School of Psychiatry, Health Education North West (Mersey), Liverpool, L3 4BL, UK.
Ashworth Hospital, Mersey Care NHS Trust, Parkbourn, Maghull, Liverpool, Merseyside, L31 1HW, UK.
BMC Psychiatry. 2019 Jan 23;19(1):37. doi: 10.1186/s12888-018-2001-7.
Cardiometabolic health significantly impacts on the mortality of people with severe mental illness. Clozapine has the greatest efficacy for Treatment Resistant Schizophrenia (TRS) but the greatest negative impact on cardiometabolic health. Balancing the risks and benefits of treatment, dignity, autonomy, liberty, mental and physical health can be challenging, particularly when imposing interventions with potentially life threatening adverse events, such as clozapine. We describe the successful administration of clozapine in the face of myocardial infarction, pulmonary embolism and hyperlipidaemia resulting in the termination of long-term seclusion for a gentleman with TRS in high secure psychiatric services.
The impact of clozapine on a 44-year-old gentleman with TRS, extreme violence requiring physical restraint and long-term segregation, and numerous other significant physical health complications is described. He had metabolic syndrome; a poor diet, sedentary lifestyle, Body Mass Index (BMI) of 31.5, poorly controlled lipids and had smoked heavily since childhood. During preparations to initiate clozapine, he suffered a myocardial infarction and pulmonary embolism. His compliance with secondary prevention medications was poor due to paranoid persecutory and somatic delusions. Despite these concerns, nasogastric administration of clozapine was approved and prescribed within nine months of his myocardial infarction and a month from his pulmonary embolism but was ultimately not required. Accepting oral medication, his mental state made a rapid and dramatic improvement. After spending 1046 days in seclusion, this was terminated 94 days after clozapine initiation. He has been compliant with all medications for 24 months, had no incidents of violence or seclusion, and has been transferred to medium secure services. His physical health stabilised despite continuing to lead a sedentary lifestyle and remaining obese (BMI of 35). He developed hypertension, Type II Diabetes Mellitus and his triglycerides rose to 22.2 mmol/L in the same month after clozapine initiation. However, with pharmacological intervention, 24 months later these are controlled, and he has had no further thromboembolic events.
We highlight that despite significant physical health concerns, clozapine can be successfully initiated and safely prescribed with a significantly positive effect on both the psychiatric and holistic care of patients with treatment resistant schizophrenia.
心血管代谢健康状况对严重精神疾病患者的死亡率有重大影响。氯氮平对治疗抵抗性精神分裂症(TRS)最有效,但对心血管代谢健康的负面影响最大。在平衡治疗的风险和益处、尊严、自主、自由、精神和身体健康方面可能具有挑战性,特别是在实施可能危及生命的不良事件干预措施时,例如氯氮平。我们描述了在一位患有 TRS 的男士中成功使用氯氮平的情况,他患有心肌梗死、肺栓塞和高脂血症,导致长期隔离结束,该男士在高度安全的精神科服务中需要身体约束和长期隔离。
描述了氯氮平对一位 44 岁患有 TRS 的男士的影响,该男士有极端暴力行为,需要身体约束和长期隔离,还有许多其他重大的身体健康并发症。他患有代谢综合征;饮食不良,生活方式久坐,体重指数(BMI)为 31.5,血脂控制不佳,且自童年起就大量吸烟。在准备开始使用氯氮平时,他发生了心肌梗死和肺栓塞。由于偏执迫害和躯体妄想,他对二级预防药物的依从性很差。尽管存在这些担忧,但仍批准并在他心肌梗死后九个月和肺栓塞后一个月内开出处方使用鼻饲氯氮平,但最终并未使用。接受口服药物后,他的精神状态迅速而显著改善。在隔离 1046 天后,在开始使用氯氮平 94 天后结束了隔离。他已经遵守了所有药物治疗 24 个月,没有发生暴力或隔离事件,并已转移到中等安全服务。尽管他继续保持久坐不动的生活方式和肥胖(BMI 为 35),但他的身体健康状况稳定下来。他患上了高血压、II 型糖尿病,在开始使用氯氮平的同一个月,他的甘油三酯升高至 22.2mmol/L。然而,经过药物治疗干预,24 个月后这些指标得到了控制,他也没有再发生血栓栓塞事件。
我们强调,尽管存在重大的身体健康问题,但仍可以成功启动并安全地开出处方氯氮平,这对治疗抵抗性精神分裂症患者的精神和整体护理有显著的积极影响。