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A Tale of 2 Cases With Dr Citrome: Part 2
(Part 2 of 2)
Leslie Citrome, MD, MPH, discusses gives more detail on the patients' initial course and the conclusions to the cases of Roger and Frank, 2 patients with schizophrenia.
In the previous part 2, Dr Citrome gives more detail on the initial happenings in the cases.
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Read the transcript:
Hello, I'm Dr Leslie Citrome, Clinical Professor of Psychiatry and Behavioral Sciences at New York Medical College in Valhalla, New York. Welcome to part two of our discussion of A Tale of 2 Cases.
You'll remember that we talked about Frank and Roger, two people who were in college and who had their first psychotic break. They were both diagnosed with schizophrenia, but each of them received very different treatments.
We talked about who will likely have the better outcome, and what would be the general outcome when someone who is treated for their first episode have.
Well, let's talk today about their initial course in their treatment journey. Frank's initial course was marked by a stay in the inpatient psychiatric facility of a well respected private institution. He is diagnosed with schizophrenia based on a careful diagnostic interview and is prescribed a branded antipsychotic with hopes that, well, it's better tolerated. He'll be more likely to take it.
It happens to be lurasidone, 80 milligrams at bedtime. Frank appears to snap out of it relatively quickly. He expresses surprise that he's in a hospital. He wants to go back to school. He's given a prescription for lurasidone with instructions to return in one month for a follow-up visit.
Well, when Frank goes back to his fraternity house, he's worried about what his fraternity brothers will say about his crazy pills, and so he throws them out. He tells himself that he feels fine, and actually, he does feel fine, and he feels he doesn't need to take his medicine anymore.
About 3 weeks later, Frank barricades himself in a bathroom, shouts repeatedly that he's in danger. The campus police are called, and Frank is brought to the local emergency department for an evaluation. He's admitted to the locked inpatient psychiatric unit under the emergency commitment statutes.
Roger's initial course was different. While under the care of psychiatrists and other healthcare professionals at a locked inpatient psychiatric unit, he responded well to risperidone. He was titrated up to three milligrams at bedtime.
His delusions are no longer intrusive, and he says he's able to think more clearly. Roger's doctor offers him the option to take a medicine only once a month, and then maybe only every three months, instead of every day.
Roger's very interested in hearing more about this, although he was surprised to hear that it was going to be administered by injection. Nevertheless, it sounded very convenient to him, and he wouldn't have to explain to his roommate why he has to take pills.
He was able to return to college for the summer session, eventually catches up to the rest of his class, and he goes on to graduate. Well, that's a very different course than Frank.
There's a twist to this story. Roger develops sexual dysfunction. What can we do next?
Here are our choices. Do we switch Roger to a subcutaneous version of the long-acting injectable antipsychotic that he's receiving? Do we switch Roger to another long-acting injectable antipsychotic that has a lesser effect on prolactin levels, perhaps?
Do we prescribe a medicine for erectile dysfunction, or do we prescribe benztropine? Actually, what we need to do is figure out why Roger developed sexual dysfunction. It could be due to elevation in prolactin. We'll have to measure that.
Let's say it is, and he does have an elevated prolactin level. Logically, we would switch Roger to another LAI that is not associated with elevations in prolactin. That'll preserve the strategy of giving him an injectable so that he's more adherent and more likely to be successful.
Frank and Roger are worlds apart, aren't they? Frank actually suffers repeated relapses and rehospitalizations. He's never offered an LAI antipsychotic, because they are seen to be stigmatizing, at least by his family.
They are considered stigmatizing also by his physicians, who aren't as well informed about LAIs as perhaps they should be. Frank's insight into his illness and subsequent adherence behavior is erratic. Sometimes, he takes his medicines, and sometimes, he doesn't.
Frank's family is actually quite accepting of this. They believe this is the normal course of events, because this is exactly what happened with other family members.
Well, Roger actually has a completely different trajectory. He graduates from college, and although he doesn't become a physician, he is interested in computers. He begins a promising career in computer and networking hardware installation under the supportive tutelage of a local tech savvy businessman.
Roger remains adherent to his long acting injectable antipsychotic medicine. Although he does experience symptom exacerbation from time to time, it is managed on an outpatient basis. Story is long acting injectables may be quite helpful in people even in their first episode of illness. It helps them stay the course.
With Roger, it gave him his life back, and he made a recovery. Not exactly what he intended to do at the beginning of college. He didn't become a physician, but he has a satisfying career, and he has plans on having a family and moving on with his life.
Frank becomes chronically mentally ill and becomes more and more difficult to treat. In five, four, three.
That's our Tale of 2 Cases. It really makes a difference how the treatment is initiated, how much the patient is engaged in treatment, and how likely that patient is to be adherent to their treatment regimen.
Schizophrenia is considered to be a lifelong illness, requiring lifelong treatment. The steps we take at the beginning have an impact on the patient's lifetime, something to consider and remember. Thanks so much for your attention.
