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• W2247355280 abstract "CASE You're a 'freak' A local mental health agency refers Mr. Z, age 23, to our inpatient psychiatry service because of increasing suicidality and psychosis. He began receiving care from the mental health agency 3 years ago, after a psychiatrist diagnosed paranoid schizophrenia. At presentation, Mr. Z is delusionally preoccupied with a brief relationship he had with a young woman at college 2 years ago. He feels embarrassed about his conduct toward her during a psychotic episode and her subsequent response. He believes strangers are ridiculing him, and he hears voices calling him a freak and making crude references to the encounter. He is also contemplating suicide and endorses a suicide plan. Mr. Z was hospitalized for 1 month last year with schizophrenia symptoms. He is medically healthy and does not abuse alcohol or drugs. We admit Mr. Z because of his suicidality. Four weeks later, he remains suicidal and hears voices telling him to rape and kill. Successive 2-week trials of risperidone, 1 mg/d titrated to 5 mg/d, and quetiapine, 200 mg/d titrated to 700 mg/d, cause intolerable akathisia. We try adding propranolol, 20 mg every 8 hours, to alleviate akathisia, but to no avail. Previous trials of olanzapine, 30 mg/d, and haloperidol, dosage unknown, were unsuccessful or caused akathisia. What medication(s) would you try for Mr. Z's paranoid schizophrenia? a) combination antipsychotics b) clozapine c) an antidepressant d) an adjunctive mood stabilizer with existing antipsychotics The authors' observations Substantial evidence supports clozapine's efficacy in treatment-resistant schizophrenia, and this second-generation antipsychotic (SGA) also might reduce suicidality. (1,2) Clinicians often combine antipsychotics, switch to an antidepressant, or add a mood stabilizer for treatment-resistant schizophrenia, (3) but little evidence supports these options. Mr. Z had failed at least 4 antipsychotic trials. We consider clozapine for patients with severe psychosis who have failed 2 or 3 antipsychotic trials or cannot tolerate these medications. Severity of psychosis and presence of suicidality warrant use of clozapine in treatment-resistant cases. If Mr. Z had tolerated risperidone or quetiapine, we would have waited as long as 8 weeks before switching to clozapine. In inpatients, improvement should be seen 2 to 4 weeks after starting an antipsychotic. Thoroughly discuss clozapine's risks and benefits with the patient and caregiver(s) before prescribing. Clozapine can cause a range of side effects, including sedation, weight gain, sialorrhea, seizures, diabetes, pulmonary emboli, and--most notoriously--agranulocytosis. These effects can occur anytime, but the risk is especially high within 1 year of starting the medication. (4) Perform blood tests weekly during the first 6 months of clozapine therapy and biweekly thereafter to check for abnormally low white blood cell counts that might suggest agranulocytosis. TREATMENT New regimen After discussing clozapine's risks and benefits with Mr. Z and his parents, we start the medication at 25 mg/d to gauge tolerability, then titrate to 300 mg/d over 10 days. Mr. Z tolerates clozapine well, with some sedation and sialorrhea. A blood test taken 7 days after we start clozapine shows a normal white blood cell count. After 10 days on clozapine, Mr. Z's delusions and hallucinations are considerably less intense. He is no longer suicidal and visits his former college with his parents without thinking about his past acquaintance. We discharge him on clozapine, 300 mg/d, and refer him to the local mental health agency. Two days later, Mr. Z's parents report that since discharge their son has had extreme fatigue, shortness of breath, leg edema, and chest pain. We advise them to immediately take their son to the ER for cardiac workup. …" @default.
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• W2247355280 date "2007-09-01" @default.
• W2247355280 modified "2023-09-24" @default.
• W2247355280 title "A Young Man's Affair of the Heart: After Several Failed Antipsychotic Trials, Clozapine Resolves Mr. Z's Delusions and Hallucinations, but Sudden Chest Pain, Fatigue, and Shortness of Breath Spell Trouble. What Next?" @default.
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