This case involves a thirty-four-year-old male patient, with a significant medical history of mental issues, including paranoid schizophrenia. He was brought to the ER by the police after a delusional episode and was treated with a number of psychotropic medications. A psychiatry consult was not called and the ER staff decided to manage the patient’s mental instability without assistance. The patient was in the ER for approximately five hours and suffered cardiac arrest due to an apparent reaction to the sedatives prescribed to him. The patient was successfully resuscitated and transferred to an ICU unit, and he spent three weeks recovering from congestive heart failure. Additionally, the patient contracted pneumonia and sepsis during his hospital stay which complicated his recovery. As a result of the cardiac arrest and severe complications of the respiratory infection, the man is not able to walk under his own power.

I believe that a psychiatric consult may have benefited this patient greatly. The role of the consultation-liaison psychiatrist is to see patients with comorbid medical conditions at the request of the treating medical or surgical consultant or team. Psychiatrists are highly trained in the side effect profile of psychotropic medications and are better suited to evaluate an individual's medical issues to prevent serious complications such as the cardiac manifestations seen here. If this patient was a known schizophrenic, and was displaying psychotic features at the time of his arrival, it would also be wise to perform a drug screen to see if he was on any other illicit drugs that could have contributed to the heart attack.

1. Should a psychiatric consult have been called in this case, and would it have altered the outcome for this patient?

Location: Ohio B.A., University of Virginia M.D., Georgetown University Residency, Emergency Medicine, University of Cincinnati Hospital Fellowship, Postdoctoral Fellow, Naval Research Laboratory Board Certification: Emergency Medicine Member, Society of Academic Emergency Medicine Member, American College of Emergency Physicians Member, Ohio State Medical Association Research, 10+ major grant funded research projects Former F****** C***** H******* Former A******** P******** E******** M******* U********* o* C********* Current A***** M****** S**** f** 3 m**** r******* h******* c****** Current A******** P******** D********* o* E******** M******* a* m**** m****** i********** Current A******* R******* I************ S***** C*********

This expert is a board certified emergency medicine physician who has remained in active practice for 12 years. He currently works in both an academic medical center, and in a community hospital, making him qualified to opine on the standard of care as it pertains to the practice of emergency medicine in the ER. Furthermore, he has also pursued several major research projects in his field, and holds an assistant professorship in emergency medicine at a major medical institution in Ohio.

Emergency Medicine Physician Neglects to Call Psychiatry Consult

This case involves a fifteen-year-old male patient who presented to the emergency room after being arrested by the police for displaying strange behavior in public. The patient was admitted to the inpatient psychiatric ward for observation and was started on a mood stabilizer for a diagnosis of Mania. The patient stayed in the hospital for two weeks and was discharged after his mood and affect appeared to be stable. The patient left the hospital with a lithium prescription and was told to follow-up with his primary care physician to set up psychiatric evaluations. The patient was found dead two days later in a hotel room next to an empty bottle of his psychotropic medication.

Caregivers should be vigilant about suicidal potential and should document their assessments in the medical record at each visit. Poor impulse control in patients with a personality disorder, particularly those with a cluster B disorder, places some degree of legal responsibility on the physician. If a patient threatens someone else with injury, the physician may have a duty to warn the intended victim, either directly or through legal authorities, under the Tarasoff ruling. Medications are in no way curative for any personality disorder. They should be viewed as an adjunct to psychotherapy so that the patient may productively engage in psychotherapy.

1. Should this patient have been admitted longer and directly handed off to a psychiatrist for further mental status evaluation?

Location: TN B.S., University of Florida M.D., University of South Florida College of Medicine Internship, Psychiatry, University of South Florida College of Medicine Residency, Psychiatry, University of South Florida College of Medicine Fellowship, Psychiatry, Neuropsychiatry, University of South Florida College of Medicine Board Certification: General Psychiatry, Forensic Psychiatry, Child and Adolescent Psychiatry Member, Child and Adolescent Committee, American Academy of Psychiatry and the Law Member, American Academy of Child & Adolescent Psychiatry Published, 20+ abstracts, book chapters, peer-reviewed publications Lectures, 40+ nationally invited lectures and presentations Former D******* V********* C**** a** A********* P********* O********* C***** Former A****** F****** N************** V********* U********* S***** o* M******* Current F****** a* f******* p********* p****** p******* Current I******** F****** C**** & A********* U*** a* m**** r******* p********** h******* Current A******** P******** a* m**** m****** s*****

This board certified and fellowship trained pediatric psychiatrist has remained in active practice for a decade, during which he has acquired a high ranking directorship of a pediatric psychiatry department, as well as academic faculty positions in clinical psychiatry at among the nation's top medical centers. He is also extensively published in his field. and has given nationwide invited lectures on the topic of child psychiatry.

Pediatric Psychiatrist Discharges Child; Results in Suicide

This psychopharmacology case involves a female patient in Rhode Island who suffered a psychotic episode and was diagnosed with schizophrenia. She was hospitalized and then prescribed several medications. Her symptoms were well controlled for several years. The patient was seen by a new psychiatrist for the first time with complaints of insomnia and agitation and the psychiatrist subsequently took her off Wellbutrin. However, three days later, the patient murdered her brother.

