A Case Study of Schizophrenia

Presented based on
ACCP Guideline Standards of Practice
For
Clinical Pharmacists

Submitted by: Mary Angelique C. Banogon

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Patient Information:
Name: N/A Age: 31 years old
Race: African American Female Sex: Female

Process of Care
Patient Assessment
I. Patient’s Chief Complaint: “I was raped by the cab driver and the dirty cops brought me
here.

II. Family History:

 Her father died due to end stage diabetic complications and her mother has a
history of hypertension, dyslipidemia and drug use. Her family history was also
significant of schizophrenia (first degree cousin on her mother side).

III. Organization of Thoughts and Range of Affect:

 Her speech is clear, constant, and pressured with many grandiose delusions and
illogical thoughts. She is quite rambling going from one subject to the other
without interruption
 Her thought process are illogical, with marked delusional thinking
 Her memory (immediate, recent and remote) is fair, cognition and concentration
are adequate, intellectual functioning are within average

IV. Presence of Mood Disturbance

 She is alert, oriented and in no acute distress
 Her affect is mood congruent, her mood is euphoric and there is marked degree
of grandiosity

V. Likelihood of harm to self or others

 There is likelihood to harm self and others which is evident to the precipitating
event today that eventually led to her hospitalization was that she stabbed a cab
driver with a pencil and kept on insisting that the she was “raped by the cab
driver and the dirty cops send me here.”

VI. Presence of hallucination, paranoia and/or delusions of control

 No current evidence of auditory hallucinations and she denies visual
hallucinations
 Denies any suicidal ideation
 Marked delusion symptoms with paranoid ideation prominent
 Insight and judgement are markedly impaired

VII. Medical Records

a. Physical examination
 BP: 140/ 80 mmHg
 P: 80 bpm
 RR: 17
T: 37.1
Wt: 97 kg
Ht: 5’3”
Skin: Scratches on both hands
Neck: Supples, no nodes; normal thyroid
Lungs: CTA & P
CV: RRR. Normal S1 and S2
Abd: (+) BS, nontender
Ext: Full ROM, pulse 2+ bilaterally
Neuro: A & O x ; reflexes symmetric; toes downgoing; normal gait;
normal strength; sensation intact; CNS II – XII intact
b. Laboratory Results

VIII. Past medical history:

 The patient’s past records indicate that she had gallbladder surgery
(cholecystectomy) 2 months ago.
 There is no record of her being raped.
 She was admitted to the inpatient psychiatric unit to determine competency to stand
trial for the assault of the cab driver.
 She had been in many previous correctional institutions with a known history of
schizophrenia and additional diagnoses of amenorrhea, hyperprolactinemia, and
obesity.

IX. Elicit the patient’s housing arrangements, social and vocational goals.
 Heterosexual; lives in an apartment alone; employment history unknown

Therapy Evaluation
I. Assessment of current treatments and outcomes of prior treatments.
a. Prior Treatment
 Patient was prescribed with Fluphenazine decanoate 50 mg IM taken every two
weeks intermittently for two years in which she had difficulty obtaining the desired
therapeutic response. After approximately two months of therapy, the patient,
presumably at steady state (~14 day half life), still failed to demonstrate any clinical
response. Thus, the Dose was increased to 125 mg IM every two weeks
 The patient was also given Fluoxetine as 20 mg orally daily
  Fluphenazine was discontinued and the patient shifted to Haloperidol decanoate IM
300 mg administered every three weeks, two weeks after discontinuation of
Fluphenazine
 Olanzapine

II. Selection of an antipsychotic based on the side-effect profile that is most appropriate and
acceptable to the patient.
 Upon assessing the outcomes of prior treatments received by the patient, it can be
inferred that she was not responsive to the drug, Fluphenazine decanoate for more
than two years and even after adjusting the dose. Based on the guidelines of the
Texas Implementation of Medication Algorithms (TIMA), an algorithm for
antipsychotic treatment in schizophrenia, the replacement of Fluphenazine to
Haloperidol is indicative that the patient is not compliant of the medication
Fluphenazine. Again, basing on the same guideline/algorithm, the unresponsiveness
of the patient towards the drug Fluphenazine even with the dose adjustments and
considering that the patient showed no improvement with her condition, I would
suggest that the patient should take Clozapine since according to published
guidelines and recommendations, clozapine should be considered after two failed
antipsychotic trials but may be considered sooner if the individual patient situation
warrants. It is also important to note that, should the Patient take Clozapine together
with Olanzapine she should be monitored closely as these drugs, when taken
together; both exacerbate EPS and neuroleptic malignant syndrome.

