Homeless Step Down Pathway Case Study 7

This is a brief outline of how a patient with a working diagnosis of Schizophrenia and Emotionally Unstable Personality Disorder (EUPD) was managed at the Mildmay. Patient Q, called this for confidentiality, was a 36-year-old man with a diagnosis of Schizophrenia for about 15 years. The Schizophrenia was being managed on high doses of Clozapine. He was referred to the Mildmay Hospital by the Homeless Team through Homeless Care Pathway.

He had delusional beliefs, and periods of great excitability, anger and frustrations, and periods of deep depression. He had suspected personality disorder and history of behavioural issues. He also had an alcohol habit in excess of 6-8cans /day. He was referred whilst living in an accommodation-based service (mental health residential setting) where he did not wish to stay. Prior to that he had been in hospital for 2 months where he had had several procedures done on his knee culminating with him having a high knee brace in situ and mobilising on elbow crutches. While his mental health was not always stable and a risk of suicide was identified, he agreed with his care team that the risk was not necessarily increased by his living in the community. His ability to cope was at risk if he was unwell. His plans were to move on to live independently in the future but expected low level regular support for the time being, and a responsive and increased level of support from time to time when needed.

On the ward, his behaviour was erratic, impulsive, intense and unpredictable. His mood had intense episodes of anxiety, irritability and dysphoria. Several times, especially late at night or early mornings, he would call emergency services to inform them he wanted to harm or kill himself. On several occasions, Ward staff had to deal with concerns expressed by emergency services personnel with regards to his safety. When staff attempted to reassure him, he would become verbally aggressive and would use some explicit racial terms to describe staff. Considering his threats to harm himself and suicidal ideation, his bedroom had had to be stripped and potential risk items removed. He once attempted to hit a member of staff with one of his crutches. Sometimes he would refuse to take his medication, especially in the mornings. He did not want to be woken up for his medication, and it was unsafe to leave it for him to take it later. His girlfriend once called the ward, and her input was quite helpful to staff in managing his moods and behaviours.

Medical staff eventually adjusted the times he took his medication to accommodate his wishes for uninterrupted sleep. Being on Clozapine meant he had to have strictly regular blood tests. He was on very high dosage of it. Medical staff ensured he was registered with the Clozapine Patient Monitoring Service (CPMS). In his case, it was every 4 weeks. The patient used to decline to have his bloods taken by a nurse as he preferred Doctors. Sometimes Doctors’ schedules meant they will not be able to do bloods on due days. Contingent measures had to be put in place in such situations to ensure bloods were done on time.

There were some guidelines to be followed with regards to Clozapine administration:

• Clozapine should NOT BE ADMINSTERED if the blood tests issued a RED blood result.
• If there is a break in treatment of 48 hours or longer the dose must be titrated up again from 12.5mg.
• If a break of more than 72 hours, blood tests will need to be done weekly again for a few weeks.
• Repeat glucose levels, LFT and blood lipids every 3 months.

After various inputs from the MDT during his period of admission, he appeared more manageable and was eventually discharged to a place of safety.