reasoning behind different antipsychotic usage?

[justabystander]

---

Members don't see this ad.

We had a pt in the ER (I'm an EMT in the ER) who came in w/sx of psychosis.

Her psych was on vacation but had been monitoring her drugs from afar 🙂eek🙂. But the way in which her drugs were being changed/increased sounded confusing to me.

I: bipolar I
II: borderline?
III: fibromyalgia, lyme disease, etc, etc, etc (oxycodone prn....???)

zyprexa 5 mg was not working, neither was 7.5 mg (did I mention her sister moved out of state yesterday--was previously living with pt, her friend was leaving for vacation, and her shrink was on vacation? can you say lonely? 🙄) so by the time she came into the ER she was on:

zyprexa 5 mg
haldol 2 mg TID
abilify 30 mg QD

(and felt like a zombie, but still complained of "mania" (read: psychosis))

Pt also complained about TD symptoms w/haldol. So why would the shrink move to use haldol instead of just increasing the zyprexa?

Also what does everybody think of Saphris? Saw someone on it recently, who said they mostly liked it except for the taste (SL administration? Really?)

 

[whopper]

I don't know what to tell you because we don't know much of that person's history.

Hey you're going to have to ask the doctor. From my experience, the majority has a good reason to explain why they prescribed meds in a manner that seemed odd to others, but a significant minority will not have a good evidenced based reason to justify their treatment decision.

I have certainly heard several non evidenced based reasons which were IMHO poor practice. E.g. "I gave zyprexa because that's what I give to all my patients", "I gave prozac to him because he lacks motivation" (the guy was schizophrenic, and the same psychiatrist took him off his antipsychotic), "There's no danger in giving someone as much xanax as they want." Or the typical, actually quite common practice of giving a borderline a psychotropic medication, and never giving the same person dialectical behavioral therapy.

(I certainly hope that doctor was not giving out opioids to treat fibromyalgia).

 

[atsai3]

We had a pt in the ER (I'm an EMT in the ER) who came in w/sx of psychosis.

Her psych was on vacation but had been monitoring her drugs from afar 🙂eek🙂. But the way in which her drugs were being changed/increased sounded confusing to me.

I: bipolar I
II: borderline?
III: fibromyalgia, lyme disease, etc, etc, etc (oxycodone prn....???)

zyprexa 5 mg was not working, neither was 7.5 mg (did I mention her sister moved out of state yesterday--was previously living with pt, her friend was leaving for vacation, and her shrink was on vacation? can you say lonely? 🙄) so by the time she came into the ER she was on:

zyprexa 5 mg
haldol 2 mg TID
abilify 30 mg QD

(and felt like a zombie, but still complained of "mania" (read: psychosis))

Pt also complained about TD symptoms w/haldol. So why would the shrink move to use haldol instead of just increasing the zyprexa?

Also what does everybody think of Saphris? Saw someone on it recently, who said they mostly liked it except for the taste (SL administration? Really?)

We see people coming in from the community with ridiculous non-evidence based medication lists all the time. My first impression generally is that the physician is chasing symptoms with medications, and either that the patient has refused intensive psychotherapy or the physician's practice is not set up to provide it. When I speak with them for collateral, on occasion I have heard some reasonable justification for a ridiculous med list, but in my experience this is rare. So my first question would be-- does this patient actually have bipolar I? If that is the case, there is little robust evidence to suggest that two (much less three) antipsychotic medications will 'work'.

-AT.

 

[strangeglove]

I would wonder why this person was not on a mood stabilizer, e.g. lithium, Depakote, instead of 3 different antipsychotics.

 

[OldPsychDoc]

I would wonder why this person was not on a mood stabilizer, e.g. lithium, Depakote, instead of 3 different antipsychotics.

[whine] "But doctor, Depakote made me gain weight...and lithium makes me all jittery...can't we try something else????" [/whine]

Welcome to my world...🙄

 

[prominence]

any early thoughts/experiences regarding Saphris?

 

[PsyDGrrrl]

"I gave prozac to him because he lacks motivation" (the guy was schizophrenic, and the same psychiatrist took him off his antipsychotic)

I'm sure that turned out well....eeek.

