Online - 2455-3891

Vol 11, Issue 6, 2018 Print - 0974-2441

Case Report

A CASE STUDY ON SCHIZOPHRENIA INDUCED MULTIPLE COMORBIDITIES

JAGADEESAN M*, KIRAN KUMAR R, JUSTIN JACOB ABRAHAM

Department of Pharmacy Practice, SRM College of Pharmacy, SRM Institute of Science and Technology, Kanchipuram, Tamil Nadu, India.
Email: [email protected]
Received: 27 November 2017, Revised and Accepted: 23 February 2018

ABSTRACT

Schizophrenia is a mental disorder characterized by abnormal social behavior which includes false beliefs, confusion, and auditory hallucination.
Antipsychotic drugs therapy increases the risk of developing diabetes mellitus and coronary artery disease (CAD) in schizophrenic patients. Hence,
we have planned for a systematic approach toward the management of comorbidities induced in schizophrenic patients. A case study was conducted
in 42-year-old female patient diagnosed with schizophrenia along with Type-2 diabetes mellitus, hypothyroidism, diabetic retinopathy, diabetic
nephropathy, systemic hypertension, CAD-acute coronary syndrome recent inferior wall myocardial infarction. The patient was treated with atypical
antipsychotics, antiplatelets, antianginals, statins, hypoglycemic agents, and other supportive measures. The patient improved symptomatically. The
antipsychotic treatment for schizophrenia induces abnormal metabolic syndrome which results in decreased glucose and lipid metabolism that
leads to obesity, hyperglycemia, and dyslipidemia associated with cardiovascular risks. Often antipsychotics are combined with benzodiazepines
and antiparkinson agents to reduce the risks caused from large doses of antipsychotic medication. However, people receiving first-generation
antipsychotics have higher prevalence of developing diabetes mellitus and cardiac risks compared to second-generation antipsychotics. Hence, we
conclude that atypical antipsychotic drugs such as amisulpride, aripiprazole, and ziprasidone should be given to schizophrenic patients because these
drugs have little effects on abnormal metabolic syndrome when compared to other antipsychotics. There is a need for proper screening of blood
glucose level and cardiovascular risks assessment before the administration of antipsychotic medications to schizophrenic patients and also during
the course of treatment regularly.

Keywords: Schizophrenia, Diabetes mellitus, Coronary artery disease.

© 2018 The Authors. Published by Innovare Academic Sciences Pvt Ltd. This is an open access article under the CC BY license (http://creativecommons.
org/licenses/by/4. 0/) DOI: http://dx.doi.org/10.22159/ajpcr.2018.v11i6.23979

INTRODUCTION the patient was diagnosed with hypothyroidism based on hypothyroid

stimulating hormone values and also with diabetic retinopathy and
Schizophrenia is a mental disorder characterized by abnormal
diabetic nephropathy based on an appropriate test. During the period of
social behavior and failure to understand the reality which includes
treatment for above complaints, the patient developed with complaints
false belief, confusion, and auditory hallucination, and lack of social
of upper abdominal pain, breathlessness for 4 h, and hence, ultrasound
engagement [1,2]. Late adolescence and early adulthood are peak
abdomen scan recommended, and its report found with bilateral mild
periods for the onset of schizophrenia which is usually later in women
pleural effusion, mild pericardial effusion, and bulky uterus with
than in men [3]. The peak ages for onset are 25 years for males and
uterine fibroid. Under the supervision of the cardiologist, the patient
27 years for females [1]. Over the years, various studies have been done
was reported with hyper values in lipid profile test expect high-density
and have reported that patients with schizophrenia are susceptible to
lipoprotein with hypo values. Electrocardiogram (ECG) was analyzed
comorbidities. However, little is known about the proper management
and reported with sinus tachycardia with Q and T wave inversion in
and treatment of such cases.
LII, LIII, and arteriovenous fistulae an echocardiogram assessed with
left ventricular ejection fraction=40% and coronary angiography was
CASE REPORT
performed and diagnosed with coronary artery disease (CAD) - single
Schizophrenia patient’s diagnosed history vessel disease, evolved inferior wall myocardial infarction, and systemic
A 42-year-old female patient visited ear, nose, and throat department hypertension.
with chief complaints of a severe headache and otalgia. She was
diagnosed with otitis externa in right ear, external auditory canal Patients investigated personal history
edema, and perforated eardrum, and advised to keep ichthammol The patient’s personal history was investigated to identify the cause
glycerin pack for 3 days. Later she was planned for tympanoplasty. and onset of schizophrenia. The patient’s birth is by normal vaginal
delivery. The patient had normal and regular menses. Patient gestated
Fasting blood sugar and postprandial blood sugar test was performed for the first time at the age of 20 years and the second time at the age
before the surgery and was found with hyperglycemia. Hence, the of 21 years. Both babies were delivered by lower segment cesarean
tympanoplasty was postponed, and under the guidance of diabetologist, section due to overweight of about 4 kg, respectively. The firstborn
the patient was diagnosed with Type-2 diabetes mellitus based on the baby lactated for 11 months and the second baby for 1 year. During
complete blood glucose profile test performed and also found with the the age of 34 years, the patient developed with symptoms of insomnia
history of insomnia for 8 years and mentally abnormal for 12 years and feeling restlessness, and confusion. During the age of 39–40 years,
without any medication. Hence, under the guidance of the psychiatrist, the patient was developed with auditory hallucination and delusions
the patient was diagnosed with schizophrenia based on the positive but left untreated for past 8 years which induce severe ear infection.
and negative syndrome scale for mental illness assessment. Meanwhile, During the age of 40 years, the patient developed with frequent severe
the patient developed with complaints of active ear discharge, pedal headache and nocturia. At present, at the age of 41 years, the patient
edema and under the guidance of endocrinologist, and nephrologist; developed with pain in the upper limb, radiating to the left scapula.
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Asian J Pharm Clin Res, Vol 11, Issue 6, 2018, 1-3

