Typically hallucinations are associated with conditions such as schizophrenia, dementia, delirium (acute confusional state), or side effects from medications or street drugs. In many cases hallucinations require treatment with antipsychotic medications. However, there are some circumstances where treatment with such medications is unnecessary.
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(Please note that in this post I will deviate from my normal policy of not blogging about real patient cases. The following is a true story. In order to maintain confidentiality, very few personal details are given about the patient.)
It was his third trip to the emergency room that day. His case manager kept bringing him back because his condition was clearly deteriorating.
He suffered from schizophrenia, but the delusions, voices, and marginal social existence that plagued him were not the concern that evening. His case manager knew that he was confused and appeared gravely ill. He was definitely not his usual self.
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I recall treating many patients with schizophrenia during my residency training. I always thought that I was doing a good job as a psychiatrist if I made a concerted effort to reduce their delusions and hallucinations (the most obvious symptoms of schizophrenia).
While there’s certainly nothing wrong with trying to reduce symptoms that we as practitioners believe to be problematic, it took me a few years to truly understand that a doctor’s treatment goals for a patient and the patient’s treatment goals often overlap but are not necessarily the same.
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The Archives of General Psychiatry published an article this month entitled, “Metabolic Testing Rates in 3 State Medicaid Programs After FDA Warnings and ADA/APA Recommendations for Second-Generation Antipsychotic Drugs.”
The retrospective analysis examines how frequently the recommended metabolic testing for second generation antipsychotic drugs (SGA’s) was performed in Medicaid patients in 3 different states. The conclusion was that the monitoring was not being done nearly as frequently as recommended. Less than one-third of patients treated with these medications, which can cause metabolic syndrome, undergo serum glucose or lipid monitoring.
Obviously this is not good news. In recent years, we’ve learned that the risks associated with SGA’s is higher than originally thought. My intent in this post, though, is not to focus on this study itself as much as to examine an ethical dilemma related to it that I have never heard discussed.
What I’ve been wondering: Is it ever appropriate to prescribe SGA’s to severely mentally ill patients who have no financial means to obtain the necessary blood monitoring tests? I’ll explain.
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