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PSYCHIATRIST’S CLINICAL DILEMMA:PATIENT WITH SCHIZOPHRENIA WHO IS SENSITIVE TO TYPICAL AND ATYPICAL ANTI-PSYCHOTICS
DR. ROHAYAH HUSAIN, MMED(PSYCH),
SENIOR LECTURER, DEPARTMENT OF PSYCHIATRY,
SCHOOL OF MEDICAL SCIENCES, UNIVERSITI SAINS MALAYSIA HEALTH CAMPUS,
I6150 KUBANG KERIAN, KELANTAN
This case report illustrates a schizophrenic patient who has been having multiple admissions and is sensitive to several anti-psychotics. In the era of the development of atypical antipsychotics this patient was given a few types of atypical antipsychotic however she also developed intolerable side effects. She was then maintained on quetiapine for some time, since she the medicine kept her slim, however quetiapine availability at the hospital, dosing and life events she experienced all affected her and resulted in relapse for her. It was a valuable experience to the treating psychiatrist and team in managing her.
Key words: schizophrenia, sensitive, anti-psychotic, quetiapine
Schizophrenia is a chronic and relapsing illness that impairs mental and social functioning. Patients present with positive and negative symptoms throughout the course of illness.(1) With the availability of atypical antipsychotic many patients had the advantage of a speedy recovery both on positive and negative symptoms, however some patients who sensitive to typical antipsychotic also developed side effect with the use of atypical side effect. Data showed that extra pyramidal side effect are the commonest type of side effect with the usage of typical antipsychotic however weight gain, is among the commonest side effect with atypical anti-psychotic. (2) The clinical dilemma arises in managing this patient includes: (a) sensitive to various anti-psychotics: developed extra pyramidal side effect to several typical antipsychotic and also unable to tolerate olanzapine ( developed seizures) and risperidone ( weight gain, amenorrhea and galactorrhoea). (b) she responded and able to tolerate quetiapine at certain dosage, however the quetiapine availability and inadequate dosage lead to relapses (c) as a person who is vulnerable to stress, presence of stressful life event also affected her illness and lead to relapses (d) dosage monitoring and patient tolerability to quetiapine also play a role in the progress of her illness. The patient history, clinical features, medication and progress were as in the case report and the clinical dilemma will further discussed.
The patient is a middle aged divorcee from Kelantan, has had schizophrenia since 1996. She completed her form five, then she helped her father who works as a rubber taper. She is able to help her mother doing house chores when she was in remission. She is the sixth of seven siblings with strong family history of mental illness; her mother and her third brother are having schizophrenia. Since year 1996, she has 9 admissions to psychiatric ward Hospital Universiti Sains Malaysia , Kelantan. Her last admission was in July 2007 due to relapses of her illness. The usual symptoms at each admission include auditory hallucination, visual hallucination and persecutory delusion.
In the early years of her illness, she was put on several type of oral typical antipsychotics (haloperidol, thioridazine, stelazine and chlorpromazine), medication kept changed since she developed extra pyramidal side effects namely acute dystonia and parkinsonism. Oral benzhexol were added but unable to reduce the side effect. The side effect also leads to poor compliance and she was tried on depot Modecate, unfortunately she developed rigidity with modecate.
In 2004 her medication switch to risperidone, her symptoms responded well to risperidone and then maintained on 3 mg daily for nearly one year. She then complaint of weight gain ( she gained 14 kg weight over 8 months) that make her difficult to help her father for rubber tapping. She was put on Olanzapine 10mg daily but developed fainting attack and the medication changed back to risperidone. Since she is functioning well, the dose of risperidone reduced to 2 mg daily, to avoid further weight gain and she was advice for proper diet intake and exercise. In 2005, she complaint of having amenorrhea for 3 months and also noted to have galactorrhoea, the treating doctor at that time referred her for the quetiapine IR clinical trial. she was enrolled to the 12 week flexible dosing study of quetiapine IR. She was then maintained on 400 mg quetiapine IR with some tolerable sedation and at that time she was in remission. Following the study, due to lack of stock of Quetiapine she was only prescribed Quetiapine 200mg for 4 weeks and this wass out of stock at the end of 4 weeks, and her medication switched to perphenazine 4 mg bd. After three days of this medication she relapsed and was admitted to the ward. There was no other stressor at that time so we postulate the reasons of relapsed were due to inadequate dosage of quetiapine and the non sedative effect of perphenazine. She requested quetiapine and she was put back on quetiapine 400 mg ON under the hospital local purchase.
