Case Presentation: Treating 27 Year Old Patient With Schizophrenia Case Presentation

The Case:

Darius is a 27-year-old man who has just been admitted to your inpatient service team. This is Darius’ fourth admission in the past 2 years, but first in nearly 11 months. Darius was working most recently at a big box retailer stocking shelves but has had to leave his job over the past month. Darius had been attending a 4-year university at the time of his first psychotic episode. In addition to his job, he has been attending a local community college part-time with just 2 more classes needed to graduate with his AA degree. He lives at home with his mom, who says she thinks he has been taking his medication, but she has noticed his behavior has changed over the past 2 to 3 weeks. He has been staying up later and later at night—she often hears him walking around in his room after 2 AM, and over the past few days, he has not gotten out of bed, even to eat meals. He has pulled the blinds closed in his room and wears headphones all day—often without any music playing in them. Darius has a history of 1 prior suicide attempt, and his mom reports that he has recently been talking more about death, and she worries he has been thinking more about suicide lately. 

On your initial exam, Darius was reluctant to talk. He did not make eye contact, and when he did answer, it was only in a brief whisper. He said he was worried that if he spoke in a full voice that “they” would hear him and know he was in the hospital where “they” could impersonate a security officer and kill him in his sleep. He believed that a gang had implanted a chip in his brain, and they were sending him messages that he did not wish to elaborate on, but he was seen on the unit responding to the gang members to leave him alone. Ultimately, he spent nearly all his waking hours since admission in his room, often with the blankets over his head. He reluctantly said that his overall plan was to leave the country as soon as he could so that the gang members wouldn’t be able to follow him where he went and that if he encountered someone he thought was a gang member, he would either kill himself or them immediately. 

Darius was most recently taking olanzapine 15 mg. A count of his medication indicates that he may have missed approximately 5 doses since his last refill 3 weeks ago. Looking back at pharmacy records, it seems he has often refilled his 30-day supply at least 4 to 5 days late each month. Of note, Darius is 6’2” and now weighs 295 pounds. He has gained over 95 pounds since his initial presentation 8 years ago, and 50 of those pounds were gained in the last year since he started on olanzapine. He has tried previous medications including risperidone (stopped due to patient preference to be off medication), quetiapine (side effects), and ziprasidone (side effects). He did gain some weight on risperidone and quetiapine, and he cited weight gain as the reason he stopped the risperidone, but after a hospitalization 3 weeks later he decided he was willing to try olanzapine, and for the past 11 months he has taken it despite telling his psychiatrist that he does not like the weight gain and fatigue has been feeling. Darius is seen at an outpatient in an academic medical center, using his mother’s private insurance, and thus does not have a case manager or community care providers. Darius is generally responsible for his medications and medical care as his mom works full time and often into the evenings.