Adult Psychiatry
Over the past 15+ years, the mental health community has shifted from a model of disease management to more recovery-focused. While it can be easy to think of recovery in substance abuse treatment, or even in self-contained single episodes of depression or anxiety, it is a much harder to conceptualize in severe and persistent mental illness (SPMI).
Meena is a 31 year old single female with a history of severe schizoaffective disorder, bipolar type. There is extensive mental illness in her family — her mother suffers from bipolar disorder, her brother has schizophrenia, and her grandmother died by suicide. During Meena’s decompensations, she has been belligerent, violent, and threatening. She has been found wandering the streets naked before, and lives with chronic paranoia. She is unable to hold down a job and is on SSDI. She lives in a subsidized apartment, but frequently gets evicted because she becomes paranoid and harasses her neighbors. She has been on numerous medications in the past, and is currently on Zyprexa 30mg qHS, Haldol 10mg BID, Cogentin 1mg BID, Depakote ER 2000mg qHS, and Prozac 40mg. Even on these medications, her symptoms are poorly managed. She was previously tried on clozapine (Clozaril) but was too paranoid to cooperate with weekly blood draws and therefore it had to be discontinued. She has not been cooperative with LAIs in the past as she is fearful and paranoid about needles. While she has a case manager that is supposed to help her with medications, she frequently refuses to let them into her apartment, and therefore the team questions how often she really does take her medication. Historically, she has been hospitalized 2-3 times a year, typically on an involuntary hold.
She weighs 200 pounds (BMI 34.3) and has type II diabetes (last HgBA1c = 8.2). She smokes 2 PPD and drinks up to 2 pots of coffee daily. She rarely drinks alcohol but does occasionally use crack cocaine. She eats primarily processed foods and while she says she understands how to manage her diabetes through diet choices, she refuses to restrict her diet as she says “my life sucks enough. If I want to eat a candy bar, I will!”
With this information available, answer the following questions.
1. What could recovery look like for a patient like Meena with SPMI?
2. Who decides Meena’s therapeutic goals?
3. How do you help a person who is often too paranoid to accept help?
4. What are your thoughts about Meena’s refusal to make appropriate diet choices for her diabetes? How do you reconcile her choices with providing clinically prudent care as her NP?
