CASE STUDY 3

​ Case Study One

Biologically, Anton is considered overweight, with a body mass index of 29.93 (Department of Health, 2021b). Anton reports consuming a poor diet, comprised primarily of fried food, caffeine, and sugary drinks. Combined with Anton’s poor diet and fluid consumption, medications prescribed, Risperdal Consta (Gautam & Meena, 2011) and Quetiapine (Zhang et al., 2017), all contribute to Anton gaining 15kgs over the past twelve months. Anton reports being a smoker, mixing the tobacco with cannabis before smoking it in a bong. From a psychological health standpoint, Anton is currently treated for a psychiatric illness with Risperdal Consta. Anton also reports difficulty sleeping from time to time and treated with Quetiapine. Anton has been using cannabis since the age of 14 and has experimented with party drugs in the past. Anton reports being impotent; this would fall under the sexual health area of his care. Anton is in a regional area with limited means of transport from a social health perspective as he has lost his license. Anton is unemployed, and a recipient of the disability support pension and left school after grade 11.

The medication prescribed for Anton’s psychotic illness, Risperdal Consta (Gautam & Meena, 2011) and Quetiapine (Zhang et al., 2017) to assist with sleeping, have been identified as contributing to metabolic syndrome. Along with providing Anton with further education about his medications, the side effects and his current diet, comprised primarily of fried food, caffeine and sugary drinks, the implementation of metabolic monitoring would be beneficial. Though it is not apparent if Anton has been diagnosed with metabolic syndrome, Anton would be an increased susceptibility to experiencing it due to his psychotic illness, poor diet and lifestyle. Metabolic monitoring will allow for any abnormalities with Anton’s cardiovascular system, insulin sensitivity or resistance, hypertension, obesity and dyslipidaemia (Holt & Peveler, 2011). Metabolic monitoring will allow for concerns to be identified and treated appropriately promptly. Anton smokes cigarettes; research has identified that smoking detrimentally impacts risperidone pharmacokinetics (Schoretsanitis et al., 2017), potentially contributing to the ineffective treatment for Anton’s psychotic illness. It is crucial to provide Anton with educational material to assist him with understanding the detrimental impact of smoking on his health and affective that smoking has on the treatment of his psychiatric illness. It is, therefore, essential to work with Anton on a smoking cessation plan; this can be achieved by reducing the amount he smokes and utilising nicotine replacement therapy (Munafro et al., 2018). 

Anton has reported being impotent; although sexual dysfunction is a common side effect of antipsychotic medications (Cuomo et al., 2018), steps can be taken to reduce the likelihood of Anton experiencing it on an ongoing basis. Studies have identified that symptoms of sexual dysfunction can be reduced in consumers undertaking psychiatric treatment by maintaining an active and healthy lifestyle (Whitehead, 2021). This incorporates physical activity, be it structured or unstructured, and consuming a balanced diet of all the major food groups (Whitehead, 2021). Approaching Anton’s sexual dysfunction from such a perspective and treatment method will mean that he is more likely to maintain his prescribed psychiatric treatment.

Anton is an unemployed disability pension recipient without a driver’s license residing in a regional area. When an individual loses their job, not only is their usual source of income gone, it also results in the loss of personal work relationships, daily structure and routine, and a sense of self-purpose. This can result in Anton experiencing a more inadequate standard of living, loss of social connection, stigmatisation and loss of self-esteem (Institute for Work & Health, 2021). Anton has the desire to get a job; however, his current sleeping pattern and self-reported stress would make it difficult for him to obtain and retain employment. It would be necessary for Anton to ease the sense of stress he feels when considering employment and help him identify the source of the stress and collaboratively compile ways to overcome the stress. As Anton resides in a regional area, his access to mental health professionals is less than his major city counterparts. According to the National Rural Health Alliance (2021), consumers in inner regional regions had 36% less access to psychiatrists, mental health nurses and psychologists; that figure blows out to 57% in outer regional areas. Anton has lost his driver’s license; this further impedes his ability to engage with appropriate services. Research has established that consumers with restricted means of transport experience poorer health outcomes than consumers with readily available transport (Syed et al., 2013). It is vital to work with Anton to identify ways to engage with mental health services given his regional location and limited access to transport. This could be achieved by assisting Anton with identifying service providers with video or phone services.

