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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