Saturday, January 26, 2008

The Psychotic Dilemma

Mrs. Gersteweiner (not her real name) has been my patient at the clinic for many years. Mostly she's fine, she cares for her elderly mother, her grandchildren, and maybe even a few great-grands. For as long as I can remember, she's been diabetic. She's was hospitalized for episodes of psychosis long before I came into the picture and she sees me just briefly every few months for a review and refills of an anti-psychotic medication. Maybe she sees her social worker therapist (at the same clinic) monthly. Mostly, things have been fine.

Mostly. A few years ago, she had an acute exacerbation of her psychotic illness. Oy. Relatives came ranting to me. Mrs. Gersteweiner was irritable, paranoid, and not herself at all-- and she absolutely didn't believe something was wrong with HER! (Ah, years later, she still doesn't think that episode was her illness). She was hospitalized, it was not nice, she may have been in seclusion for a while, she may have been released and needed readmission, I just remember that no one was happy and I'd rather not go there again.

Somewhere in the course of this, Mrs. Gersteweiner's anti-psychotic medication was changed from one atypical to another atypical, the dose was futzed with and with regard to the diabetes, well, I'm not sure which came first, the atypicals or the diabetes, it's been years for both, but people do get diabetes who are not on atypical anti-psychotic agents and she had both illnesses before the meds were linked to diabetes. Not that that particularly matters, but....

Mrs. Gersteweiner is mostly fine (now).

Her therapist, however, has been contacted by the patient's primary care doc-- her sugars are high, her cholesterol is high, can't we prescribe something other than Atypical X? I forgot to mention that while Mrs. Gersteweiner is in denial about her psychiatric illness, she also isn't so keen on having diabetes and diet/exercise/life style changes/fingersticks/ or even compliance with the primary care doc's meds aren't very high on her list....she doesn't quite buy that she really has diabetes.

Would it help to stop Atypical X in terms of diabetes and cardiac risk factors? Maybe.
Would another Atypical antipsychotic with a more favorable profile still work without worsening her diabetes? Maybe.

Remember, she's already failed one anti-psychotic, so I wonder if one med will work as well as another? Probably not. A little bit of a crap shoot here. The risk is that I change the anti-psychotic agent in the Hope that it helps her labwork, decreases her cardiac and diabetic risk, and the Hope that it works as well as Anti-psychotic X. The changeover could result in another episode of psychosis requiring hospitalization.

I try to present the risks and let it be the patient's choice. Except the patient doesn't believe she has a psychotic illness, and she simply says she doesn't want diabetes, and so far my conversations with her have ended with my saying, "Why don' t you just stay on this for now?"

You'll forgive the confabulated details, but I've had the same scenario happen enough times that I can't be the only one with this dilemma.


Anonymous said...

If she is not willing to acknowledge her diabetes and make the necessary lifestyle changes for improving it, then it seems likely that changing the drug may not help her sugars. Then she could end up with unstable psychosis AND still will high sugars. In my nonprofessional opinion the only logical thing to do would be to really get on her case about lifestyle and diabetes management, BEFORE yanking a drug that's helping her.

Anonymous said...

I've seen this scenario in multiple configurations in my practice as well. Compliance with diabetic treatment can only really happen if her psychiatric sx are in remission, or at least stable. I'm not sure that the research indicates whether withdrawing the neuroleptic reverses the metabolic abnormalities, even if the diabetes was caused by the meds in the first place. And lastly, people with psychosis can respond to intensive psychoeducation regarding medical illnesses.
I would ask the PCP to refer her to a diabetes education/home health/health monitoring type situation. Her family should also bear some responsibility for educating her about her diabetes, maybe even some of them have it too?
I wouldn't change the medication and risk recurrence of psychosis. Just another opinion, hopefully that helps.

Aqua said...

A question: If she doesn't think she has a psychotic illness, why does she even bother to take the antipsychotic medication? Just curious as to what would be behind her medication compliancy?

Dinah said...

Thank you for your thoughts.

I have not been successful at getting patients to change their lifestyles when they don't want to.

asmd: I don't know what the research shows; I've taken a couple of people off atypicals when they've started to develop abnormal labs and they've either started to get better or gotten better-- in these scenarios the abn labs clearly started after the meds and the risk of hospitalization was lower (no recent past history, or a past history of good response to older agents).

aqua: excellent question. I don't know the answer, but it's also a common scenario that the patient denies the illness but is still willing to come for treatment and take meds. While I'm not good at getting people to change their lifestyles (when they don't want to), I am good at getting them to at least try meds and, if it seems right, to stay on them. I've had one such patient simply say, "I trust you." At some level, I think others sense that life is better when they're on the meds then when they're not. The other reality is that if someone has no insight that their problem is an illness, if they don't want to take meds, they just don't come and that scenario doesn't make it to the blog.

Anonymous said...

Start her on a diet of Gerste Weiners and her cholesterol will go down.

Midwife with a Knife said...

It seems like the attempted switch would be a lot safer if the patient had some insight into her disease.

I also agree with Sorrel that at some point the patient has to take some sort of responsibility and try the lifestyle changes which will likely be much safer and much more helpful than a new antipsychotic trial.

Then again, that raises more questions.. how do you teach people to have insight? I've never had any luck, but I'm no shrink...

And how do you motivate people to change their lifestyle? Again, I've been disappointed with my attempts at that, too.

Anonymous said...

I love the choice of the graphic. It's perfect.

FooFoo5 said...

