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Ray is a 25-year-old man who presents to you as a new patient. You will assume his psychiatric medication management. He has also been referred to Silver State Behavioral Health for supported employment services and counseling; your role is medication management. Ray’s history of mental health symptoms dates to his early adolescent years. He reports he had episodes of depression all though junior high and high school. He admits that he often feels sad, has no energy, and just doesn’t look forward to anything. He is not suicidal now but has had suicidal thoughts in the past. When he was in 10th grade his parents took him to a psychiatrist who put him on sertraline, but it didn’t help at all. All it did was give him a headache. Upon further discussion and history taking, Ray admits that while in junior high and high school he would vacillate between episodes of profound depression and periods of feeling “on top of the world.” He says that when he felt good, he felt “really good.” He would ride his bike for hours and was always the risk taker among his friends. He would often get in trouble for being disruptive in class. This was a problem, but his parents just thought he was being a typical teenager. Ray graduated from high school when he was 18 and got a job in an Apple store. After working for several months, Ray began to hear voices that told him he was worthless. He started to believe that his boss was planting cameras and video recording devices to catch him making mistakes. Ray became increasingly agitated at work, particularly during busy times, and began behaving very strangely. Reportedly, one customer asked for help, and Ray said that they needed to move away from the mirrored background because the CIA was behind the mirror recording his activity. After several more months, Ray quit his job. He started yelling to his boss that he could not take being observed through the mirrors all the time. Ray was living with his parents at the time. After quitting his job, he became increasingly agitated and non-functional. His parents finally took him to the emergency room, where he was referred to an inpatient psychiatric facility. He was given thorazine by the admitting on-call psychiatrist. While it did help his psychosis, Ray developed painful twisting and contractions of his muscles. He was switched to Haldol and had a lesser adverse effect profile. From time to time Ray stopped taking his Haldol, and the voices and paranoia became stronger. He says he knew he needed to take the Haldol, but he just didn’t like that it made him feel “numb.” During the next seven years Ray was hospitalized five times, usually because he went off his meds. For the last year, he has taken his Haldol and other meds as ordered and he now receives SSI. With the assistance of a case manager Ray has moved into his own apartment. Now, at the age of 25, he is a member of a psychosocial “clubhouse” for people with mental illness. He attends the clubhouse three times a week, and answers the phone there as a volunteer. Ray also helps write the clubhouse newsletter. He has a few friends at the clubhouse, but he has never had an intimate partner relationship. Ray shared with his case manager he would like to get a job so he can earn more money and maybe buy a car. He also confides he would like have a girlfriend. Although he knows he needs medication, he does not like the haloperidol. Today Ray tells you that he wants to take medications to help him; he knows he has a psychiatric disorder. He admits that while the Haldol helps the voices, he still sometimes gets very depressed, and just doesn’t want to leave his apartment. When he is depressed, he doesn’t even want to take a shower or brush his teeth or eat. Sometimes though, he has no patience, and he gets so full of energy and frustration he doesn’t know what to do! When he is at his worst and not taking is meds, he hears voices telling him he is worthless, he is not motivated to do anything, he feels irritable, has low energy and just can’t get interested in anything. Even though he knows he is lucky to have his living arrangement and case manager looking out for him, he just can’t seem to look forward to anything. Ray is very worried about looking for a job. He doesn’t know how to explain his disorder to a potential employer, and he is afraid of becoming overwhelmed. As his new provider, you recognize that Ray has schizoaffective disorder; a combination of bipolar disorder and schizophrenia. You have now assumed his care, and you have numerous new medications available as samples. Assuming that cost is not a concern, answer the following questions. Use what you have learned to pick the best medication options for Ray, considering his history, presenting symptoms, concerns, and medication adverse effect profile. 1. What is the neurobiology of Ray’s disease? Explain the theorized biologic mechanism of his schizophrenia and his mood disorder. 2. Was sertraline an appropriate medication for Ray when he was in school? Why or why not? 3. Was Haldol a reasonable choice for Ray when he was first admitted to an inpatient setting? Why or why not? 4. What is your medication plan for Ray? What is the pharmacodynamics behind the presumed effectiveness? Why did you pick this medication over others available in class? Write in prescription form what you prescribe for Ray today and why. 5. Assuming Ray does well with what you prescribe today, is there anything else that is in your future plan of care? If so, write it in prescription form, briefly discuss the pharmacodynamics, and tell me why you picked this over other ones in class. 6. How will you counsel Ray about this medication regimen? Being realistic, what will your patient education about these meds include today? 7. What, if any, are the genetic and cultural influences on your prescribing choices?

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