Attending physician’s mental notes: six months

At the time of this treatment, metabolic disorder was not well understood or appreciated, guidelines did not exist, and laboratory blood samples were not drawn for monitoring very often

Initially, this patient looked easy to treat as his initial atypical antipsychotic was effective at usual dosing guidelines

Now, he is looking more treatment resistant as his second atypical antipsychotic is requiring very high doses to alleviate his psychosis

Olanzapine (Zyprexa) was approved at doses up to 20 mg/d

• – The use of 30 mg/d is off-label

• – There is little available data to support this practice but he is responding

• – Theoretically, his dose must now be blocking enough D2 receptors to provide antipsychotic effects

What were the causes of his relapses on risperidone (Risperdal) and lower dose olanzapine (Zyprexa)?

• – Treatment resistance and his more severe illness

• – An artifact of switching his medications and a window of undertreated psychosis during the cross-titration when both atypical antipsychotic doses were relatively low

He is being very compliant despite weight gain and EPS side effects

Will need to convince him to stay on his medications over the long term to avoid a worsening prognosis and social downward drift

Case outcome: interim follow-ups through nine months

EPS are easy to monitor and to treat

• – Patient is offered benztropine (Cogentin) 1 mg/d to control his EPS and this was effective without any burdensome anticholinergic side effects

Case outcome: interim follow-ups through 18 months

Continues to see his supportive psychotherapist, who also intervenes more with family in sessions aimed at decreasing household stress and high expressed emotions

Olanzapine (Zyprexa) 30 mg/d is continued

• – At the time of this treatment, metabolic disorder was not well understood, guidelines were not available, and laboratory blood samples were not analyzed, but his weight was followed sequentially. His weight gain did not progress past 15 lbs

He continued to do well with only mild negative symptoms

Attending physician’s mental notes: through 20 months

Patient is doing very well

Have to continue his simple medication regimen as long as possible

It appears we began treatment in his first psychotic break

His prognosis is promising

Question

How long should you treat this patient with his antipsychotic?

After remission of psychosis, treat one year and then discontinue

After remission of psychosis, treat five years and then discontinue

After remission of psychosis, treat 10 years and then discontinue

After remission of psychosis, treat indefinitely as only 10% of schizophrenics go on to maintain remission without medications and to lead relatively normal lives

After remission of psychosis, treat indefinitely unless side effects complicate ongoing treatment

Case outcome: interim follow-ups through 24 months

The patient gradually presents with difficulties

• – Increased stress due to issues with his family

• – Now has insomnia

• – He is not depressed, nor suicidal

• – Starts to have problems at work, which require intervention and moving to yet another assembly line

• – In session, he admits his psychosis is back to a moderate level. His hallucinations are mostly neutral but more now have negative and critical content

• – Mild IOR are back and they may be delusional, as he feels a local company’s work trucks are following him around (this regional company has thousands of service trucks randomly around at any given time)