The question you should ask is, 'if I got this as a letter would it give me enough information to know what happened, what to do next, what could I expect and what should my response be if something goes wrong'. NB. you are on a specialist unit providing guidance to a non-specialist
Yet again a familiar case.......
17 yo unemployed male living with his family. Several
months of social withdrawal, unkemptness and poor hygiene. Heavy tobacco smoker
and regular cannabis user. Previous experimentation with amphetamines and LSD.
Experiences paranoid beliefs that he is under surveillance by bikie gangs, phone
is tapped and that listening devices are in his house. Also experiences auditory
hallucination of persecutory nature and more recently, command hallucinations to
commit suicide.
Examination revealed casually dressed male with evidence of poor self-care. He
was orientated to time, place and person but appeared anxious, fearful and
agitated. Conversation was often tangential and preoccupied by themes of being
killed by bikie gangs. He demonstrated impairment in short term memory that may
have been influenced by his thought disorder. He showed poor insight and
judgment and was resistive to admission and treatment.
The patient was detained to the locked ward of a mental health unit whereupon he
became increasingly agitated and paranoid and attempted to abscond. This
required temporary physical restraint. Eventually spontaneously settles without
chemical sedation. Commenced on risperidone and agitation settles overnight but
paranoia persists. Later in the week, behaviour settles and patient is
transferred to open ward. Patient begins complaining of muscle stiffness and
pain, stiff gait and hand tremor which is temporarily relieved with benztropine
but followed by blurred vision and dry mouth. Persistent stiffness results in
medication changed to olanzapine responding with gait improvement a few days
later. The patient continued with individual supportive counseling and family
meetings were organised for education.
Outpatient group sessions were offered and various community support groups
suggested. Symptoms resolved by the end of week 3 and the patient was
discharged.
After several weeks of treatment, the patient complained of excessive appetite
and weight gain but remained amotivated, socially withdrawn and poorly
communicative. Exercise was recommended and heeded with temporary weight
improvement. Erectile dysfunction became problematic later and psychiatric
symptoms worsened again with paranoia and poor sleep. Compliance to exercise and
psychotherapy was therefore affected. The patient was switched to clozapine with
regular blood counts arranged. The patient experienced sleepiness and increased
salivation but after several weeks of treatment, paranoia settles and patient
begins to develop insight into his illness. Participating in living skills and
vocational rehabilitation allowed the patient to enter a trade apprenticeship.
Sexual function improved but weight gain remains an issue (associated with mild
glucose intolerance) which required dietetics input. Several months later, the
patient re-experiences mild paranoid ideation in the context of missing his
medication and experimenting with amphetamines. This quickly resolves with
resumption of medication and further education is given. During his studies
experiences a failed relationship with a woman but despite this coped well. The
patient remains compliant to medication and follow-up and advised that treatment
will be life-long.
Letter to GP or private psychiatrist at time of discharge......
Dear Dr. Allthings,
Thank you for continuing the care of Jared Callahan
He is a 17 year old male admitted to the psychiatric ward for three weeks for
the assessment and treatment of new-onset paranoid psychosis. He has a history
of cannabis use but it was felt that his likely problem was a first presentation
of acute schizophrenia.
Initially he was quite agitated and required admission to the closed ward for
several days. He later settled on medication. Due to an inability to tolerate
risperidone from extrapyramidal side effects, he was finally managed with
olanzapine.
When he was first seen he demonstrated intense paranoid beliefs that he was
under surveillance by bikie gangs, his phone was tapped and that listening
devices were in his house. He also experienced auditory hallucination of a
persecutory nature and command hallucinations to commit suicide. Mental state
exam revealed a young man with evidence of poor self-care. He was orientated to
time, place and person but appeared anxious, fearful and agitated. Conversation
was often tangential and preoccupied by themes of being killed by bikie gangs.
He demonstrated impairment in short term memory that may have been influenced by
his thought disorder. He showed poor insight and judgment and was resistive to
admission and treatment. All of these symptoms eventually settled with
treatment.
The patient continued to participate with individual counseling and several
meetings with the family occurred through our social worker. After 3 weeks he
was discharged into the care of his family. He has an appointment for outpatient
group sessions and been given contact with community groups. Can you monitor him
for compliance to his medication and address any problems resulting from them?
We have warned him of the potential weight gain and of sexual dysfunction with
olanzapine. Questions about any issues can be directed to the consultant
psychiatrist, Dr. S. Freud.
Sincere Regards,
Dr. D. Lee Gent (Psychiatry RMO)
cc. Psychologist - Dr. Pavlov
cc. Community Psychiatric Team (Upper Kumbukta West)