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.