Schizophrenia Who Wants to Stop His Antipsychotic Because of Weight Gain — Free SCA Practice Case

Character Overview: You are Jamal Osborne, a 45 year old stock controller at a builders' merchant. You live in a rented flat with your girlfriend Keisha, a bookkeeper, together about eighteen months. About twenty years ago, in your mid twenties, you were diagnosed after you started hearing voices. You never use the name of the diagnosis; you say "my mental health" or "what I was diagnosed with". In the years after that you were on risperidone, which you took only when you remembered. Just over two years ago, after losing your job and your flat, you stopped sleeping and ended up in hospital for six weeks, your only admission. Olanzapine was started there and you have taken 15 mg at night ever since, every night, without missing one. You have been well since and you are back at work. But you have put on three stone and it is all you think about. A health check six weeks ago shook you, and you have decided to stop the tablets tonight. You have told nobody, and you are sure you are well enough not to need them. You are friendly and quick with a joke, but you bristle if you feel lectured or managed, and you are quietly ashamed of your weight. Your voice drops when you talk about how you look and gets brisker when someone seems to be telling you what to do.

Opening Sentence: "Hi doctor. I want to come off the olanzapine, tonight if I can. I've put on three stone since I started it and I can't take it any more. I've been fine for ages, so I don't see why I still need it."

History if Asked (Data Gathering Phase)

• ●The weight gain: "About three stone in two years. I was just under thirteen stone when I came out of hospital and now I'm nearly sixteen. Most of it went on in the first year." Hungry all the time, even straight after tea. Some nights he gets up in the early hours and eats cereal or toast, then feels disgusted with himself. He tried a gym and fewer takeaways for a few months: "I lost a bit, then it all came back. It feels like the tablets, not willpower."
• ●What it has done to him (if asked): "None of my trousers fit, I've stopped swimming and I avoid the pub quiz because everyone will comment. Keisha says she doesn't mind, but I mind."
• ●How he takes it and why he wants to stop now (if asked how he takes it, whether he misses any, why now, or what made him decide): "Every night, last thing, with a glass of water. I've not missed one since I came out of hospital, not one. That's why I know it's the tablets making me fat, I've done everything right." If asked why now: "The health check. The nurse put me on her scales and I saw a hundred and one, then she said my sugar was a bit high. I came out of that surgery and thought, that's it, I'm done." He plans to stop completely tonight and has not tried going without them.
• ●Whether his team knows (if asked): "No. Kirsty, my care coordinator, would just tell me not to. I haven't told the psychiatrist either. I'm not seeing him for a few months."
• ●The last time he was ill (if asked): "Just over two years ago. I'd been on risperidone but only took it when I remembered. I'd lost my job and flat, I was drinking loads and smoking weed. I stopped sleeping, a few nights with nothing at all. Then I heard a man's voice commenting on everything I did, like a running commentary. Six weeks in hospital." The sleep went first, then he stopped eating. Keisha says she would spot it now.
• ●How he is now (if asked about voices, strange thoughts, sleep, mood or harm): "No voices, nothing like that. Nobody's out to get me. I sleep about eight hours, if anything too much. I'm fed up about the weight but I'm not low and I still enjoy things. I'd never hurt myself or anyone."
• ●Drink and drugs (if asked): "Three pints on a Saturday. I haven't touched weed since I came out of hospital."

Ideas, Concerns, Expectations

Gating note: Jamal raises none of this himself. Each part comes out only when the doctor asks what he thinks is behind the weight or the tablets, what is worrying him, or what he was hoping for today.

• ●Ideas: He believes the olanzapine has done this and that once he is off it the weight will drop and he will be himself again. He thinks he has been well so long that he is "better". Last time was different, he says, because he was not taking the risperidone properly and was drinking and smoking. "I reckon it's the tablets, one hundred percent. Last time I was a mess and I wasn't taking them properly. I've taken every single one since, so it's not the same."
• ●Concerns: His main worry is turning into his dad. At the health check the nurse said his sugar was a bit high and all he could think of was his dad. If the doctor explores further, a quieter fear emerges: he does not want to go back into hospital, but he is more scared of being fat and stuck on tablets for years. "I'm forty five and I'm going the same way."
• ●Expectations: He hopes to be told stopping is fine, or at least to be listened to and not lectured. "If you say I can't, I'll probably just stop anyway."

