What would you do?

[Maggie Martin]

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[hamstergang]

Are you saying that a patient with schizoaffective disorder presents with mania, and you're asking what to do? It would be really helpful to know where you are in terms of your training in order to provide a good answer. What have you thought of already?

 

[michaelrack]

tapering paxil would be a consideration

 

[Maggie Martin]

Are you saying that a patient with schizoaffective disorder presents with mania, and you're asking what to do? It would be really helpful to know where you are in terms of your training in order to provide a good answer. What have you thought of already?

Precisely. She has no history of mania however just severe depression and and moderate psychosis that comes goes hence the schizoaffective. She has been relatively stable minus the alcohol incident. Considering she's already on serequel and topamax. I'm thinking of reaching for the depakote. I realize this isn't popular, but at the same time, her psychotic symptoms tend to be treatment resistant. The topamax should have been mood stabilizing already.The patient also has general hatred of doctors and isn't likely to follow up with lab work for clonzapine. I should probably add that the patient has been on every anti depressant except prozac and most antipsychotics in the past.

 

[hamstergang]

The topamax should have been mood stabilizing already.

Based in what evidence do you claim Topamax to be a mood stabilizing agent?

Also, where in your training/career path are you?

 

[Maggie Martin]

Based in what evidence do you claim Topamax to be a mood stabilizing agent?

Also, where in your training/career path are you?

Psychiatry. I'm in my 2nd year. Topamax is an anticonvulsant for migraines. However, it is used off label as a mood stabilizer for bipolar people. Oddly, enough, she had recently had her PCP lower her topamax...so that ups my suspicion.

 

[hamstergang]

Topamax is an anticonvulsant for migraines. However, it is used off label as a mood stabilizer for bipolar people.

That's not evidence. You'll see Topamax, Trileptal, and Gabapentin used off-label for bipolar disorder, but for your own learning you should review the available evidence for these 3.

 

[Armadillos]

I suspect your missing the forest for a tree when worrying about the topamax. How much zyprexa was she on and how much seroquel did you switch to?

 

[Maggie Martin]

I suspect your missing the forest for a tree when worrying about the topamax. How much zyprexa was she on and how much seroquel did you switch to?

She was on 10mgs of zyprexa. Although, she said at one point she was on 40 mgs over a year ago. It was switched to 100mgs of seroquel.

 

[Armadillos]

She was on 10mgs of zyprexa. Although, she said at one point she was on 40 mgs over a year ago. It was switched to 100mgs of seroquel.

Mystery solved

 

[birchswing]

She was on 10mgs of zyprexa. Although, she said at one point she was on 40 mgs over a year ago. It was switched to 100mgs of seroquel.

Oh, dear. You switched her from an antipsychotic to an anti-histamine.

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[Crayola227]

this sounds to me more like a thinly veiled question from someone other than a physician, maybe I'm wrong

 

[ara96]

Why did you switch from Zyprexa to Seroquel?

 

[Maggie Martin]

Why did you switch from Zyprexa to Seroquel?

She had been complaing of auditory hallucinations. Plus she was having issues sleeping. She kept reminding me she USED to be on a lot more Zyprexa. However, I don't like to over medicate, and she was obese. Additionally, due to the past alcoholism she doesn't have the best liver or kidney function. I was planning on slowly increasing the seroquel but the voices appeared to have drifted away.

 

[Maggie Martin]

Oh, dear. You switched her from an antipsychotic to an anti-histamine.

At this point I'm thinking of upping the seroquel and consulting the PCP about restoring the toprimate to the original dose and then having the pt see me in two weeks.

 

[Maggie Martin]

this sounds to me more like a thinly veiled question from someone other than a physician, maybe I'm wrong

Yep I'm one of those psychiatric service animals that there is no evidence for, but in any case, I, the hedgehog, now handle all of the woman's meds.

 

[birchswing]

At this point I'm thinking of upping the seroquel and consulting the PCP about restoring the toprimate to the original dose and then having the pt see me in two weeks.

You certainly think a lot about this patient.

Don't do anything because of anything I said.

I am not a doctor. Or a medical student. Or anything remotely like any of those things.

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[hamstergang]

consulting the PCP about restoring the toprimate to the original dose

But again, there is no evidence that Topiramate works for bipolar disorder. Upping Seroquel isn't unreasonable, but if you're concerned about weight gain then I don't see why that's better than resuming Zyprexa at a higher dose since it helped before.

