A Tale of 2 Cases With Dr Citrome: Part 1

(Part 1 of 2)

Leslie Citrome, MD, MPH, discusses who may have the better outcomes and the most likely results for Frank and Roger, the 2 patients who are the subject of this case, after receiving their first antipsychotic.

In the upcoming part 2, Dr Citrome gives more detail on the patients' initial course and the conclusions to the cases.

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. This is a case presentation in two parts. I'm going to be discussing how to best manage people with schizophrenia from the very beginning.

Actually, I'm going to talk about two different cases. This is a tale of two cases, one where the outcomes actually are better than the other. Let's talk about our first case first.
Frank. He's a 20-year-old white sophomore at a prestigious private university who lives in a fraternity house. He comes from a well-educated and wealthy family. However, mental illness is no stranger to the family. Frank has an aunt and a great uncle who were diagnosed with schizophrenia and a cousin who committed suicide after several psychotic relapses and hospitalizations.

During the winter break, Frank's mother becomes worried when Frank refuses to leave his room. He doesn't allow any of his friends to visit him, and he appears preoccupied with Satan and the end of days. He's eventually coaxed into seeing his pediatrician, a family friend. Frank passively allows his admission to a famous and well respected inpatient psychiatric facility.

Then we have Roger. Roger is a 19-year-old African American freshman at a local state college. He's the first in his family to attend college. Roger has ambitions to become a physician, based in part on the chronic physical ailments that his grandmother suffered with before she passed away in Roger's senior year of high school. There's no family history of mental illness.

In the fall semester of his first year of college, he finds himself already falling behind in his schoolwork, has difficulties with concentrating. He becomes preoccupied with thoughts that satellites are beaming instructions to the chosen few in the capital cities of Europe. It sounds pretty strange to anyone who listens to him.

By winter, he has failed a course and received a D in another, and he's put on academic probation. In March, he's arrested at a local supermarket after destroying part of the dairy section, claiming the food is tainted by aliens.

The police are called, and Roger's brought into the local emergency department for an emergency evaluation. He's admitted to the locked inpatient psychiatric unit.
We have Frank and Roger, both entering the mental health system, of sorts, in two different ways. Who will have the better outcome?

Will it be Frank, because he was admitted to a famous and well respected inpatient psychiatric facility, and the family has access to many helpful resources? Or is it Roger, because he doesn't have a family history of psychotic disorders? Frank does.

Or perhaps both have very poor prognoses, or perhaps both can do well, provided that they continue in treatment. What's the most likely outcome when either Frank or Roger first receives an antipsychotic? Is it because both Frank and Roger are young adult males, they are likely to experience side effects, want to stop their medicine, and then they won't do well?

Some of these side effects include dystonia, akathisia, and sexual dysfunction. Or is it that both Frank and Roger will experience a substantial resolution of their acute psychotic symptoms, actually do well, and that's their outcome?

Or perhaps, because Frank's family can afford it, Frank will be able to get a branded antipsychotic medication that is better tolerated, and thus will be more likely to be adherent to his medication regimen?

Or is it, because Roger's family has no prior experience with anyone else in the family having a mental illness, they will not understand the importance of Roger continuing on medication beyond his hospital stay?

Who will have the better outcome, and what's the most likely outcome? Well, frankly, we really can't answer that right now. There's no guarantee being admitted to a famous, well respected inpatient psychiatric facility, that that will lead to substantially better outcomes, and it really doesn't matter that much about a history of psychotic disorders, other than...Well, if you have a family history of psychotic disorders, then you're going to be more likely to develop an illness, but it may not have any bearing on the actual prognosis.

In reality, both prognoses, or actually, I should say, both Frank and Roger have pretty prognoses, provided that they take medicine.
Because both Frank and Roger are young adult males, they are more likely to develop side effects, and it will be a challenge for them to be adherent if they experience these side effects and don't see the benefit from their medicine.

Both are likely to have substantial resolution of their symptoms, actually, if we think about it. It's their first episode, and usually, people in their first episode will get better. They may not completely get back to their baseline, but pretty close to it for many of them.

Whether or not they continue the medicine is a different story. Now, it's always nice to have a medicine that people are well tolerating, and they are more likely to continue taking it, because it's not creating some troublesome side effects, but there's no guarantee that adherence will occur, particularly if they don't feel they still need their medicine.

The family is really important here, and we need to educate families about the importance of continuation with a medication regimen as the best guarantee about reducing the risk of relapse. It doesn't completely eliminate the risk, but reduces it substantially.

Stay tuned for part 2 of 'A Tale of Two Cases'.