Therapeutic dilemma in a female 72years old patient with Schizophrenia

[Iparksiako]

I was referred a female schizophrenic 72 years old patient. She does not have any positive symptoms right now. But she has been having mixed depressive/anxiety symptoms with anxiety being the prevalent one - starting with the covid19 pandemic. She is afraid to leave the house (she used to every day) and she is afraid to do anything without the presence of his son, who lives with her (she is scared she might fall - she complains of dizziness, or something bad happens to her and hes not there to help her). When he tries to change room, she starts calling him to come be with her. CBT has been tried with minimal effect. These, I repeat, are not due to psychosis.

She is on:

clozapine 100mg : 2 - 0 - 2
citalopram 20mg : 1 - 1- 0
lamotrigine 50mg: 1- 0 -1

Sertraline was used before citalopram, at 100mg but the patient couldn't tolerate it.

What would be your next move?

My thoughts:

1. increase clozapine - as it is known to respond well to depression secondary to schizophrenia.

2. Change citalopram to SNRI

3. add low dose clonazepam like 0.5mg/d


I would like to hear your thoughts.

---

Members don't see this ad.

 

[deleted1100659]

Cases like this are very challenging, tbh. When did this start? Was it all the sudden or insidious? How new is this? How is her cognition? Shes at the age range for its not impossible to be developing a dementia type syndrome. Medically, how is she doing?

Typically in Geri patients my understanding is they recommend a short acting benzo over long acting due to the longer half leading to it sticking around longer and causing adverse effects. Though I strongly avoid benzos in the elderly. You have to consider fall risk too. Clozapine is a fall risk in itself, plus her age, and then klonopin would worsen that.

Why couldn't she tolerate the the sertraline? Nausea?

It would not be unreasonable to trying another SSRI like prozac, or even effexor. However, this is not evidence based so to speak (purely personal experience treating patients) but I have had good results with trintellix in those who failed SSRIs and SNRIs.

Another thing is, what is the treatment for seperation anxiety? Seperation. Everytime he runs back into the room, he reinforces her anxiety. Exposure is how we improve anxiety symptoms, the son may be reinforcing her anxiety.

Also, she used to leave the house every day. So the question is, WHAT CHANGED? I would start asking that. Something must have had happened medically or mentally. What was that change? I think identifying that will provide insight. Is she afraid because she gets dizzy? if so, maybe her medications, including the clozapine need to be adjusted? Elderly are more sensitive to medications, she could be having adverse effects from other medications. What are her other medications? Perhaps she gets orthostatic, which is very common with clozapine. Other medications could be worsening this as well, and maybe she isnt hydrating enough.

My recommendation, take a step back and look at the big picture. What is causing this? Sudden shifts in personality are often driven by some known or unknown variable.

 

[Celexa]

I would get her off citalopram given the qtc risks and trial Lexapro or Prozac, going slow but trying to push all the way up to max doses eventually.

That you feel the need to emphasize this is anxiety and not psychosis makes me think this has an ocd aspect to it and she needs a trial of high dose SSRI.

I would be very cautious with benzos. I have actually had very good success with gabapentin in this type of patient (but would try and maximize the SSRI first). Also would start low and go slow but not hesitate to increase. Also, gabapentin 100mg makes an excellent not-techncially-a-placebo prn for people who need the psychological comfort of one.

Another possibility (not exclusive of the above) is new dementia causing the anxiety; has she had cognitive testing? In this case also SSRI would be my go to for the anxiety, but she may need neurology consult, consideration of Aricept etc, and psychoeducation and additional practical support at home.

 

[Iparksiako]

Cases like this are very challenging, tbh. When did this start? Was it all the sudden or insidious? How new is this? How is her cognition? Shes at the age range for its not impossible to be developing a dementia type syndrome. Medically, how is she doing?

Typically in Geri patients my understanding is they recommend a short acting benzo over long acting due to the longer half leading to it sticking around longer and causing adverse effects. Though I strongly avoid benzos in the elderly. You have to consider fall risk too. Clozapine is a fall risk in itself, plus her age, and then klonopin would worsen that.

Why couldn't she tolerate the the sertraline? Nausea?

It would not be unreasonable to trying another SSRI like prozac, or even effexor. However, this is not evidence based so to speak (purely personal experience treating patients) but I have had good results with trintellix in those who failed SSRIs and SNRIs.