 

[Maggie Martin]

But again, there is no evidence that Topiramate works for bipolar disorder. Upping Seroquel isn't unreasonable, but if you're concerned about weight gain then I don't see why that's better than resuming Zyprexa at a higher dose since it helped before.

Mostly bc she went from a normal weight to obese on it, and when she was switched she claimed to be losing a significant amount of weight without effort. Diabetes plus a potential alcohol relapse could end poorly

 

[thepoopologist]

this sounds to me more like a thinly veiled question from someone other than a physician, maybe I'm wrong

Yeah, seconded. Someone should close this thread.

 

[st2205]

At this point I'm thinking of upping the seroquel and consulting the PCP about restoring the toprimate to the original dose and then having the pt see me in two weeks.

You could consult the PCP, but they weren't prescribing it as a mood stabilizer and if you felt that strongly about it then I'd consider the fact that you're also a physician treating this patient. But before considering that, I'd consider whether or not coming off Topamax had anything to do with this. I won't give you my opinion but I'd talk to your attending if you have questions about that. The other thing is that you're trying to weigh risks and benefits, which is what led to the original decision to switch, and I'd consider the known risks of what you have before you. Somewhere along the line you'll have to appropriately weigh acute risks with long-term risks. If weight gain is an issue, there are other options, and again you can talk to your attending about that.

 

[Maggie Martin]

You could consult the PCP, but they weren't prescribing it as a mood stabilizer and if you felt that strongly about it then I'd consider the fact that you're also a physician treating this patient. But before considering that, I'd consider whether or not coming off Topamax had anything to do with this. I won't give you my opinion but I'd talk to your attending if you have questions about that. The other thing is that you're trying to weigh risks and benefits, which is what led to the original decision to switch, and I'd consider the known risks of what you have before you. Somewhere along the line you'll have to appropriately weigh acute risks with long-term risks. If weight gain is an issue, there are other options, and again you can talk to your attending about that.

That is pretty sound advice. I do plan on talking to the attending when I go back in, but at the same time I am going to make sure I have ALL of her current med labs/script information. I tend to prefer to take a holistic approach. I consult regularly with her therapist, as well, for example. Plus as we all know, with regards to PCP consulting, sometimes physical problems can present as emotional problems, if we're not to careful we run the risk of erroneous decision making. (Hormonal imbalances in PCOS for example.) I guess I might be in that overly cautious phase, or I'm just anal.

 

[smalltownpsych]

The very first statement "has seen lots of psychiatrists in the past all with the same diagnosis "schizoaffective depressive type" doesn't ring true. A patient like this would most likely have had multiple diagnoses from multiple providers.

 

[WisNeuro]

The very first statement "has seen lots of psychiatrists in the past all with the same diagnosis "schizoaffective depressive type" doesn't ring true. A patient like this would most likely have had multiple diagnoses from multiple providers.

Not necessarily. If they are in the same system, some providers have a habit of just copying and pasting old diagnoses rather than confirming and updating.

 

[FlowRate]

My money is on troll.

 

[Maggie Martin]

The very first statement "has seen lots of psychiatrists in the past all with the same diagnosis "schizoaffective depressive type" doesn't ring true. A patient like this would most likely have had multiple diagnoses from multiple providers.

I am aware of that, but we have done an in depth history. When she originally came to this clinic we weren't about to read 20 years worth of medical records. However, we did go through this with her. Did doctor A) ask you bunch of questions when went to see her/him? Do you remember the diagnosis? Most of the doctors she saw for a few years at least. The only dr she said had her diagnosed as something else was from years ago who said she had undifferentiated schizophrenia w/o depression. Then she said she saw a psychiatric nurse practitioner who said she had schizoaffective bipolar, ocd, gad, agoraphobia, and I think maybe also schizoid personality disorder. (I'd have to double check.) It was kind of hard reading the work up on that the pt claimed, "Yes, I had anxiety. the nurse kept trying to hug me." So okay, two outliers.

In any case ladies and gentlemen, I just came here for some semi-anonymous advice from my fellow psych students. Maybe, you guys do things different in your outpatient? I don't know. In any case, I'm pretty sure I know what I plan on doing at this point, and yes, it will be both cautious and anal, that is my style. So if you find my posts not-indicative of being who I say I am, I guess that's that. If anyone does want to lay a couple of golden nuggets of wisdom, that would be, of course, always appreciated.