Anton is currently managed in the community by his general practitioner, who could commence metabolic monitoring and monitor it for any abnormalities (The Royal Australian College of General Practitioners, 2021a). Should any be identified, they would refer Anton to the appropriate specialist, such as an endocrinologist or cardiologist, for further investigation and treatment. Anton would also benefit from being referred to a dietician. Research has highlighted the benefit of engaging with a dietician to effectively combat metabolic syndrome by implementing an appropriate diet to improve his metabolic health (Agency for Clinical Innovation, 2021). Anton is currently medicated with 100mg of Quetiapine to assist with sleep, which is considered off-label (Arts, 2017); a referral to a psychiatrist could be beneficial. This would allow Anton’s current medications to be reviewed and identify potential alternative medications such as Melatonin, which is far less likely to contribute to metabolic syndrome (Dean, 2020). Given Anton’s age, he would likely benefit from connecting with community groups in his area that target young adults, such as GROW Australia. It is a peer support-based group based on and developed through lived experiences; it provides consumers with a mental illness with support and personal development. Grow Australia has been designed for young adults, providing access both face to face and online; residential rehabilitation and supported accommodation are available for young consumers in need (GROW Australia, 2021).

             Anton’s metabolic monitoring will be carried out on an ongoing basis. Should the initial screening show no abnormalities, it would be appropriate for his general practitioner to conduct ongoing metabolic screenings every month, as suggested in the literature (Agency for Clinical Innovation, 2021). Once Anton has had the initial consultation with the dietician, and a plan was implemented, it would be appropriate for Anton’s plan to be reviewed by the dietician every 3-6 months. This will allow the plan to be implemented and adhered to before reviewing the plan’s success and making changes when needed to best address Anton’s health needs (Martínez & Zulet, 2018). Should the psychiatrist believe that a medication change to assist Anton with sleeping would be beneficial, it is essential that his dose be tapered slowly to ensure that Anton does not experience withdrawal symptoms (Horowitz et al., 2021). Moving forward with Melatonin would be introduced to assist Anton with sleep.

Case Study Two

Breeze has type 2 diabetes, although currently well managed, mothers with type 2 diabetes experience increased congenital abnormalities (National Diabetes Services Scheme, 2021). Breeze has indicated that she smokes daily; research has established that babies of mothers who smoke are at increased risk of experiencing congenital heart defects and problems with the structure of their heart (The Royal Australian College of General Practitioners, 2021b). Breeze reports consuming 4-6 standard drinks per week. However, this is within the recommended guidelines (Department of Health, 2021a), literature is overwhelming in recommending that women who are trying to conceive or pregnant consume zero alcohol as consumption can cause congenital disabilities such as fetal alcohol syndrome (Paediatrics & Child Health, 2002). Breeze has a BMI of 25.86; this is categorised as overweight (Department of Health, 2021b); a BMI of 25 or above can increase risks for mothers and their babies during pregnancy (Witkop, 2013).

Breeze is currently prescribed Carbamazepine; although considered a low-risk medication, studies have linked it to congenital malformation during pregnancy (Galappatthy et al., 2018; National Alliance on Mental Health, 2021). Breeze has a diagnosis of bipolar affective disorder; according to the Royal Australian College of General Practitioners (The Royal Australian College of General Practitioners, 2021c), childbirth can trigger a relapse of the condition in 37% of cases; this figure blows out to 66% if women are unmedicated. Breeze has been hospitalised for depressive episodes; this increases the likelihood of her experiencing depression during her pregnancy (The Royal Australian College of General Practitioners, 2021c). Breeze has previously been prescribed lithium and fluoxetine; fluoxetine is rarely used during pregnancy, while lithium is contraindicated during pregnancy and breastfeeding (Galappatthy et al., 2018).

Breeze has contraception through Implanon. However, she contemplates having it removed as she would like to conceive a baby with her long-term partner. Breeze works in retail and has been in a stable long-term relationship with her partner. 

Breeze is considering having her Implanon removed as she would like to have a baby with her long-term partner. Although pregnancy can occur anytime after the capsule is removed (Reader, 2009), research has established that pregnancies are most likely to occur 7-14 days after removal (Reader, 2009). Breeze should be provided education about this timeframe should she choose to have it removed and wait before attempting to fall pregnant, as alternative contraception would be encouraged during this time. As Breeze is 34, it may be beneficial to highlight that fertility and pregnancy complications increase in women 35 years and older (Jolly, 2000). 

Breeze reports smoking daily; this can have a detrimental impact on her rate of fertility (The Royal Australian College of General Practitioners, 2014). Furthermore, should Breeze continue to smoke during her pregnancy, the risk of miscarriage is increased (The Royal Australian College of General Practitioners, 2014), along with fetal experiencing cardiac or pulmonary conditions (The Royal Australian College of General Practitioners, 2014). Should Breeze stop smoking before conceiving, she will be able to reduce the risk of such complications to be in line with non-smoking women. It is worth noting that mothers who cease smoking before or during pregnancy, the instance of relapse are as high as 70% (The Royal Australian College of General Practitioners, 2021c). It is therefore crucial that Breeze implement a smoking cessation plan before conceiving with ongoing follow-up post-pregnancy.

