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Polysubstance-induced relapse of schizoaffective disorder refractory to high-dose antipsychotic medications: a case report

Tucker, Murray G., Kekulawala, Sebastian, Kent, Michelle, Mostafa, Sam and Harvey, Richard 2016, Polysubstance-induced relapse of schizoaffective disorder refractory to high-dose antipsychotic medications: a case report, Journal of medical case reports, vol. 10, pp. 1-7, doi: 10.1186/s13256-016-1031-3.

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Title Polysubstance-induced relapse of schizoaffective disorder refractory to high-dose antipsychotic medications: a case report
Author(s) Tucker, Murray G.
Kekulawala, Sebastian
Kent, Michelle
Mostafa, Sam
Harvey, Richard
Journal name Journal of medical case reports
Volume number 10
Article ID 242
Start page 1
End page 7
Total pages 7
Publisher BioMed Central
Place of publication London, Eng.
Publication date 2016-09-06
ISSN 1752-1947
Keyword(s) methamphetamine
substance-induced psychosis
psychiatric emergencies
rapid sedation
medication safety
pharmacogenetic testing
Adult
Amphetamine-Related Disorders
Antipsychotic Agents
Chlorpromazine
Clopenthixol
Droperidol
Drug Administration Schedule
Emergency Medical Services
Humans
Hypnotics and Sedatives
Lorazepam
Male
Marijuana Abuse
Psychotic Disorders
Time Factors
Treatment Outcome
Violence
Summary BACKGROUND: The high prevalence of comorbid illicit drug use in persons with chronic psychotic illness represents a strong determinant of psychotic relapse and rehospitalization. Epidemiological studies indicate changing patterns of illicit drug use in Australia, which are concerning because of increased use of crystal methamphetamine, also known as "ice." An important complication of habitual use of crystal methamphetamine is the development of a dose-dependent acute psychotic reaction. We report a case of an acute psychotic relapse in response to polydrug use most notable for multiple recent binges of crystal methamphetamine. Unlike previously described case reports, our patient's acute psychosis was refractory to ultra-high doses of multiple antipsychotic medications. This presented safety challenges due to the risk of serious side effects with high-dose antipsychotic medications.

CASE PRESENTATION: A 30-year-old white man with a past history of schizoaffective disorder was brought to our emergency department by the police in a state of extreme agitation, combativeness, and paranoia after use of cannabis and crystal methamphetamine. Despite existing compliance with zuclopenthixol decanoate depot medication, he required multiple emergency injections of zuclopenthixol acetate, and regular high-dose droperidol, chlorpromazine, and lorazepam. However, he remained severely agitated and psychotic with continuous threats of harm to others. A test of antipsychotic drug metabolism by cytochrome P450 enzymes did not reveal a pharmacogenetic cause for the poor therapeutic efficacy of antipsychotic medications. His psychosis did not appear to be modified by psychoactive medications but was instead self-limited to the presence of endogenous methamphetamine within his system. He fully recovered 96 to 120 hours post-presentation and was discharged home with out-patient clinic follow-up.

CONCLUSIONS: The current case highlights the challenging nature of a severe psychotic relapse precipitated by illicit substances that is resistant to medical management. High doses of multiple antipsychotic medications may be required to manage dangerous behaviors associated with these acute psychotic relapses. These patients require close monitoring for adverse effects with adjustment of dosing to ensure the optimal balance of risk versus benefit while the patient is acutely psychotic. The results are of relevance for the management of psychiatric emergencies in emergency departments and acute mental health settings.
Language eng
DOI 10.1186/s13256-016-1031-3
Field of Research 110399 Clinical Sciences not elsewhere classified
1199 Other Medical And Health Sciences
Socio Economic Objective 970111 Expanding Knowledge in the Medical and Health Sciences
HERDC Research category C1 Refereed article in a scholarly journal
ERA Research output type C Journal article
Copyright notice ©2016, The Authors
Free to Read? Yes
Use Rights Creative Commons Attribution licence
Persistent URL http://hdl.handle.net/10536/DRO/DU:30093124

Document type: Journal Article
Collections: Faculty of Health
School of Medicine
Open Access Collection
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Every reasonable effort has been made to ensure that permission has been obtained for items included in DRO. If you believe that your rights have been infringed by this repository, please contact drosupport@deakin.edu.au.