Psychotic and needing prayer

Mr. A adheres to treatment but begins to develop early signs of tardive dyskinesia (mild lip smacking and some tongue protrusion). Therefore, haloperidol decanoate is discontinued and replaced with oral olanzapine, 20 mg/d. Mr. A is no longer psychotic, and his psychotic symptoms are in remission. He continues to hold fast to his Christian Science beliefs.

One month before the end of his 3-year commitment, Mr. A informs his psychiatrist that he plans to stop his antipsychotic when the commitment ends and to pursue treatment with his Christian Science practitioner via prayer. He wants to prove to everyone that medications are no longer necessary.

What should Mr. A’s treating psychiatrist do?

a) immediately readmit Mr. A involuntarily because of his potential dangerousness and impending treatment nonadherence

b) pursue guardianship because Mr. A is incapable of understanding that he has a serious mental illness

c) not pursue legal action but continue to treat Mr. A with antipsychotics and encourage compliance

d) readmit Mr. A to the hospital, request an extension of the commitment order, and consider a medication holiday in a safe setting to address Mr. A’s religious beliefs

OUTCOME: Court-ordered treatment

Mr. A agrees to hospitalization and at a court hearing is committed to the hospital for a period not to exceed 5 years. The judge also orders that Mr. A undergo a period of reducing or stopping his antipsychotic to see if he decompensates. The judicial order states that if it is determined that Mr. A no longer needs medication, the judge may reconsider the terms of the long-term commitment.

Mr. A, his inpatient and outpatient psychiatrists, and a Christian Science practitioner work together to develop a plan to taper his medication. Over 2 weeks, olanzapine is tapered from 20 mg/d to 10 mg/d. Two weeks into the taper, Mr. A becomes increasingly irritable, paranoid, and vigilant. The staff gives him prompt feedback about his apparent decompensation. Mr. A accepts this. He resumes taking olanzapine, 20 mg/d, and his symptoms resolve. He feels discouraged because taking medication is against his religious values. Nevertheless, he accepts the 5-year commitment as a court-mandated treatment that he must abide by. He is conditionally discharged from the hospital. For a summary of Mr. A’s clinical course, see Table 2.

Mr. A continues to do well in the community. New Hampshire’s law allowing up to a 5-year commitment to the hospital has been effective in maximizing Mr. A’s treatment adherence (Table 3).⁶ He has not been re­hospitalized and his psychotic symptoms are in remission. Mr. A still believes his symptoms can be best treated with Christian Science prayer, but sees the state-imposed conditional discharge as a necessary “evil” that he must adhere to. He continues to be an active member of his church.

The author's observations

With the support of his outpatient and inpatient psychiatrists, treatment teams, and Christian Science practitioner, Mr. A has successfully integrated 2 seemingly opposing views regarding treatment, allowing him to live successfully in the community.

From this case, we learned that clinicians:

• need to understand patients’ religious beliefs and how these beliefs can impact their care
• must be aware that caring for patients from different religious traditions may present unique treatment challenges
• need to put their personal views regarding a patient’s religious beliefs aside and work with the patient to alleviate suffering
•  must give patients ample opportunity to meet with their faith community, allowing adequate time for discussion and problem solving

Bottom Line

Balancing a patient’s clinical and spiritual needs can be challenging when those needs seem mutually exclusive. Clear communication, legal guidance, careful planning, and a strong therapeutic alliance can create opportunities for the patient to make both needs work to his advantage.

Related Resources

• Christian Science. www.christianscience.com.
• de Nesnera A, Vidaver RM. New Hampshire’s commitment law: treatment implications. New Hampshire Bar Journal. 2007;48(2):68-73.
• Ehman J. Religious diversity: practical points for health care
  providers: www.uphs.upenn.edu/pastoral/resed/diversity_points.html.

Drug Brand Names

Haloperidol • Haldol

Olanzapine • Zyprexa

Disclosure

Dr. de Nesnera reports no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.