The patient is a 38-year-old Caucasian female who presented to the emergency room involuntarily by ambulance after police were summoned to a service station, where the patient was reportedly threatening to kill the service attendant with a banana she believed to be a knife. In the emergency room the patient reported the attendant had assaulted and attempted to rape her on orders to do so from the government. The patient reported she was “holding” the attendant until police could arrive and that the “stupid police” arrested her of a conspiracy to keep her as a “sex toy” and for “experiments”.
During the crisis evaluation and throughout the current hospitalization the patient reported being the victim of ongoing sexual abuse and assaults at the hand of fellow patients as well as staff members of previous institutions and of the current facility. The patient has a history of many previous incarcerations for assaultive behaviors as well as seven institutionalizations for psychosis and two suicide attempts.
The patient was diagnosed at the age of 17 with Bipolar Disorder with psychotic features; a diagnosis that was altered to Schizophrenia, paranoid type, with significant psychotic features including auditory hallucinations as well as paranoid delusions at the age of 21 based on DSM-IV criteria (5th ed. ; American Psychiatric Association, 2013). The patient’s history of hospitalizations has resulted in poor follow-up and medication compliance as an outpatient.
Two of the patient’s previous hospitalizations include reports of alcohol and illicit drug use and current blood and urinalysis results are positive for alcohol and methamphetamines. The patient denied the presence of any auditory or visual hallucinations, but continued to exhibit paranoid delusions and a lack of insight, displayed verbally aggressive and intimidating behaviors toward both staff and peers, and refused to participate in group or individual therapeutic regimens. The patient’s medication history includes the use of the antipsychotics Haldol, Mellaril, Prolixin, Zyprexa, Seroquel, and Geodon.
Based on the patient’s history of failed antipsychotics Clozaril (Clozapine) was initiated and the dosage was incrementally increased to be taken in addition to her current medication regimen of Amitriptyline, Haloperidol, and Lithium. Indications/Counter-indications Clozaril was initially indicated as an available treatment as an antidepressant, but studies found this medication effective in the management of psychotic symptomology and has since been indicated for the treatment of schizophrenia; specifically treatment resistant schizophrenia (Young, Longhurst, Bowers, & Mazure, 1997).
Original requirements for this medication restricted it’s use to only those over the age of 16, diagnosed with schizophrenia, who displayed a resistance to typical antipsychotic medications or experienced adverse reactions, but has since been utilized as a treatment for a variety of disorders in addition to schizophrenia including mood disorders such as Bipolar Mania, Depression, and Schizoaffective Disorder; neurologic conditions such as Tardive Dyskinesia, Parkinson’s Disease, Essential Tremor Disorder, and Huntington’s Disease; Comorbid Substance Abuse, and “aggressive behavior” (Young, Longhurst, Bowers, & Mazure, 1997).
There are a number of medical conditions in which Clozaril is contraindicated. Special consideration should be given for patients suffering certain myeloproliferative disorders in which individuals suffer an abnormal growth of blood cells; uncontrolled epilepsy; certain intestinal conditions or obstructions; those who experience increased eye pressure; individuals with a history of irregular heartbeats, heart arrest, or QT prolongation; a history of high or low blood pressure; heart, kidney, lung, or liver disease; or those who are pregnant or breast feeding (Sandoz Pharmaceuticals, 2013).
Side Effects While this medication has been shown to be effective for those nonresponsive to other typical psychotropic medications, there are a number of potential side effects patients must be aware of.
Clozaril may cause disturbances of the central nervous system such as confusion, drowsiness, dizziness, lightheadedness, fainting, headaches, incoordination, or tremors; sleep disturbances such as fatigue, lethargy, nightmares, or restlessness;
Muscle weakness, pain, or rigidity; cardiovascular issues such as increased heart rate, changes in blood pressure, chest pain, or cardiac arrest; respiratory problems including shortness of breath, difficulty breathing, and nasal congestion; gastrointestinal complications such as nausea, vomiting, constipation, diarrhea, loss of appetite, and heartburn; genitourinary complications such as incontinence, abnormal ejaculation, and increase in urinary urgency or frequency (Gaertner, Fischer, Hoss, 1989).
Additionally, there are a number of miscellaneous side effects including a decrease in blood cell counts, skin rash, weight gain, salivation or dry mouth, and visual disturbances (Sandoz Pharmaceuticals, 2013). There are also notable consequences of abruptly stopping this medication, often resulting in withdrawal like symptoms in addition to the return of illness symptomology (Gaertner, Fischer, Hoss, 1989).
To address this concern recommendations have been made for a gradual decrease in the medication dosage over a period of up to four weeks for those halting the use of Clozaril (Shore, Matthews, Cott, & Lieberman, 1995). Medication Effects In the weeks prior to the initiation of Clozaril the patient’s symptoms included paranoid delusions, lack of insight, verbal aggression, intimidating behaviors, and high agitation.
Over the subsequent two weeks the patient made noted improvement in her interactions with others, a decrease in her level of agitation, experienced a significant improvement in mood, reported a near complete deterioration in the frequency of her delusions with those remaining being notably less intense, and by week three of the introduction of the Clozaril, the patient was able to return home. The patient reported experiencing an increase in her level of salivation, hypersalivation, which was deemed to be a side effect of the Clozaril and there were no other side effects reported by the patient or medical staff.
When presented with her options regarding the possibility of discontinuing the medication, the patient reported the benefits outweighed the disadvantages and she opted to remain on the regimen. Additionally, the patient reported the improvement in her condition would likely contribute to or improve her adherence in continued treatment on the outpatient level as she felt “more hopeful” for a “better future” while remaining on the Clozaril regimen.
Considerations
There are a number of issues to be addressed with any client considering or currently taking Clozaril, or any medication for that matter; which would ethically fall under the purview of informed consent in pharmacology (Laurence, 1999). The elements involved in such discussions should include the nature of the medication of topic, alternatives available, a risk/benefits analysis with a thorough description and discussion of the potential side effects, and an evaluation of the patients understanding of the presented facts.
For patients taking Clozaril, the discussion must also include the expectations for continued monitoring throughout the course of treatment in the form of weekly, biweekly, or monthly blood draws (Young, Longhurst, Bowers, & Mazure, 1997). As the patient of topic also has a noted history of alcohol consumption, a discussion of the recommendations to avoid drinking caffeinated or alcoholic beverages would be warranted as both have been shown to cause adverse reactions (Gaertner, Fischer, & Hoss, 1989).
References American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed. ). Arlington, VA; American Psychiatric Publishing Gaertner, H. J. , Fischer, E. , & Hoss, J. (1989). Side effects of clozapine. Psychopharmacology, 99(Suppl. ), 97-100. Laurence, D. R. (1999). Ethics and law in clinical pharmacology. British Journal of Clinical Pharmacology, 27(6), 715-722. doi. 10. 1111/j. 1365-2125. 1989. tb03433. x Sandoz Pharmaceuticals.
(2013). Patient information leaflet: Holzkirchen, Germany Author. Shore, D. , Matthews, S. , Cott, J. , & Lieberman, J. A. (1995). Clinical implications of clozapine discontinuation: Report of an NIMH workshop. Schizophrenia Bulletin, 21(2), 333-338. Young, C. R. , Longhurst, J. G. , Bowers, M. R. , & Mazure, C. M. (1997). The expanding indications for clozapine. Experimental And Clinical Psychopharmacology, 5(3), 216-234. doi:10. 1037/1064-1297. 5. 3. 216.