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25-year-old Sam is brought in by the police due to public concern regarding some bizarre and distressed behaviour in the city centre. The police say Sam will only speak of being “scared of ‘them’ ”. He’s currently curled up in a ball over in the corner of the room.

Mental health act

Which section of the Mental Health Act allowed police to bring Sam to hospital??

Section 136

Section 136 allows police to bring a person from a public place to a place of safety.

The place of safety can be A&E, a police station or a specific ‘136 Suite’.

A person can be held under Section 136 for a maximum of 72 hours.

During this time an assessment of the individual should take place by a mental health professional.

What are the criteria for detention under Section 2 of the Mental Health Act?

If a person:

  • has/is deemed to have a mental disorder which requires assessment or treatment
  • is suffering from a sufficiently serious disorder that means admission is necessary for either the health and safety of the patient themselves, or the public
  • requires hospital admission for assessment/treatment
  • is unable and/or unwilling to agree to admission

Two registered medical practitioners (one of which must be Section 12 approved) and an Approved Mental Health Professional (AMHP – usually a social worker) submit reports which support that the case satisfies the above criteria.

The history…

When talking to Sam, you manage to elicit the following snippets of information

“They’re after me…they’re going to get me. I’ve heard them talking about me.”

“They know what I’m doing, they know where I am. They follow me everywhere. They put a tracker in my head while I was asleep a year ago. Now they know where I am and what I think.”

“They know what I’m thinking, and they make me think about hurting my family. I don’t want to hurt my family, but I keep getting these thoughts…It’s getting worse.”

“The chip was put in my brain last year. They’ve been getting louder ever since.”

It is not possible to obtain any more of a medical history from Sam.

Diagnosis

What is your differential diagnosis?
  • Acute psychosis
  • Drug-induced psychosis
  • Schizophrenia
  • Schizoaffective disorder
  • Psychosis due to a medical condition
  • Bipolar disorder
  • Delusional disorder
  • Schizotypal personality
Which of Schneider’s first rank symptoms is Sam displaying?
  • Third person auditory hallucinations
  • Thought insertion
  • Thought broadcasting

Further investigations

What investigations could you perform to narrow your differential diagnosis?

Routine drug screening – urine & blood – typical suspects are cannabis, amphetamines & LSD

FBC – white cells/infection markers

U&E – electrolyte disturbances may indicate an underlying medical cause

Random blood glucose/fasting blood glucose – diabetes

Medication history – can get this from the patient’s GP

Neurological examination – to rule out organic causes – space occupying lesions etc

CT/MRI head – to rule out organic causes

EEG – if seizure activity suspected

The story continues…

You return to Sam to discuss the need for blood tests, and find a lady sat with him. Jane introduces herself as Sam’s mother, and explains that Sam usually lives with her.  She explains that Sam is known to have schizophrenia. This was diagnosed during university, and has been somewhat turbulently managed since. He has been on several different antipsychotic medications in the past 4 years, none of which have seemed to control the symptoms. Sam has not been able to find a job since university and has few friends. There is no known illicit drug use and he has no other past medical history. 

Management

Given the history, why may Clozapine may be an appropriate treatment?

Sam has a history demonstrating schizophrenia that has not responded to first line treatments (treatment-resistant schizophrenia).  Clozapine is indicated for treatment resistant schizophrenia, specifically when the illness has been unresponsive to at least 2 antipsychotic medications (at least one of which is an atypical antipsychotic).

What investigations are required before Clozapine therapy is initiated?

Baseline bloods – FBC (particular attention to white cell count & neutrophil count)

Cardiovascular risk status / BMI / fasting lipids – ↑ cardiovascular disease / myocarditis

Fasting blood glucose or HbA1c – Clozapine is associated with an increased risk of diabetes

Baseline vital signs – Clozapine can cause postural hypotension

ECG – to act as a baseline – ↑ risk of cardiovascular disease with Clozapine

How is Clozapine treatment initiated?

Often initiated during an inpatient staystarted on a low dose and titrated upwards.

Plasma clozapine should be measured after the initial target dose is reached (approx 2 weeks).

A normal maintenance dose is 300-600 mg daily.

Blood pressure should be monitored regularly, as postural hypotension can occur.

How should a patient on Clozapine be followed up? What is monitored and why?

Myocarditis

For the first month patients on clozapine should have the following monitored:

  • Vital signs – temperature (?fever) / blood pressure / pulse
  • ECG
  • CRP
  • Troponin levels

This is because a rare side-effect of clozapine therapy is myocarditis, which can lead to myopathy.

 

Agranulocytosis

During the first 6 months of treatment WCC should be measured weekly, then fortnightly.

1 in 1000 people on treatment develop agranulocytosis, and this usually in the first 6 months of treatment.

Clozapine should be temporarily stopped or discontinued if granulocytopenia develops.

 

Weight gain / Impaired glucose tolerance

Weight should be monitored regularly as weight gain is likely.

Alongside this, insulin-resistance may develop, so HbA1c should be measured 6 monthly.

References

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