If Asked: Medical History and Medications

Gating note: Jamal answers each of these plainly when the doctor asks about it.

• ●Health and medicines: No other health problems, medicines or supplements. No allergies. Never smoked.
• ●Effects of the olanzapine: "Tired in the mornings, a bit slow first thing." No shakes, stiffness or restlessness. No thirst or night time urine. No palpitations, fainting or breast changes. If asked sensitively about sex: "I'm not as interested as I used to be and things take longer."
• ●The health check (if asked): "The nurse said my sugar was borderline and gave me a leaflet. Nobody's followed it up."
• ●Family history (if asked): "Dad's got type 2 diabetes. He was diagnosed in his early fifties, he's on injections now and he's lost some feeling in his feet."

Social History and Lifestyle Impact

• ●Work and home: Has missed no work through illness since hospital. Keisha knows about the illness and the admission and is supportive. "She'd notice if I wasn't right."
• ●Food and activity: "Takeaway about twice a week. Two cans of cola at work most days. I eat big portions and I'm still hungry." He walks twenty minutes to work. He used to swim.
• ●Crisis plan (if asked who would notice, or whether he has a plan): Keisha would spot the sleep change straight away. "Kirsty gave me a card with the crisis number but I've not looked at it for ages."

Responses to Management (The Negotiation Phase)

• ●If the doctor says stopping suddenly is not a good idea, or that feeling well for two years on the tablet does not prove he would stay well without it:
  • ●Reaction: Defensive but listening. "I've taken it every night for two years and I've been well. It's not the same as last time, I wasn't taking the risperidone properly and I was drinking and smoking weed." If the doctor acknowledges that, including how reliably he has taken it, and explains why the risk is still real, he softens: "So even if I'm fine now, I could go wrong in a few weeks? That's really annoying." If the doctor warns he will end up back in hospital: "So I'm stuck with it and getting fatter? I'll probably just stop anyway." He engages again if asked what would make him hold off.
• ●If the doctor suggests contacting his care coordinator or psychiatrist:
  • ●Reaction: Wary. "They'll just tell me to take it. Kirsty always says give it time." If told the call is to ask about alternatives and he will hear what comes back: "Okay. Would you ring them? I'd rather you did." If it is done without asking him: "You're going behind my back?" He asks, "When do I hear back? I don't want it hanging for weeks," and "So what do I do tonight, take it?" If told to take it as usual while the team is contacted and a review is booked within days: "If it's days and not months, I can do that. But I'm not signing up for years without a plan."
• ●If the doctor offers ways to tackle the weight (a switch, a slower reduction, metformin or an injection):
  • ●Reaction: Interested in a switch. "Would I actually lose the weight? How long does a swap take? Will I feel rough?" If told weight loss is not guaranteed: "Fair enough. At least that's a straight answer. I just want a chance." On metformin: "Isn't that a diabetes tablet?" He accepts it once told the specialist would need to agree.
• ●If the doctor explains his blood test, or suggests a lifestyle or weight programme:
  • ●Reaction: Anxious. "So have I got diabetes?" Relieved if told it is a warning range, not diabetes, that it can come down and his dad's diagnosis is the reason to act now: "So it's not too late." On a programme: "I've done the gym. Is it a group? I don't want a room full of strangers looking at me." He is open if told it is tailored and that night hunger is a known effect of olanzapine: "So it's not just me being greedy?"
• ●If the doctor asks about involving Keisha, or how long he would need tablets:
  • ●Reaction: "She'd help. Just let me tell her myself." On duration: "How many more years are we talking? Is there any way off them?" He accepts a straight answer: nobody can say for certain, it is usually years, it is reviewed yearly, and any reduction would be slow and done with the team.
• ●If the doctor gives vague safety netting, leaves it as his choice, or threatens to stop prescribing:
  • ●Reaction: On vague advice: "Worse how? What am I looking out for? What do I do if I can't sleep and it's the middle of the night?" He wants specific signs and a named number. If left to decide alone: "So I just stop tonight and nobody checks on me? That doesn't feel right either." If prescribing is threatened: "Right. So I'll just not collect it then." He stays on the call if told the prescription will continue while a plan is agreed.