Cases That Test Your Skills

Can a wakefulness-promoting agent augment schizophrenia treatment?

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Continued treatment: Improving symptoms

After 1 month, we increased Mr. X’s modafinil dosage to 200 mg/d and olanzapine to 40 mg/d. Both were well tolerated. No extrapyramidal symptoms were noted.

Over the next 4 months, his negative symptoms improved to the point where he had some concept of self-image. He was more alert, less isolated, and better groomed.

Once too sleepy to even eat breakfast, Mr. X began to participate in an exercise program, performing aerobic exercise including regular use of a treadmill, at a local gymnasium 3 days a week. This may have contributed to his loss of 20 pounds across 4 months. Over the next 6 months, the patient maintained his weight at 210 pounds, with a resultant BMI of 28.5. (He has lost slightly more weight since then.)

His socialization skills, while still far from mainstream levels, also improved. His mother began taking him to support group meetings at the local office of the National Alliance for the Mentally Ill (NAMI). There, he interacted with persons with schizophrenia and other psychiatric disorders.

During this time, his psychiatric condition remained stable, and his paranoia showed a mild improvement. Whereas Mr. X once required hospitalization every 6 months to 2 years, he has now been an outpatient for more than 2 years.

The modafinil dosage was titrated to 400 mg/d to further improve his negative symptoms and prevent antipsychotic-associated sedation. Mr. X has noted a continued increase in his alertness. He is still exercising, remains well groomed, and has begun taking vacations with his family. His mother, an active NAMI member, has continued to be his advocate and encourage his improvement.

Overall, we estimate that Mr. X is now functioning at about 65% of normal human capacity. When we began olanzapine with modafinil augmentation 2 years ago, he was functioning at barely one-half that level.

In your view, what should be the next step toward reintegration for Mr. X?

Drs. Yu’s and Maguire’s observations

The olanzapine/modafinil regimen brought about great improvement, but pharmacologic therapy only goes so far. As of this writing, Mr. X has never held a job or lived independently. Also, socialization beyond the family and NAMI support group meetings remains nonexistent.

Behavioral strategies may be just as important as medication treatment for patients with schizophrenia. We would consider behavioral therapy for Mr. X, employing token economies and social skills training to increase social abilities, self-sufficiency, practical skills, and interpersonal communication—skills that may further improve his negative symptoms and lessen the chance of relapse. Social skills training through the use of videotapes, role playing in therapy, and homework assignments to practice specific skills may allow Mr. X to improve his maladaptive behaviors.

Educating the patient and his family would help them understand what to expect in the course of his illness and can enhance treatment. NAMI is one useful referral source. NAMI and similar organizations offer emotional and practical advice about obtaining care in today’s complex health care delivery system.

A case manager also plays an invaluable role, ensuring that efforts are coordinated and that the patient keeps appointments and complies with treatment plans. The case manager may make home visits and even accompany the patient to work. The program’s success depends on the educational background, training, and qualifications of the case manager, which are variable.

Other behavioral strategies that could help Mr. X and other patients with schizophrenia include:

  • Group therapy, which focuses on real-life plans, problems, and relationships. Group therapy effectively reduces social isolation, increases cohesiveness, and improves reality testing. Groups led in a supportive rather than interpretative manner appear to be most helpful in schizophrenia.
  • Cognitive-behavioral therapy, which has been used in schizophrenia to improve cognitive distortions, reduce distractibility, and correct errors in judgment.
  • Individual psychotherapy, which has been shown to effectively complement pharmacologic treatment.18

As patients’ symptoms improve, we as psychiatrists can help by encouraging them to gradually reintegrate into society, often by offering resources such as NAMI or referrals to appropriate rehabilitation programs.

We plan to continue Mr. X’s olanzapine/modafinil regimen to keep positive and negative symptoms at bay while improving his chances at reintegration. Careful monitoring of medications during reintegration is key to preventing relapse. We will continue to see Mr. X once a month.

Related resources

Drug brand names

  • Clozapine • Clozaril
  • Ephedrine • Rynatuss
  • Haloperidol • Haldol
  • Modafinil • Provigil
  • Olanzapine • Zyprexa
  • Quetiapine • Seroquel
  • Risperidone • Risperdal
  • Ziprasidone • Geodon

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