they may be experiencing. Having this first detail of symptoms is beneficial because a counselor can compare this to symptoms which the client is experiencing after taking medications. I also believe that clients should rate their symptoms on a scale so that the counselor has a quantitative way to judge whether or not a medication is actually working. It is understandable that clients may have difficulty when it comes to describing symptoms of sexual dysfunction and it is essential that a safe space is created for clients to discuss these things. While it may be difficult for clients to open up the rapport which the client and counselor build throughout sessions should make sharing easier.
The counselor should also pay close attention to things such as the client’s appearance and effect because symptoms such as weight loss, irritability, and fatigue can be seen through direct observation. This should be written down in the counselors’ client notes because the client can look back and assess if there are any noticeable changes. For example, if a client came into the first session happy, awake and willing to talk they can note this in their notes. If within the next few sessions the client is no longer willing to speak and looks overly tired, the counselor may want to discuss what the client believes caused this change in order to rule out adverse effects from the medication.
There are adverse effects which occur when taking Risperdal which can exacerbate psychological disorders. While using Risperdal, clients may feel as if they are depressed due to the side effects of fatigue which can be present. The client may mistake this significant change from mania to a more sedative state and contribute it to depression. I do not believe that this particular medication can be seen as useful if there are no changes being seen. This medication is used for chronic illnesses and should, therefore, be able to decrease the side effects so the client can have a better quality of life. For example, if a schizophrenic client hears voices and after they have been on the medication for a substantial period of time the voices have not dulled or gone away, it may be time to look into an alternate medication or intervention. No change, in this case, does not equate controlling the diagnosis, but it does show that the medication is not working for that particular individual.

IX. Research of effects
To fully understand the effect which medication has on a client, the efficacy of the medication through research must be discussed. The effectiveness of Risperdal Consta, the intramuscular injection, specifically the 25 milligram and 50-milligram dosages, were tested using schizophrenic patients in a 12-week trial (CITE). In this study, all clients were diagnosed with schizophrenia using DSM criteria. There was a control group in the study which was given a placebo.
The trial was a 12-week study in which stable patients with Schizophrenia were
Further trials included a 12-week non-inferiority comparative trial in stable patients with schizophrenia, in which RISPERDAL CONSTA was shown to be as effective as the oral tablet formulation (RIS-INT-61). The long-term (50 weeks) safety and efficacy of RISPERDAL CONSTA was also evaluated in an open-label trial of stable psychotic inpatients and outpatients who met the DSM IV criteria for schizophrenia or schizoaffective disorder (RIS-INT-57-see figure 2). Over time efficacy was maintained with RISPERDAL CONSTA.

These efficacy trials used the internationally recognized PANSS scale. The total score (30 items) is divided into subscales: 8 items covering positive symptoms (e.g., hallucinations and delusions), 7 covering negative symptoms (e.g., blunted affect), 7 covering disorganized thought, 4 covering uncontrolled hostility/excitement and 4 covering anxiety/depression. Each item is scored on a seven-point item-specific Likert scale ranging from 1 to 7.
Bipolar Disorder
In a pivotal 24-month placebo-controlled trial (RIS-BIM-3003) male and female patients aged 18 to 65 with Bipolar Disorder Type I who achieved remission on RISPERDAL CONSTA during an open-label 26-week initial stabilization phase were randomized to receive either RISPERDAL CONSTA as monotherapy or placebo during a 2-year, double-blind treatment period. A total of 559 patients were enrolled in the study, of which a total of 303 subjects (54%) were randomly assigned to double-blind treatment with RISPERDAL CONSTA (n=154) or placebo (n=149). Patients receiving RISPERDAL CONSTA demonstrated superiority over placebo in preventing recurrence of a mood episode. There was a statistically significant difference (p?0.001; log-rank test) between treatment groups in the time to recurrence during double-blind treatment in favor of RISPERDAL CONSTA, with 30% of patients experiencing a recurrence in the RISPERDAL CONSTA group versus 56% in the placebo group during the 2-year double-blind follow-up period. The relative reduction in risk of recurrence, as reflected by the treatment:placebo hazard ratio 95% CI, was 0.40 0.27, 0.59. The majority of recurrences were due to manic rather than depressive symptoms. RISPERDAL CONSTA was not effective in delaying the time to occurrence of a depressed mood episode.
XI. Counselor Considerations III
As with any other medication, it is imperative that the client is given all of the information needed to outweigh the pros and cons of a medication to make an informed decision. In order for a client to choose a medication, they should be able to say with assurance that they believe that the benefits outweigh the risks. It would be unethical for a counselor to make that decision for a client because we have to allow the client to advocate for themselves, as well as take all steps necessary to do what best for the client. The decision to begin Risperdal may be challenging, especially when having to go into an in-depth medical history. It is essential for the clients to ask about other medications and compare them to make sure that they are subjectively selecting the best one for them. There are several first-generation antipsychotics available, but it has been asserted that second-generation antipsychotics are safer so that is something which may cause the client to seek Risperdal. Compared to other medications, Risperdal can be seen as a safe option for specific populations. If a client is elderly, they may stay away from Risperdal because it has fatal side effects for those who are higher in age.

Medications which are comparable to Risperidone are Zyprexa, Seroquel, Geodon, Abilify, and Invega (Bou Khalil, 2012). While they are all classified as antipsychotics, each medication comes with its own benefits and limitations. Zyprexa, also known as olanzapine is a medication which is also only available with a prescription. It is one of the medications which is most frequently compared to Risperidone. Both medications are advertised as having the ability to help control the thoughts and moods of the clients it treats. Zyprexa is advertised to help treat psychosis, mania, and agitation (Voruganti ; Awad, 2000). While this medication may succeed in lessening symptoms, it is criticized for its likelihood to cause clients to gain weight and experience extreme fatigue. Both of these drugs have adverse effects. Risperidone is commonly associated with movement disorders and sexual dysfunction and olanzapine with considerable weight gain. For this reason, I believe that it is essential to give the client all of the information available so that they can pick which side effects they are more equipped to deal with.
I believe that while most counselors strive to have psychotherapy be the primary modality of treatment, there are benefits and limitations to this approach. Due to the severity of both Schizophrenia and Manic episodes of Bipolar disorder, there is only so much that psychotherapy can achieve for a client. Psychotherapy may provide a space for the client to be heard, but due to the other symptoms which occur with each of these diagnoses, the client may not show up to counseling. It may also be challenging for clients to be fully present and attentive if they are going through periods of psychosis. A benefit of medication would be that it can minimize the symptoms which an individual experiences which in turn may allow them to focus better in everyday activities. The medication can also help to give the client a sense of control over their diagnosis which they may not have.
While psychotherapy is definitely beneficial, I do believe that the best form of treatment is a combination of the two. Medications may allow the individual to get their symptoms under enough control to actually benefit from counseling. Although this can be the case for most clients, I do believe that in more severe cases of each diagnosis medication is the most beneficial intervention. Psychotherapy in the case of schizophrenia and bipolar disorder would be a second, complementary intervention. The client must ultimately find a balance between the two. Overall, not understanding pharmacology would contradict the ethical virtue of benevolence because this lack of knowledge can prevent clients from getting the best treatments possible.

American Counseling Association (2014). ACA Code of Ethics. Alexandria, VA: Author.

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