Patient’s - schizophrenia and comorbidities pathogenesis DISCUSSION

The combination of genetic and environmental factors play a key
Treatment for schizophrenia
role in the development of schizophrenia [3,4]. Environmental
The management of schizophrenia includes both psychosocial
factors associated with the development of schizophrenia include
interventions and psychotropic medication. Both typical and atypical
social isolation, drug use, and prenatal stressors. Maternal stress
antipsychotic drugs address the positive symptoms of schizophrenia
may induce hypermethylation and underexpression of reelin
whereas negative symptoms of schizophrenia responses more favorably
(large extracellular matrix glycoprotein that regulates neuronal
to atypical antipsychotics [13]. Often antipsychotics are combined with
migration and positioning in developing brain by controlling cell-cell
benzodiazepines and antiparkinson agents during the actual phase of
interaction) [5]. This leads to a reduction in gamma-aminobutyric acid
treatment to reduce the risks caused by large doses of antipsychotic
receptors and maternal nutritional deficiencies as well as maternal
medications [1]. Hence, in this case, the patient with positive symptoms
obesity and Reduced metabolic activity in the frontal cortex and,
should be treated with atypical antipsychotic drugs such as amisulpride,
serotonin, glutamate through dysfunction of its N-methyl D aspartate
aripiprazole, and ziprasidone because these drugs have little effect on
receptor are identified as possible risk factors for schizophrenia [1].
weight gain [14].
Since the positive symptoms of schizophrenia occur at the earlier age
but because of lack of knowledge regarding this, the patient was left
Treatment for schizophrenia with diabetes mellitus
untreated.
The management for diabetes in schizophrenic patients according to
standard treatment guidelines includes the proper screening of glucose
Fig. 1 shows an outline of the pathogenesis of schizophrenia [6].