III. Consider collaboration with other professionals or family members.

 Considering the Philippine setting (unlike in the US or in Europe where they have
standardized psychosocial treatments), as a Pharmacist I would suggest that the
patient must always submit herself to therapy sessions with a psychiatrist. Being the
pharmacist, I would closely monitor her adherence to the medication. After which,
an assessment must be done to assess the patient’s condition and determine whether
there are improvements with the medication.
Care Plan Development
I. Collaboratively, develop a treatment plan that addresses medication adherence and healthy
lifestyle goals, including substance and cigarette use

 Constant and close monitoring of the patient medication therapy must be done
to ensure that the prescribed drug is taken at the right time and at the right
dose. A healthy diet must be followed so as to ensure that the patient receives
sufficient amount of nutrients for normal body functions. Cigarette smoking and
especially Alcohol intake must be avoided so as to prevent any interaction with
the medication the patient is taking.

II. Communicate that treatment plan adherence will enhance the likelihood of meeting goals.
 It is important to stress that the cornerstone of treatment is antipsychotic
medications, and most patients with schizophrenia relapse when not medicated.
As a Pharmacist, it is necessary to perform patient counselling and make the
patient understand that if she chooses not to take her medication she will not be
 making any improvements for her condition. She will again experience a great
fear that she is in constant danger.

III. Devise a plan to optimize compliance.

 Treatment with long-acting formulations should be encouraged if the patient
has relapsed due to non-adherence. Olanzapine is available as a long-acting
injectable-formulation.

IV. Educate the patient and, with patient consent, their family about the illness, medication
treatments, possible side effects, and goals of treatment.
 Education of the patient and family regarding the benefits and risks of antipsychotic
medications and the importance of treatment adherence must be ongoing and
integrated into pharmacologic management. Involve families (if there are any) in the
education and treatment plans because family psychoeducation may decrease
relapse, improve symptomatology, and enhance psychosocial and family outcomes.
After all, the family can be a very effective support system to encourage the patient
to remain compliant with his medication. Be clear that there is no cure for
schizophrenia and that medication can be effective to decrease and improve many
symptoms. Common and rare but dangerous side effects must be explained. Stress
the importance of medication and treatment adherence for improving long-term
outcomes. The patient together with her family must be involved in the Decision
making process on the best course of treatment.

Follow-up evaluation and Medication Monitoring

I. Schedule appointments more frequently initially to assess effectiveness, adverse drug

reactions, drug interactions, and allergies.
 Weekly consultation with the Psychiatrist and drug monitoring must be done by the
Pharmacist so as to check whether dosage adjustments must be made or if there is a
need for drug replacement especially when adverse drug reactions such as
Extrapyramidal Symptoms is exacerbated.

II. Monitor appropriate laboratory measures to prevent or minimize adverse effects, including
metabolic abnormalities.
 Many assessments are available to objectively rate positive and negative symptoms,
level of function, and life satisfaction. The most commonly used scales include:
i. Positive and Negative Symptom Scale (PANSS)
ii. Brief Psychiatric Rating Scale (BPRS)
iii. Clinical Global Impression (CGI) Scale
Using these scales on a regular basis, particularly when switching medications or
changing doses, is a more reliable means of monitoring symptoms. Symptom
assessments cannot capture the full range of possible improvements, but they can be
useful in deciding whether a medication is having substantial benefit.
 Perform orthostatic blood pressure measurements before initiating antipsychotics
and regularly throughout treatment.
 Encourage patients to have annual eye examinations because several antipsychotic
medications have been associated with the premature development of cataracts.
 Perform baseline electrocardiography for patients with preexisting cardiovascular
disease or risk for arrhythmia.
 With clozapine therapy, there is a risk for the development of agranulocytosis,
which is greatest in the first 6 months of treatment. Required monitoring of white
blood cell counts
 Monitor EPS with the Simpson Angus Scale (SAS) and the Extrapyramidal
Symptom Rating Scale (ESRS)