Another thing is, what is the treatment for seperation anxiety? Seperation. Everytime he runs back into the room, he reinforces her anxiety. Exposure is how we improve anxiety symptoms, the son may be reinforcing her anxiety.

Also, she used to leave the house every day. So the question is, WHAT CHANGED? I would start asking that. Something must have had happened medically or mentally. What was that change? I think identifying that will provide insight. Is she afraid because she gets dizzy? if so, maybe her medications, including the clozapine need to be adjusted? Elderly are more sensitive to medications, she could be having adverse effects from other medications. What are her other medications? Perhaps she gets orthostatic, which is very common with clozapine. Other medications could be worsening this as well, and maybe she isnt hydrating enough.

My recommendation, take a step back and look at the big picture. What is causing this? Sudden shifts in personality are often driven by some known or unknown variable.

Thank you for your answer. It is very insightful.

I will see her next week, and I'll report back again.

I have the report that she stopped sertraline due to causing agitation.

 

[Iparksiako]

I would get her off citalopram given the qtc risks and trial Lexapro or Prozac, going slow but trying to push all the way up to max doses eventually.

That you feel the need to emphasize this is anxiety and not psychosis makes me think this has an ocd aspect to it and she needs a trial of high dose SSRI.

I would be very cautious with benzos. I have actually had very good success with gabapentin in this type of patient (but would try and maximize the SSRI first). Also would start low and go slow but not hesitate to increase. Also, gabapentin 100mg makes an excellent not-techncially-a-placebo prn for people who need the psychological comfort of one.

Another possibility (not exclusive of the above) is new dementia causing the anxiety; has she had cognitive testing? In this case also SSRI would be my go to for the anxiety, but she may need neurology consult, consideration of Aricept etc, and psychoeducation and additional practical support at home.

I have never tried Gabapentin PRN. At doses of 100mg would it have any anxiolysis, or will it cause mostly dizziness? Seems interesting approach.

As for Prozac, I am afraid of possible pharmacokinetics interactions with clozapine (2d6 inhibition). So a high dose Prozac of 40-60mg in an elderly outpatient would require much of a vigilance.

I will definitely test get cognition, but I have no older reports to document a change. I am sure a depressed chronic schizophrenic will have many deficits.

I will try to contact his old psychiatrist and I will report back.

 

[Stagg737]

Agree with most of the above. I avoid starting benzos in the elderly every way possible. Gabapentin is a reasonable alternative given the dosing flexibility, but I'd still be very cautious if there's a significant fall risk. I'd also switch over to a different SSRI. Could switch to lexapro easily and would likely be safer to increase than citalopram. I also would not r/o fluoxetine. You would need to monitor clozapine more closely d/t interactions, but you may be able to eventually come down on the dose a bit. Could also consider very low dose trazodone, we use 12.5mg on our consult team for agitation/anxiety in the elderly and it can be very effective at times.

I also agree that behavioral modifications for the separation anxiety would be beneficial and that her son may just be reinforcing her anxiety. Educating the family and caregivers is often just as important as directly treating the patient.

 

[smalltownpsych]

Also could try a different therapist. Therapeutic fit is probably more important than anything else we do. A good and experienced therapist is not always the right fit as I well know. Sometimes a weaker or less experienced therapist who meshes better can be more helpful.

 

[Taddy Mason]

You just started seeing this patient - how confident are you of her history and diagnoses (being accurate)? It would also be worth ascertaining the exact details, onset, and trajectory of these supposed changes as well as her prior functioning. What medical comorbidities does she have? The details in your initial post are limited but there seems to be a lot of important unanswered questions, and as is the overall clinical picture raises more questions/doesn’t quite seem to make sense (e.g. lower-ish dose of clozapine, what’s even the purpose of lamotrigine and why bid dosing, supposed “CBT” in someone psychotic enough to warrant clozapine, etc., etc.). First step should be clarifying all of this before deciding what to do next with her meds.

 

[elbandito1]

Agree with above in considering dementia just given her age and her diagnosis of Schizophrenia. You can start with an MMSE or MOCA and wouldn’t necessarily need a baseline to compare if she scores, let’s say, a 22 / 30. If you’re confident with your diagnosis, and if the symptoms are debilitating enough, would you, patient, and her family consider ECT? Does she also have additional support at home ie. home health aid? It might help too in alleviating her anxiety

 

[DJKitty]

Hi, I'm a geriatric psychiatrist and I just wanted to chime in and say, please don't start benzodiazepines unless there is an approved indication (catatonia, RBD, etc). I spend an enormous amount of time in my practice tapering patients off of benzodiazepines that were started inappropriately by primary care or a general adult psychiatrist. There are a lot of other options for geriatric anxiety including medications and psychotherapy.