Her remission was maintained for one year, till her mother suffered stroke in July 2006 and she was the one who taking care of her bedridden mother. We notice slight behavioural changes whereby she would dress sexually provocatively every time she came for follow up or to day-care, however upon questioning she denied having any problems and seemed able to take care of her ill mother at home. In early 2007 she wrote a letter to one of the male doctors, stating that she knew thedoctor was in love with her. The doctor then transferred her to a female doctor, a plan of increasing the quetiapine dose was discussed with her however she refused to increase the dose because she was afraid of excessive sedation. Two weeks prior to admission she gave three love letters to the treating doctor, her medication was increased to 600 mg daily. Ultimately in July 2007 she developed persecutory delusions about her neighbour and auditory hallucinations that lead to admission. For this current admission quetiapine dose increase to 400 mg bd, she complained and noted to be sleepy for the first two weeks but then she was able to control the sleepiness by involving herself in ward activity. Her persecutory delusion and hallucinations subsided, however she was reticent about the delusion of love with the male doctor. She was given home leave in the third week and subsequently discharged.
This case illustrates the some of the challenges in treating Schizophrenic patient who sensitive to antipsychotic. A strong family history of Schizophrenia predisposed her to have schizophrenia. Effective pharmacologic treatment of schizophrenia has been available since the 1950s. Some schizophrenic patient are more sensitive to antipsychotic compared to others, however with the development of atypical antipsychotics doctors has more choice to choose what medication suitable to their patients. Initially, at 400mg Quetiapine MZ was able to function well. Her weight maintained at 49 kg and she regain her menses after 6 week with quetiapine. Although newer atypical antipsychotics are associated with fewer neurological side effects, they confer a higher risk of other side effects such as diabetes, hypercholesterolemia, and weight gain. (3)
Apart from tolerability, the cost and availability of the antipsychotic also play an important role. The dilemma for the treating doctor is the difficulty to get quetiapine from the hospital. Many requested local purchase forms sent, were turn down even with the support of Head of Department. This is due to financial budget for drugs at the hospital at that time. Retrospectively analysis, we thought that the inadequate dose she received and the abrupt switching to another antipsychotic (from quetiapine to perphenazine) contribute to her relapsed in early 2006.
Life events occur to everyone and as in this patient her mother developed stroke in mid 2006, and she carried the burden of taking care of her bedridden mother. Since then she gradually developed a delusion not unlike de Clerambault's (she believed that the doctor was in love with her), however no other obvious symptoms were noted until she wrote few letters to the doctor. She was still functioning well and there was no complaint by the family members. At that time the treating doctor failed to persuade her to increase the quetiapine dosage - she was afraid of excessive sedation that would prevent her taking care of her mother.
Ultimately she has had a full blown relapse and was admitted to the ward ( Summer 2007), quetiapine dosage were increase gradually to 800mg daily and the side effect observed. The sedation was worse in the first two weeks but when she started to engaged with ward activity, she was able to tolerate the sedative effect and improved.
The individual variations in response to medications are likely due to multiple factors that may be difficult to elucidate. Response to a treatment is affected by patient characteristics, including an individual's toleration of side effects. Previous treatment history and response to previous medications may be informative in selecting a new antipsychotic. In the CATIE Study about switching medication in chronic schizophrenia, perphenazine, quetiapine and olanzapine were more effective than risperidone, as reflected by longer time to discontinuation for any reason. however in the context of other results from the CATIE study, the effectiveness and acceptability of antipsychotic drugs appears to vary considerably according to clinical circumstances.(4) The other recommended anti-psychotic for her is Clozapine, however due to the logistic problem and difficulty in monitoring the white cell counts, this option will only be utilized if she failed to respond or unable to tolerate a higher dosage of quetiapine.
(1)Bromet EJ, Fennig S. Epidemiology and natural history of schizophrenia. Biol Psychiatry, 1999;46:871-81.
(2) Antai-Otong, D. Metabolic effects associated with atypical antipsychotic medications. Perspectives in Psychiatric Care, 2004; 40(2): 70-72.
(3) Norman L Keltner. Metabolic Syndrome: Schizophrenia and atypical antipsychotics. Perspectives in Psychiatric Care, 2006; 42(3): 204-207.
(4) T Scott Stroup, Jeffrey A Lieberman, Joseph P McEvoy, Marvin S Swartz, et al. Effectiveness of Olanzapine, Quetiapine, and Risperidone in Patients With Chronic Schizophrenia After Discontinuing Perphenazine: A CATIE Study. American Journal of Psychiatry.2007;164(3): 415- 427.
Copyright © Priory Lodge Education Limited 2007
First Published August 2007