ONE OF MY MOST DIFFICULT CASES
The Woman with Chronic Schizophrenia
Psychiatry is a unique specialty in medicine that blends medicine, philosophy, culture, sociology, neurosciences, psychology, spirituality and humanity such that it positively leads to search for self and purpose,” Dr. Jayendra Patel says.
Patel became enamored of the field of psychiatry while living in India for medical school. After moving to the United States in 1987, he learned that his residency in psychiatry was not recognized, so he repeated his residency in psychiatry at the Massachusetts Mental Health Center at Harvard Medical School in Boston. Following residency, he completed two years of fellowship in schizophrenia and research, and he continued his academic work involving research in schizophrenia and bipolar disorder at Harvard until 2000. In 2010 Patel moved to Lake Charles.
While he was working in Boston as the medical director of a research and evaluation unit, parents of a severely ill 46-year-old woman, who was suffering from chronic schizophrenia, approached Patel. The case would become one of Patel’s toughest cases not only because of its complexity, but also because the parents were close friends with his chairman at the time.
“Success in such situation brings fame, and failure would be disaster,” Patel reflects.
With added pressure to prove his competency as a psychiatrist, Patel delved into the patient’s medical history. She showed symptoms of obsessive-compulsive disorder during her childhood, and her academic performance and hygiene had declined around puberty with an insidious onset of schizophrenia. With the advent of auditory hallucinations, she was hospitalized during adolescence. Treatment with antipsychotic medication was helpful but did not completely alleviate her symptoms.
The patient was readmitted at the age of 39 after assaulting a 3-year-old. At age 41, all psychopharmacological agents were withdrawn in preparation for a trial of clozapine – a wonder medication that has caused dramatic improvements in the lives of many. However, it has significant side effects that can be life-threatening. The clozapine was helpful, but unfortunately it caused the patient’s OCD behaviors to worsen, a side effect that is well-known. Clozapine was discontinued but was started again at age 45. However, clozapine alone was not enough, and augmenting it with other medication was also not helpful.
“After reviewing her case, I decided to introduce the then-new antipsychotic risperidone and simultaneously taper her other medications on my unit,” Patel says.
During the simultaneous taper of clozapine and introduction of risperidone, there was a progressive and substantial improvement in the patient’s capacity to communicate. Paroxetine was also judiciously added and gradually increased to the patient’s medication to control her compulsive behaviors. After an extensive aftercare plan to ensure that she would comply with the treatment, she was able to move back to a supervised community residence. Five years after her discharge, she continued to take her medications and sustain herself in the community with considerable assistance provided by her family and the residence staff.
According to Patel, her recovery was only made possible with an unusual and creative combination of medications at a time when such concepts were rather new and not well-accepted. He also notes that these combinations could be dangerous, too.
“[Psychiatry] is one of the most challenging jobs in medicine; it puts demands on me to come up with creative ways to use medications, combinations of medications, using medications in combination with psychotherapy, working with families and doing this while respecting their individuality, religious and cultural beliefs and restoring faith in themselves,” Patel explains.
He has authored and co-authored more than 100 peer-reviewed publications, book chapters and abstracts. For the last four years, Patel has been recognized by Best Doctors of America as one of the top five percent of doctors in the U.S.
He concludes: “I plan to continue working as a psychiatrist in the community, teaching mental health professionals and eradicating stigma, one patient at a time.”