             

Breeze’s consumption of alcohol is within the recommended guidelines; however, as she anticipates conceiving soon, it would be recommended that she cease consumption to optimise the likelihood of becoming pregnant (Paediatrics & Child Health, 2002). Should Breeze continue to drink during her pregnancy, birthweight is often lower, and the likelihood of the child experiencing neurological delays or long-term deficits is increased (Paediatrics & Child Health, 2002). 

Although Breeze is considered overweight with a BMI of 25.86, this is marginally outside the upper limits of the healthy range of 18.5-24.9 (Department of Health, 2021). Breeze may fall into the healthy range with amending her dietary intake and implementing exercise into her routine. In saying this, with smoking cessation implemented, her appetite will likely increase (Gratziou, 2008). Breeze should be provided with the education of this and a plan compiled to overcome the increase in appetite.

Breeze is prescribed Carbamazepine 600mg BD; studies have established a link between Carbamazepine and congenital disabilities of the head, face and developmental delays (Galappatthy et al., 2018). Breeze should work with her treating prescriber as her dose may need to be reduced, or they may consider changing her treatment. Should this course of action be chosen, studies have identified the benefits of planning pregnancy to facilitate change in medication management (Galappatthy et al., 2018). As Breeze has experienced depressive episodes in the past, requiring hospitalisation, it would be beneficial that she engage with services or programs that will reduce the likelihood of her experiencing a relapse episode.

Breeze’s general practitioner can remove Breeze’s Implanon under local anaesthetic (Reader, 2009). The general practitioner would provide education regarding contraception between removing the Implanon and planning the pregnancy (Reader, 2009). A smoking cessation plan can be implemented and managed by the general practitioner (The Royal Australian College of General Practitioners, 2021), with nicotine replacement beneficial in subsiding cravings associated with abstaining from cigarettes. As Breeze is currently prescribed Carbamazepine 600mg BD, it would be recommended that a referral be made to a psychiatrist who will be best placed to manage adjustment in dose or change in medication. Although yet to fall pregnant, it should be flagged that a referral to perinatal mental health in the early stages of her pregnancy as Breeze is at risk of experiencing a relapse (Galappatthy et al., 2018; National Alliance on Mental Health, 2021).

A referral to an organisation such as Bipolar Australia (Bipolar Australia, 2021) may be beneficial in the ongoing care planning for Breeze. Bipolar Australia are active across Australia; they not only provide support and peer-supported guidance for the consumer with the diagnosis, but they also provide support and education to those who support the consumer, which would be beneficial for Breeze’s long-term partner. Bipolar Australia has resources for family planning and anti-natal support, and Breeze would likely benefit from such support. 

The removal of the Implanon will mean that Breeze will be able to fall pregnant immediately. However, it is most likely that a timeframe of 7-14 days is most likely (Reader, 2009). Given that Breeze smokes ten cigarettes per day, she should progressively reduce the number of cigarettes each day over some time with the assistance of nicotine replacement therapy. For the best help outcomes for Breeze and her future child, the optimal goal would be for Breeze to stop smoking before conceiving. Due to the high relapse rate in women post-birth, it should be flagged with her general practitioner to revisit her smoking status in the year post-birth (The Royal Australian College of General Practitioners, 2014). Breeze’s bipolar affective disorder and depression will need to be managed closely throughout the family planning, pregnancy and post-natal period. As it is likely that medication will be reviewed and possibility adjusted before Breeze falling pregnant (Galappatthy et al., 2018; National Alliance on Mental Health, 2021), the ongoing care post-pregnancy to ensure that she does not experience a relapse of her condition (The Royal Australian College of General Practitioners, 2021c).

References

Arts, M. (2017). Off-label prescriptions of Quetiapine for sleep disturbances. https://doi.org/10.26226/morressier.588f064fd462b8028d891883

Agency for Clinical Innovation. (2021, May 278). Metabolic syndrome fact sheet. NSW Government. https://aci.health.nsw.gov.au/projects/long-term-follow-up-bmt/fact-sheets/metabolic-syndrome

Bipolar Australia. (2021, June 1). Recovering together. https://www.bipolaraustralia.org.au

Cuomo, A., Goracci, A., & Fagiolini, A. (2018). Medication-associated sexual dysfunction in patients with mental illness. https://doi.org/10.1007/978-3-319-68306-5_21

Dean, C. E. (2020). Antipsychotics and the metabolic syndrome, cardiovascular disease, and mortality. The Skeptical Professional’s Guide to Psychiatry, 72-94.