 

[whopper]

I don't claim to be the world's smartest doctor, but making a mistake on that order is to the point where it makes you question how the idiot, ahem, cough cough, other doctor graduated from medical school and passed through a residency when his reasoning is to get a schizophrenic patient off of an antipsychotic medication that is working, then put the patient on an antidepressant, and the only reasoning is "lack of motivation."

Yes, antidepressants can improve energy and bring someone back to participating in their interests (lack of interests and low energy being 2 DSM criteria for depression), but never once did the doctor talk about it under DSM guidelines.

I mentioned to him that IMHO the person's "lack of motivation" was actually negative symptoms of psychosis. He did not understand what I was talking about.

When I called the attending doctor to ask why he took the patient off of an antipsychotic (I was a PGY-1 at the time, and the attending was a private doctor outside the residency program), he didn't exactly appreciate a PGY-1 questioning him as if the roles were reversed.

I mentioned this in a previous thread-I took over several patients in a moonlighting gig and the majority of them were on medication regimens that did not make sense.

E.g. person with panic disorder was on---
Wellbutrin, Neurontin, Topamax, Ranitidine, Depakote, Clonazepam and Risperdal.

(Of these medications, the only evidenced based medicine that they would help her condition were Clonazepam and Neurontin. THe data with Neurontin isn't much, and Clonazepam should only be used on a short term basis--not for over 6 months. He had her on it for over a 1 year.)

Yes--the person had panic disorder, and that was it, nothing else. It was so blatantly apparent the person had panic disorder. It wasn't one of those weird cases where the person had a strange presentation that did not fit the DSM criteria.

I kept the person on the same regiment for 2 months because I kept thinking to myself "no doctor is this stupid, there must have been some reason why he did what he did." I eventually decided to taper the person off of all her meds and only put the person on an SSRI. Panic attacks decreased to the point where I was able to get her completely off benzodiazapines. She still has panic attacks, but they went from multiple times a day to once a month.

She's to the point where she does not want more medication than what she's on. She said she can fully deal with one panic attack a month, so we're using psychotherapy to help deal with that.

I was right--as was in the case of most of the patients that were handled by this other doctor. I had to start most of them all over again on a completely new regimen.

Again, I don't claim to be a genius. I was just practicing standard of care medicine. That's the scary part. I've seen several doctors practice psychiatry in the manner I mentioned. They seem to have a zen-hippie-art approach to it. "I think the patient is depressed. No he didn't say he was depressed, I can just tell even though I didn't see any signs or hear any symptoms mentioned. I'm going to start him on an antidepressant, and just because I want him to have a good Christmas, I'll also give him some Xanax."

 

[kugel]

We had a pt in the ER (I'm an EMT in the ER) who came in w/sx of psychosis.

Her psych was on vacation but had been monitoring her drugs from afar 🙂eek🙂. But the way in which her drugs were being changed/increased sounded confusing to me.

I: bipolar I
II: borderline?
III: fibromyalgia, lyme disease, etc, etc, etc (oxycodone prn....???)

zyprexa 5 mg was not working, neither was 7.5 mg (did I mention her sister moved out of state yesterday--was previously living with pt, her friend was leaving for vacation, and her shrink was on vacation? can you say lonely? 🙄) so by the time she came into the ER she was on:

zyprexa 5 mg
haldol 2 mg TID
abilify 30 mg QD

(and felt like a zombie, but still complained of "mania" (read: psychosis))

Pt also complained about TD symptoms w/haldol. So why would the shrink move to use haldol instead of just increasing the zyprexa?

First step, try to verify the story. It's probably not quite what it looks like (it almost never is). If the psychiatrist is not available, look at the bottles. Were they all prescribed by the same person at the same time? If not avail, get the pharmacy to fax the records. Did the MD change the meds, but the pt cont'd the discontinued ones? Did the pt demand the changes, and now seems to have no idea why the doc changed them? Can the sister verify if the pt is usually compliant? Not taking them is the most common reason for not working.

Why did the pt come to the ER instead of whoever is covering for the psychiatrist? Kind of odd to think the ER doc is going to figure out a complicated psychiatric medication case that the attending psychiatrist can't. What did the pt want from this ER visit? That may explain some of what has been going wrong.