People with untreated schizophrenia have a higher risk of obesity, Table 1: Estimated prevalence of modifiable cardiovascular risk
Type 2 diabetes mellitus, dyslipidemia and hypertension and factors in people with schizophrenia
contribute to the overall cardiovascular disease risks [7]. However,
in this case, the patient with schizophrenia and diabetes mellitus left Modifiable risk factor Prevalence (%) Relative risk
untreated for an extended period. The pathology of schizophrenia Smoking 50–80 2–3
resembles that dysregulation of hypothalamic-pituitary axis and Dyslipidemia 25–69 ≤5
high serum cortisol levels in people with elevated serum cortisol Diabetes 10–15 2–3
increases gluconeogenesis, insulin resistance, and metabolic Hypertension 19–58 2–3
syndrome [8]. The prevalence of diabetes and cardiovascular Obesity 45–55 1.5–2
disease is increased 2–3 fold in people with schizophrenia [9]. Metabolic syndrome 37–63 2–3
Since antipsychotic medications may also cause adverse metabolic
effects due to non-adherence, it result in irregular glucose and Table 2: Prescribed medication
lipid metabolism that may induce obesity, hyperglycemia, and
dyslipidemia which associated with cardiovascular risks [10,11]. Dosage form Drug name Dose Frequency
Due to withdrawal from health care among family members may
Tablet Clopidogrel+aspirin 150 mg 0‑1‑0
result in multiple comorbidities. The prevalence of modifiable risk Tablet Rosuvastatin 40 mg 0‑0‑1
factors is shown in Table 1 [12]. Tablet Carvedilol 3.125 mg 1‑0‑1
Tablet Furosemide 40mg ½‑½‑0
Management given Tablet Nicorandil 5mg ½‑0‑½
The patient initially was admitted with chief complaints of a severe Tablet Losartan 25 mg 1‑0‑0
headache and otalgia and was diagnosed with external auditory Tablet Trimetazidine 35 mg 1‑0‑1
canal edema, otitis externa, and perforated eardrum. The patient Tablet Amisulpride 400 mg 0‑0‑1
treated with tablet ranitidine 150 mg bid and tablet amoxicillin Tablet Pantoprazole 40 mg 1‑0‑1
250 mg+clavulanic acid 125 mg Q8 h, and ear drop ciprofloxacin Capsule Becosules 1‑0‑0
1* bid given for 1 week. The random blood sugar and postprandial Ear drops Ciprofloxacin 2 drops 1‑0‑1
Tablet Metformin 500 mg 1‑0‑1
blood sugar were assessed before tympanoplasty and diagnosed with
Tablet Vildagliptin 50 mg 1‑0‑1
Type-2 diabetes mellitus, continued the medication along with tablet
Tablet Levothyroxine 100 mcg 1‑0‑0
metformin 500 mg bid for next 1 week. Meanwhile, the patient was Tablet Spironolactone 25 mg 0‑1‑0
identified with the history of insomnia and mental abnormalities
for past 8 years under no medication. Then, she was diagnosed
with schizophrenia, treated with atypical antipsychotics - tablet
amisulpride 400 mg 0-0-1 for next 2 weeks. Subsequently, she was
found with abnormal thyroid stimulating hormone value-13.8,
and diagnosed with hypothyroidism, Type-2 diabetic retinopathy,
and nephropathy and continued all medication along with thyroid
supplement tablet levothyroxine 100 mcg 1-0-0 for next 3 weeks.
During the treatment, the patient developed with breathlessness and
ultrasound scan was recommended and reported with mild pericardial
effusion, and acute coronary syndrome (ACS). Consequently, coronary
angiography performed and the patient diagnosed with CAD - single
vessel disease, elevated myocardial infarction. The patient was treated
with tablet clopidogrel+aspirin 150 mg (antiplatelet+thrombolytic)
0-1-0, tablet rosuvastatin 40 mg (antihyperlipidemic) 0-0-1, tablet
furosemide+spironolactone 40 mg (diuretics) ½-½-0, tablet
nicorandil 5 mg (antianginals) ½-0-½, tablet losartan 25 mg
(antihypertensive) 1-0-0, carvedilol - 3.125 mg (antihypertensive)
1-0-1, tablet trimetazidine 35 mg (antianginals) 1-0-1, and continued
along with previously mentioned medications for 1 week. The patient
improved symptomatically and was discharged with following Fig. 1: Pathogenesis of schizophrenia-inducing adverse metabolic
prescribed medications (Table 2). syndrome

2
 Jagadeesan et al.
Asian J Pharm Clin Res, Vol 11, Issue 6, 2018, 1-3

level combined with measurement of glycated hemoglobin (HbA1c) both AUTHORS CONTRIBUTIONS
before and after administration of antipsychotic agents and medications
include oral hypoglycemic agents like metformin which shows significant Dr. Jagadeesan M - contributed in choosing the topic, guided throughout
effects on controlling the diabetes mellitus along with coadministration the progress of case study and cross-checked the case study on
of atypical antipsychotic medications [15,16]. If the blood glucose completion. Kiran Kumar R - contributed in collecting the pieces of
level is higher than 450 mg/dl, then insulin therapy is recommended. information regarding patient for case study and accounts for case
The additional management includes dietary modification, increased study writing. Justin Jacob Abraham - contributed in collecting the
physical activities, and weight loss reduces the incidence of Type-2 pieces of information regarding comorbidities pathogenesis for case
diabetes. Hence, in this case, the patient with high HbA1c, high blood study and accounts for case study writing.
sugar level should be treated with metformin and vildagliptin which is
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