Department of Health. (2021a, June 4). Australian alcohol guidelines revised. Australian Government. https://www.health.gov.au/news/australian-alcohol-guidelines-revised

Department of Health. (2021b, June 4). BMI calculator. Australian Government. https://healthyweight.health.gov.au/wps/portal/Home/helping-hand/bmi/

Galappatthy, P., Liyanage, C. K., Lucas, M. N., Jayasekara, D. T., Abhayaratna, S. A., Weeraratne, C., De Abrew, K., Gunaratne, P. S., Gamage, R., & Wijeyaratne, C. N. (2018). Obstetric outcomes and effects on babies born to women treated for epilepsy during pregnancy in a resource limited setting: A comparative cohort study. BMC Pregnancy and Childbirth, 18(1). https://doi.org/10.1186/s12884-018-1857-3

Gautam, S., & Meena, P. S. (2011). Drug-emergent metabolic syndrome in patients with schizophrenia receiving atypical (second-generation) antipsychotics. Indian J Psychiatry, 53(2), 128-133. http://doi.org/10.4103/0019-5545.82537

Gratziou, C. (2008). Review of current smoking cessation guidelines. Smoking Cessation, 35-43. https://doi.org/10.1183/1025448x.00042005

GROW Australia. (2021, June 6). Mental wellbeing programs. https://grow.org.au/

Holt, R. I., & Peveler, R. C. (2011). Metabolic syndrome and mental illness. The Metabolic Syndrome, 177-193. https://doi.org/10.1002/9781444347319.ch11

Horowitz, M. A., Murray, R. M., & Taylor, D. (2021). Tapering antipsychotic treatment. JAMA Psychiatry, 78(2), 125. https://doi.org/10.1001/jamapsychiatry.2020.2166

Institute for Work & Health. (2021, June 4). Unemployment and mental health. https://www.iwh.on.ca/summaries/issue-briefing/unemployment-and-mental- health

Jolly, M. (2000). The risks associated with pregnancy in women aged 35 years or older. Human Reproduction, 15(11), 2433-2437. https://doi.org/10.1093/humrep/15.11.2433

Martínez, A. J., & Zulet, A. M. (2018). Precision nutrition and metabolic syndrome management. MDPI.

Munafro, M., Drury, M., Chambers, R., & Wakley, G. (2018). Smoking cessation matters in primary care. CRC Press.

National Alliance on Mental Health. (2021, May 25). Carbamazepine (tegretol). https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Carbamazepine-(Tegretol)

National Diabetes Services Scheme. (2021, June 7). Diabetes and pregnancy risks, for women with type 2 diabetes. https://www.ndss.com.au/about-diabetes/pregnancy/type-2-diabetes/diabetes-and-pregnancy-risks/

National Rural Health Alliance. (2021, June 5). Mental health in rural and remote Australia. https://www.ruralhealth.org.au/sites/default/files/publications/nrha-mental-health-factsheet-dec-2017.pdf

Paediatrics & Child Health. (2002). Fetal alcohol syndrome: What you should know about drinking during pregnancy. https://doi.org/10.1093/pch/7.3.177

Reader, C. A. (2009). Pregnancy at time of change of implanon implant. Journal of Family Planning and Reproductive Health Care, 35(4), 265-265. https://doi.org/10.1783/147118909789587402

Schoretsanitis, G., Haen, E., Stegmann, B., Hiemke, C., Gründer, G., & Paulzen, M. (2017). Effect of smoking on risperidone pharmacokinetics – A multifactorial approach to better predict the influence on drug metabolism. Schizophrenia Research, 185, 51-57. https://doi.org/10.1016/j.schres.2016.12.016

Syed, S. T., Gerber, B. S., & Sharp, L. K. (2013). Traveling towards disease: Transportation barriers to health care access. Journal of Community Health, 38(5), 976-993. https://doi.org/10.1007/s10900-013-9681-1

The Royal Australian College of General Practitioners. (2021a, June 5). The metabolic syndrome. https://www.racgp.org.au/afp/2013/august/the-metabolic-syndrome/

The Royal Australian College of General Practitioners. (2021b, June 7). Management of smoking in pregnant women. https://www.racgp.org.au/afp/2014/januaryfebruary/smoking-in-pregnant-women/

The Royal Australian College of General Practitioners. (2021c, June 7). Management of bipolar disorder over the perinatal period. https://www.racgp.org.au/afp/2016/december/management-of-bipolar-disorder-over-the-perinatal-period/

Witkop, C. T. (2013). Preconception and pregnancy care in overweight or obese woman. Obesity During Pregnancy in Clinical Practice, 33-52. https://doi.org/10.1007/978-1-4471-2831-1_3

Whitehead, D. (2021). Erectile dysfunction guidebook: The complete sexual health solution to identifying, working on and curing ED and impotence: Natural remedies, psychology, sex addiction, exercise, diet and more. Independently Published.

Zhang, Y., Liu, Y., Su, Y., You, Y., Ma, Y., Yang, G., Song, Y., Liu, X., Wang, M., Zhang, L., & Kou, C. (2017). The metabolic side effects of 12 antipsychotic drugs used for the treatment of schizophrenia on glucose: A network meta-analysis. BMC Psychiatry, 17(1). https://doi.org/10.1186/s12888-017-1539-0