Download Module 3 – Case Study 1: First Episode Psychosis Mark`s

Module 3 – Case Study 1: First Episode Psychosis
Mark's Pharmaceutical Care Plan
Mark is a 24-year-old European man who has been admitted to an acute psychiatric unit for
assessment after his family reported that they were concerned about his attempts to harm himself.
History at presentation: Mark presents with a psychotic episode of acute onset. He is a young male aged
24 years (peak incidence for schizophrenia). Important symptoms at presentation include: Withdrawn
behaviour (social/work), agitation, incoherence, and self-harm behaviour (slashed wrists). On interview he
showed: Speech latency, auditory hallucinations, lack of self-esteem, quiet, euthymic mood, guarded,
fearful. Although psychotic symptoms (auditory hallucinations) appear to have developed in the past month
or two, social withdrawal (described as depression) and concentration problems have been present for
over two years. His DSM-IV diagnosis using the multi-axial classification is summarized below:
Axis I – First episode psychosis
Axis II – No reported personality disorders or mental retardation
Axis III – No known or history of concomitant medical condition
Axis IV – Currently in an apprenticeship program as a plumber
Axis V – Global Assessment of Functioning (GAF) score is unavailable. Based on current
presentation, estimated GAF score = 50 (patient at 50% his normal functional state).
Possible diagnosis: First episode psychosis. Patient needs to be monitored closely and frequently
for subsequent episodes. Subsequent episodes may require a review and change of the initial
diagnosis. Mark is at an increased risk for schizophrenia. Other psychiatric disorders may be
considered in the differential diagnosis (eg. Psychotic depression).
Management: The most immediate management goal for Mark is to minimize the risk for another selfharm episode, which can be achieved by decreasing the causative symptoms (hearing a male voice calling
his name, telling him he is bad and that he deserves to die). Achieving this first goal will likely lead to a
decrease in the acute distress associated with his psychotic symptoms, all of which will likely improve his
quality of life and functionality.
Mark was consequently prescribed Olanzapine 15mg nocte. This is a suitable choice, as atypical
antipsychotics are the medications of first choice for the management of first episode psychosis.
Other alternative agents include risperidone, quetiapine, ziprasidone and aripiprazole. However,
funding issues may need to be considered and discussed with Mark.
Monitoring Plan: Upon initiation of an atypical antipsychotic patients need to have a series of initial
(or baseline) monitoring parameters, including those needed to monitor for the metabolic syndrome
(e.g. weight, blood lipids, fasting glucose, and blood pressure). Some also advocate that a baseline
electrocardiogram (ECG) should be done. Other monitoring parameters that may be required include
renal function, liver function tests, and a full blood count (FBC). Serum prolactin is particularly
important for risperidone and for typical antipsychotics, but may not be as crucial for olanzapine or
other atypical agents. On admission, Mark’s physical examination and all blood tests were normal;
thus, Mark will not require a repeat of these monitoring parameters if they were initially investigated
on admission. According to monitoring guidelines for the metabolic syndrome, it is recommended to
monitor these parameters again at 6 months of treatment, and up to 2 years after treatment initiation.
Taking these opportunities to monitor treatment adherence is also of particular importance, especially
in first episode psychosis. Monitoring for medication efficacy will require interviewing Mark and
enquire for any changes in his initial presenting symptoms, such as his initial negative symptoms and
mood (ex: improved social interaction, no suicide ideation/attempts, increased work function,
improved concentration) and thought content ( ex: not hearing voices, improved speech and
cognition, less guarded or fearful, not responding to auditory hallucinations or delusions). Adherence
can be monitored by recording the number of tablets left on his vials, asking the patient, asking about
adverse events, by checking his residual symptoms and identifying overall improved parameters. It is
important to remember that there are a number of contributing factors to non-compliance with
medications, including: attitudes of family, unmanageable or uncomfortable side effects, perceived
stigma, and the fact that most patients are not involved initially in the choice of treatment.
Follow up: Mark reports feeling tired all the time. This medication related problem has affected both,
his work performance and his social life (he has slept in twice in the last week and has been getting
to work late. His girlfriend has also complained that he doesn’t seem interested in going out
anywhere). It is obvious that Mark is experiencing significant sedation associated with the high
sedating properties of olanzapine. Of all the atypical antipsychotics, olanzapine and clozapine show
the highest incidence of sedation. It is this property which leads to the usual recommendation of
dosing them at night (as prescribed for Mark); however, many patients do have carry-over effects
until the next morning, making it difficult for them to be active during the first hours of the day.
Management strategies for this side effect may include:
Decreasing the dose to lowest effective dose: Mark has responded quite well to 15 mg, he may
remain well at a night time dose of 10 mg. Monitor for recurrent psychotic symptoms closely and ask
for regular and continuous feedback from family (girlfriend).
If it is considered that 15 mg is actually the lowest effective dose for Mark, the following management
strategies may be tried:
• Change the administration time to early evening (right after 6 PM supper) rather than leaving it
for late night.
• Split the dose, leaving the largest dose for the evening. New dosing regimen could be 5 mg AM
and 10 mg in early evening as suggested above).