Past case 1: Chronic schizophrenia

Question 1

Catherine is a 27-year-old unemployed single woman with a five-year history of schizophrenia. You are her GP and she comes to see you to renew her script and appears agitated, distracted and mildly dishevelled and smells of cigarettes. She concedes that her usual auditory hallucinations are becoming more distressing and threatening and she is feeling frightened. She has tried a number of other medications including aripiprazole which made her agitated, oral risperidone which caused symptomatic hyperprolactinaemia and depot paliperidone and haloperidol which gave her abnormal movements. She has responded reasonably well to olanzapine but over the past 2 years she has gained 20kg. She was recently discharged from hospital on 20mg olanzapine but has since reduced her dose to 10 mg. She complains that she is getting too fat. She is a heavy smoker, rarely leaves her house other than to visit the corner shop and has a diet high in junk food.

Answer 1

Impression/initial thoughts to case

• current presentation may represent symptoms relapse
• ?olanzapine and nicotine interaction
• may not be getting a therapeutic dose of olanzapine for schizophrenia symptoms

Summary of case
- multiple medication trials
- current deterioration in mental state
-

Question 2

Assessment approach

Answer 2

History

• sx; characterise symptoms of relapse: psychotic (AH, VH, delusions, corroborate on MSE.
• screen for depression, suicide, violence, personality, mania
• medications: current regime and previous trials, any adverse effects (now and in the past)
• substance use disorder
• PMHx - particular focus on cardiovascular disease risk factors, and assessment for readiness to change re quitting smoking
• rest of psych history as required

MSE
- A/B
- Content + form - look for signs of psychosis
- I/J - would assist in risk assessment
Other examination:
- cardiovascular exam
- endocrine exam, diabetes examination
- anthropometric measurements, vitals

Risk assessment
- risk of harm to self (reputation, self-harm), to others (psychosis), does she require admission?

Investigations:

• Bedside: urine drug screen, ECG, anthropometrics
• Bloods: FBC, UEC, LFT, lipid panel,
• Imaging: echo if starting Clozapine

Question 3

1 - Discuss alternative pharmacological and on-pharmacological treatment options and your approach to discussing them with Catherine

Answer 3

Approach
- invest in therapeutic alliance, work with the patient and develop solution which serves their best interests/preferences

Pharmacological considerations

• is Olanzapine dose correct? need to clarify reasons for cessation, adverse effects, efficacy regarding schizophrenia symptoms
• 15kg weight gain considered red zone, consider switching to AP with less metabolic side effects
• given multiple medication trials previously, may require clozapine if treatment resistance is what is occurring there - need to discuss starting clozapine (occurs on inpatient basis, regular monitoring instituted - may be better for staying on-top of metabolic side effects)
• Consider starting metformin given already considerable weight-gain, can look to adding in GLP-1 antagonist given their weight-loss effects too once effects of metformin are determined

Non-pharmacological

• lifestyle modifications for metabolic effects
• PT referral
• dietary input
• multidisciplinary team: GP, EP, PT, dietician, etc
• discuss value of psychotherapy

Question 4

2 - Discuss approach to Catherine’s concerns regarding the medication side-effects

Answer 4

Approach

• patient-centred approach, maintain therapeutic alliance
• discuss any existing side effects
• ask about what greatest concerns are
• educate on the specific adverse effects of particular treatment options:
• increasing olanzapine
• switching to clozapine
• ?depot medication (olanzapine, paliperidone)
• also explain the risks of NOT taking medications