The research would suggest that glucose problems are endemic to psychotic disorders themselves, and that the choice of medication (be it typical or SGA) is not that significant. I know you have taken exception to the suggestion in the past, but a phenothiazine (I humbly proffer) might be appropriate. Or at least the research would suggest...

Anonymous said...

foofoo -
I wonder whether that correlation (psychosis associated with diabetes/pre-diabetes) is actually due to lifestyle factors? That is, those with psychotic illness (or dementia, as may have been the case in the paper you linked, since they were elderly) are less likely to pay attention to their diet or to exercise. I personally think the influence of non-lifestyle factors (meds, genetics, whatever), while present, is small in comparison to the influence of lifestyle, for type 2 diabetes.

Anonymous said...

It's funny isn't it that Mrs G has a family around when they need her to take care of the grandkids and they come out of the woodwork when she just isn't herself.
The system is set up in such a way that the pdoc worries about the psychosis and the primary care doc worries about the diabetes and the family worries only that Mrs G's services are available.
Whether the woman lapses into psychosis or dies of diabetic complications--either way she isn't going to be there for her family. You would think that this would be where that social worker therapist might come into the picture in terms of working together with the patient, the family, and the docs.
When you do lab work on a patient and start seeing changes in kidney function, I would assume you start looking at alternatives or something. Given that no one seems to recall the onset of the hypothetical Mrs G's diabetes you really don't know whether a change wouldn't help some. As for Foo's suggestion, I know how very much docs are afraid of TD but why not ask the patients which would be worse in this case?

Anonymous said...

here's a different point of view. this client has priorities different from those of her health care providers (no big surprise there.) over time she has shown little to no interest/ability to make lifestyle changes that (for her, anyway) seem to be about loss and limits (don't eat foods you enjoy, do stick your finger a couple of times a day, do go see MDs who keep telling you what you should do, etc.) Instead of changing the psych med that seems to be keeping her psychotic symptoms at bay, what about the PCP ADDING meds to treat her blood sugar and cholesterol, focusing on one behavior change (such as walking, and tie it in to HER goals - maybe her therapist can help here), and check her Hgb1Ac, liver panel, lipids, kidneys, etc. a couple of times a year, and manage with medication as much as possible...she does seem to be compliant with psych meds, and i bet if she isn't feeling labeled as 'bad' and 'failing' by PCP, she will do ok taking daily meds for medical stuff, and her therapist might be able to work with her about this too. I know, this is not how current best practices read, or treatment algorithms at HMOs are written..but she is a PERSON, not just a bunch of diagnoses.

a psychiatrist who learned from veterans said...

If she can't see in some way that she has had problems helped with medication, then the medication aint perfect to begin with. I don't know that she has to muse, 'I don't know for sure that 295.90 (Schizophrenia...)is right but it doesn't seem to be a 296.4 (Bipolar Disorder...) though does it doc?' None of us like to declare/ be told how ugly we are. She has given a preference to address the diabetes; so Geodon or Abilify or Invega seem right if available; would cross taper even to Risperdal if she were on Zyprexa. I have seen labs normalize with Rx changes.

Assrot said...

Tough call there doc. Since I am not a doctor I can only give a patients point of view.

I'd want you to do what is least likely to kill me in the long run. If changing the meds would more than likely cause a psychotic break that could reach the point of self injury or suicide I'd say stick with what is working.

On the other hand if what is working is driving my blood sugar to un-manageable levels, that is sure to kill me slowly and miserably from the many ramifications of having uncontrolled diabetes. I mean, who wants to slowly go blind, have their organs fail, lose a limb or two etc. and finally succumb to pneumonia. (My aunt died a slow, miserable death from diabetes.)

I guess if I was in that position I would want my doctors to put their heads together and try to find the lesser of all evils be it changing the psych meds or changing the diabetes meds. Mayhap that I'd want them to put me in a place where these things were managed for me if I was not of sound mind and incapable of accepting my illnesses and doing what the doctors recommend in managing all my illnesses.

I know one of the things doctors supposedly live by is "First, do no harm." or some such saying.

So there you go. I have probably offered you nothing that helps but I can tell you this. If I was in your patient's shoes I would prefer a quick death to a slow, painful one drawn out for many years.

I think I would have you hospitilize me and try the psych meds change to see how I react. If all goes well fine. If it doesn't then at least I'm in a controlled environment where self injury and injury to others may be prevented or at least less likely. You would also have the option of going back to the meds that were working if necessary.

Just some thoughts from the non-medical side of your readers. Hope they helped or at least gave you something to think about.

Unknown said...

I'm commenting on this although it is old:

Please do not blame your patients for this.

Prior to medication I was active, ran marathons, never overweight. Type A

I got high blood sugar levels on an SSRI, gained over 30lbs (too some big deal I went from 120 to 155) and had high blood pressure. The medications lowered my thyroid levels, prior levels normal.

Dr. said since the meds I was on were "weight neutral" I had to try life style changes.

I'm telling you from experience, the meds zap any ambition. I think studies call it SSRI Indifference. I can only imagine what an antipsychotic does which is pretty much a toxic sedative.

It was only after I began slowly tapering off these meds I began to regain my energy and my personality back.

Lost the weight and I am running again.

Please don't blame your patients for not being able to help themselves when you are the ones placing them in medical shackles.

Yes please take all the credit you want for keeping them off psychosis but also take the fall for handing them a life time of health problems. Don't lay it on them, I believe in your field that is called "displacement".