Jay is a 21-year-old man who was in his second year of university when he started to isolate himself from friends and family. He would not return calls and started to miss classes. Jay's behaviour started to change a few weeks after he began experimenting with ecstasy and marijuana. He would spend the night awake, pacing around the room. His roommate started to observe that Jay covered the windows with newspaper to avoid being "seen by people." He also started to accuse his roommate of trying to poison him and began to threaten him, saying, "I will do whatever I need to do if I prove that my roommate poisoned my food."
Jay's roommate contacted Jay's family for help since Jay refused to seek help voluntarily. Jay agreed to be checked by his family doctor to investigate the poisoning. At the family doctor's office, Jay was quite guarded and did not want his parents to talk to his doctor. He also told his doctor that he did not trust his parents because he got "wind that they were going to put him away." He stated that a newscast on the radio told him about his parents' intentions.
Given the obvious social isolation, poor sleep, recent drug use, paranoia and overt threatening behaviour toward his roommate, the family doctor issued a form to admit him to hospital involuntarily. The police were involved because Jay refused to go to the emergency room voluntarily.
Jay was admitted as an involuntary patient to the hospital's sychiatric ward but refused to accept any medication. He claimed that the hospital was trying to poison him too. He was found unable to make treatment decisions, and his father became the substitute decision maker.
After five weeks of being on a 10-mg daily dose of olanzapine, Jay was no longer paranoid or experiencing ideas of reference. On the other hand, he started to feel depressed, helpless and irritable because he was likely unable to finish his university courses. He was not suicidal, but he felt quite frustrated about not being able to read or follow a TV show.
On admission to the psychiatric ward, Jay enjoyed very good physical health. While in hospital, he gained nine kilograms and started to smoke two packs a day. His BMI jumped from 24 to 29.
After five weeks of treatment, Jay's fasting glucose was 5.8, and his insulin levels were nearly 50 per cent higher than normal, with hemoglobin A1c measuring 0.060. Jay's father has type II diabetes treated with metformin and had a recent myocardial infarction. His mother takes a beta blocker for hypertension and Lipitor for high cholesterol.
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Key questions:
- Do the benefits of the medications outweigh the side-effects?
- If the antipsychotic is changed for another SGA, how should the practitioner decide which SGA is the best choice for this client? Should an FGA be considered for this client given the metabolic impact of using an SGA (olanzapine)?
- What is the chance that a different SGA will have similar efficacy?
- What is the standard protocol for monitoring the metabolic indicators?
(Oud & Meyboom-de Jong, 2009)
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