 

[Iparksiako]

Hi, I'm a geriatric psychiatrist and I just wanted to chime in and say, please don't start benzodiazepines unless there is an approved indication (catatonia, RBD, etc). I spend an enormous amount of time in my practice tapering patients off of benzodiazepines that were started inappropriately by primary care or a general adult psychiatrist. There are a lot of other options for geriatric anxiety including medications and psychotherapy.

Thank you for the answer.

I saw her records, she has been on Venlafaxine 150mg, Sertraline 100mg, Amitriptyline 75mg in the past. I doubt any antidepressants would work.

So gabapentin is another option here - but considering her orthostasis and dizziness I doubt it is safe per se.

Do you have any suggestions regarding medication?

Psychotherapy to a chronic 72 schizophrenic sounds like quite a stretch, but I don't exclude it ofc.

 

[DJKitty]

Hi there,

I guess my first thought is, are her concerns valid? Has she been having falls? Is she actually unsteady on her feet? Will she leave the house if she is in a wheelchair or if someone is accompanying her? Is she actually orthostatic? If so, I would try to work with her gait instability/orthostasis/dizziness/etc and figure out the underlying etiology. Is this a side effect from the clozapine or another of her medications? Does she need to be seen by OT or PT? Does she need to see Neurology?

If she has had a work-up for her symptoms and nothing has been found to be physically wrong, then I would still make sure that you are looking at a fear of falling/anxiety versus a fear of something "bad" happening to her/paranoia type picture. Could any of her psychotropic or non-psychotropic medications be causing anxiety or depression?

How sure are you that the underlying diagnosis is schizophrenia? Does she need that high of dose of clozaril if she is not having positive symptoms? Also, how capable is she to perform her IADLs and her ADLs independently? Is there more than the baseline issues with executive functioning and disorganization that you would see with someone with long-standing chronic psychosis?

If you are truly dealing with anxiety and not some mixture of paranoia or actual correct symptom-reporting, I would start low and go slow. Like others have mentioned, I'm not a huge fan of citalopram given the max dose is 20 mg in older adults and the black box warning for QTc prolongation. Also, why is the citalopram being dose BID? How long were the trials on Venlafaxine and Sertraline? How long was she on maximum dose? Agree with not retrying amitriptyline. I'm not convinced yet that other antidepressants wouldn't work. How are her kidneys? You still could try fluoxetine, lexapro, duloxetine, mirtazapine, trintellix or vilazodone. I use a lot of buspar both on and off label in older adults with GAD-type symptoms. I do also use low dose gabapentin (think like 100-300 mg po QHS); however, if your patient is already dizzy and having falls, I agree that this may not be the best option.

I would also try to tease apart whether this is anxiety, depression or both? Do you ever administer objective scales like the GAD-15 or 30 or the GAD-7? If there is a significant component of depression, you also have at your disposal TMS, ECT and other neuromodulation therapies. In terms of therapy, CBT may not be the best fit, but she could potentially do supportive therapy with a focus on increasing pleasant activities/events to aid meaning and purpose back to her life.

I think the first thing to figure out though is where the gait unsteadiness, dizziness, falls(?) are coming from. That will help you decide which pathway to go down. Hope my thought process makes sense and is helpful to some degree.

 

[smalltownpsych]

Thinking of psychotherapy as a means to treat the symptoms directly sometimes misses the point. Good psychotherapy can help alleviate distress for a variety of reasons and reduced distress can help all mental health issues. I have done psychotherapy with geriatric populations and it is rarely about getting better. More typically it is about improving quality of life.

 

[Desired Member]

There's A LOT of missing information plus this is an internet forum so should not provide specific advice but generally would suggest getting a trough clozapine level and going from there.
If she complains of dizziness I would take that seriously, the alpha-1 receptor blockade can cause bad orthostasis. Plus the anticholinergic dizziness and mental "fuzziness" that can occur. Would want to screen for OCD which clozapine can actually cause, particularly at high levels. I would concur with DJ Kitty regarding inappropriate benzo prescriptions