Treatment Resistant Psychosis: A Case Study
The Combination of Electroconvulsive Therapy and Clozapine in Treatment Resistant Psychosis: A Case Study
Brittany Mott, M.D., Jessica Ee, M.D., Robert Weisman, D.O. and R.P. Singh, M.D. University of Rochester Medical Center
Charles E. Steinberg Fellowship in Psychiatry and the Law
Introduction
Case: 42M with Treatment Resistant Schizoaffective Disorder
Schizophrenia approximately
is a significantly impairing and disabling psychiatric disorder affecting 1% of the population worldwide. Schizoaffective Disorder occurs less
This
case
involved
a
4-2year- old,
Hispanic
male
with
history
of
Schizoaffective
Disorder
Bipolar
frequently (estimates of 0.32-0.8%) and features both symptoms of schizophrenia Type since age 17, characterized by psychosis, mania, and impulsive, unpredictable assaultive
and bipolar disorder, making diagnosis and treatment difficult. Electroconvulsive behaviors. Consequently, he was often homeless and lacked the ability for- csaerlfe in the
Therapy (ECT) was first used in Italy as a treatment for schizophrenia in 1938 beforecommunity, which resulted in frequent justic-einvolvement and psychiatric hospitalizations. He
being adopted in the US in 1939. The introduction of antipsychotic medications in was found incompetent to stand trial on felony assault charges and subsequently admitted to a
the 1950s, as well as the side effects to its decline as a treatment modality
and controversial public in subsequent decades.
perception Despite
of
ECT,
ledmaximum
security
forensic
psychiatric
unit.
developments in pharmacologic treatment of psychotic disorders, a small group of individuals diagnosed with Schizophrenia fail to respond and are deemed
Pervious Psychiatric Medication Trials:
"treatment resistant (TR)." A lack of consensus defining TR existed until the
? Haloperidol, Risperidone, Quetiapine, Chlorpromazine, Olanzapine, Clozapine, Prolixin, Lithium,
Treatment Response and Resistance in Psychosis (TRRIP) Working Group published Depakote, Lorazepam, Clonazepam
a minimal and optimal criterion for the diagnosis of treatme-nrtesistance
schizophrenia in 2017. [1] A similar criterion does not exists for schizoaffective disorder at this time.
Medication Responses: ? > psychosis without high doses of clozapine
Minimal TRRIP criteria for treatmen-tresistant schizophrenia: ? DSM- 5 diagnosis of schizophrenia; ? At least moderate symptom severity (>3 in psychotic symptom items) as rated
? > psychosis without multiple antipsychotics ? > aggression with lower doses of Lithium and Depakote ? > irritability with insomnia without a benzodiazepine
using a standardized scale (eg, Positive and Negative Syndrome Scale [PANSS] or
Brief Psychiatric Rating Scale [BPRS]); ? At least moderate impairment measured using a validated scale (eg, Social and Occupational Functioning Assessment Scale); ? At least two trials of 6 weeks at a therapeutic dose (equivalent to 600 mg chlorpromazine) with adherence 80 percent of prescribed doses.
Adverse Side Effects: ? Lithium: higher doses resulted in lithium induced hypothyroidism and decreased kidney function ? Clozapine: doses higher than 350mg resulted in severe constipation, despite maximum doses of
laxatives and stool softeners; required medical treatment for partial ileus ? Clonazepam: increased clozapine levels and worsened constipation
Optimal TRRIPcriteria for treatment- resistant schizophrenia: The minimal criteria (above) with the addition of: ? Prospective evaluation of symptom severity using a standardized scale (eg, PANSS or BPRS) confirming ................
................
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