Question

What would you do now?

Superdose the olanzapine (Zyprexa) up to 40 mg/d to recapture efficacy

Add a typical antipsychotic as a combination therapy

Switch to a new atypical antipsychotic

Switch to a typical antipsychotic monotherapy

Attending physician’s mental notes: 24-month follow-ups

Life stress likely has caused his recurrence

Need to make sure psychotherapy is in place and need to discuss with his work how to keep him employed without losing his job. Consider disability

40 mg/d of olanzapine (Zyprexa) seems high, but he did very well for many months on the 30 mg/d dose, and could temporarily use a higher dose until psychosis subsides

Switching to the other, then currently available, a typical antipsychotic, quetiapine (Seroquel), is possible, but the cross-titration and its lower affinity may allow for more breakthrough psychosis to evolve

Clozapine (Clozaril) is an option but perhaps his schizophrenia is not sufficiently resistant yet to require clozapine and its excessive side-effect burden

Does psychotherapy treat schizophrenia?

The patient is getting supportive, intermittent family interventions but not formal family therapy in an ongoing manner. This type of therapy has an evidence base for treating schizophrenia

CBT also has data to support its use in schizophrenia, more so for improving cognition and executive functioning

Unfortunately, he likely needs more medication to lower his positive symptoms over the acute period to save his job in the short term

Case outcome: interim follow-up, 36 months

Olanzapine (Zyprexa) monotherapy is increased to 40 mg/d to no avail and his psychosis continues

Rather than cross-titrate over to the lower-potency quetiapine (Seroquel), use of a high-potency typical antipsychotic is used in combination with his olanzapine

• – Thiothixene (Navane) 5 mg/d is added to a reduced olanzapine (Zyprexa) dose (30 mg/d) to “top up” his failing atypical antipsychotic

• – This approach should make olanzapine seem more like a higher-potency antipsychotic with much more D2 receptor antagonism available

• – Psychosis resolves

Parkinsonism increases

• – Benztropine (Cogentin) is increased to 2 mg/d with some mild anticholinergic constipation side effects emerging

After a few months of combined antipsychotic therapy his psychosis resolved again

• – With the presence of moderate EPS and anticholinergic side effects, the patient complains of tolerability issues

  • Typical antipsychotic thiothixene (Navane) is lowered to avoid side-effect burden while olanzapine (Zyprexa) is continued

Trazodone (Desyrel) 50 mg/d is given as needed to control insomnia flare-ups and to avoid future psychotic relapses

He does well for a few more months with only residual negative symptoms present

Unfortunately, lateral tongue movements develop and are noticed on routine annual AIMS examination. He is informed this may become permanent TD and is given treatment options

The olanzapine (Zyprexa) is slowly discontinued. He is treated with vitamin E 800 IU to help alleviate the TD. The TD does gradually resolve

Fearing for a relapse into psychosis, the patient chooses to start quetiapine (Seroquel)

• – Its lower D2 receptor affinity antagonism and its shorter half-life may benefit the patient due to a lower EPS risk profile

• – It is titrated to 600 mg/d

• – Higher doses are found to be too sedating

• – The psychosis begins to return

Quetiapine (Seroquel) is topped up again with a different typical antipsychotic, perphenazine (Trilafon) 8 mg/d and the psychosis continues

Quetiapine (Seroquel) is abandoned and tapered off while the typical perphenazine (Trilafon) is increased as a monotherapy to 40 mg/d

• – Psychosis continues

• – Parkinsonism increases

• – TD returns