I have a great deal of experience with patients like this as I have been a psychiatrist for 28 years. I was the Clinical Director for a state hospital for 4 years, where I treated hundreds of patients with schizophrenia. I also have a great deal of experience with Wellbutrin. In fact, I was involved in a study back in the 90s, when Wellbutrin was temporarily taken off the market due to it causing seizures. I am sure I've prescribed Wellbutrin over 1000 times. As far as the standard of care, it depends as it is multifactorial. I am Triple Board Certified and am a fellow of The American Psychiatric Association, which is the highest rank in that organization.

1. Do you routinely treat patients such as the one described in this case? 2. Do you routinely prescribe Wellbutrin? Is it within the standard of care to take a patient of this medications without titrating down the dose?

Location: MS BS, University of Kansas MD, University of Kansas Medical Center Internship, Psychiatry, University of Kansas Medical Center Residency, Psychiatry, University of Kansas Medical Center Fellowship, Child and Adolescent Psychiatry, Johns Hopkins Hospital Board certified, Psychiatry and Neurology Board certified, Pain Management Board certified, Addiction Medicine Former A******** C**** & A********* P*********** F****** G****** H******* Former A******** P******** D********* o* P********* L*** L**** U******** Former C******* D******* S**** M********** S**** H******* Former M****** D******* A***** P********** & C********* Current M****** D******* a p****** p*******

Northeast

Rhode Island

This triple board certified psychiatrist earned his BS and MD at the University of Kansas, where he also completed his internship and residency training in psychiatry. He completed additional fellowship training in child and adolescent psychiatry at Johns Hopkins. Formerly, he was the clinical director of the South Mississippi State Hospital. Currently, he is the medical director and an attending physician at a private practice.

Psychiatry Expert Discusses Inappropriate Cessation of Wellbutrin in Schizophrenia Case

This case involves a mother in her twenties who was being treated for seven years by the same psychiatrist for paranoid schizophrenia and psychosis. The patient had been stabilized on an antipsychotic for 5 years with no episodes. The treating psychiatrist then left the state, leaving the patient’s care under a new provider. In the months after the new individual took over the care of the patient, he felt that the patient was exhibiting signs of anxiety and paranoia. Without consulting the previous psychiatrist or another psychiatrist, the provider discontinued the antipsychotic with no taper and started the patient on another antipsychotic. Within one week of the medication change, the patient caused serious injuries to her child during a psychotic episode. An expert forensic psychiatrist to review the records and opine on how the care provided by the nurse practitioner could have impacted the patient’s behavior.

I am board certified in psychiatry and forensic psychiatry and I have been practicing psychiatry since 1996 and forensic psychiatry since 2005. I am a professor of psychiatry and neurology and I teach medical students and psychiatry residents. I am also licensed to practice and currently work in a private practice in an east coast state. I am very familiar with the effects of discontinuing antipsychotic medications and relapse of psychosis as well as switching strategies for antipsychotics and tapering schedules. I have reviewed similar cases and treated 1000+ cases of schizophrenia and related disorders.

1. What is your experience reviewing cases involving patients with histories of paranoid schizophrenia and psychosis? 2. Are you familiar with the effects of discontinuing antipsychotic medication without tapering?

Schizophrenic Patient Suffers Psychotic Episode After Abrupt Change In Medication

This case involves a woman who fatally stabbed her husband while having a schizophrenic episode. The woman had been diagnosed with schizophrenia the year prior to the incident and prescribed antipsychotic medication. The woman had developed insomnia from the antipsychotic, and elected to stop taking the medication in the 2 months prior to the incident. The woman was subsequently treated at a state mental hospital and as a result of treatment, her episodes stopped. The woman was interested in moving to a half-way house designed to rehabilitate such individuals. An expert forensic psychologist was sought to review the medical records and evaluate the woman to determine whether or not she remained a danger to the public.

As a forensic psychologist at a state hospital for 14 years, I frequently evaluated patients for violence risk regarding potential conditional release into the community. I also supervised postdoctoral fellows in forensic psychology who conducted over 100 such evaluations. Conditional release generally requires that the person would not be a danger to others while under conditional release settings in the community. As such, one's mental illness would need to be under good control pharmacologically, the patient would need substantial insight into the nature of the mental illness and the need for continued treatment, and the patient should otherwise have few significant risk factors for violence. Evaluation generally would require a probing face-to-face interview, possible psychological testing, and review of the extensive records from the psychiatric hospitalization.

1. Please describe your background in forensic psychology. 2. What might qualify such an individual for release on conditions? 3. How would you evaluate such a patient?

Forensic Psychologist Evaluates Potentially Dangerous Patient

This case involves a 24-year-old female schizophrenic inmate who died at a state mental hospital after being tackled by an orderly. Prior to her incarceration, she had been successfully treated with Risperdal for 2 years. Although it was acknowledged that the inmate was mentally ill, this medication was not administered to her during her incarceration. The inmate’s condition worsened over the course of her time at the mental hospital to the point that she attacked a supervisor. The inmate was immediately tackled by the orderly, who weighed over 100 lbs more than her, and given two injections. The patient passed away several hours later. An autopsy revealed that patient had 5 broken ribs and a punctured lung. An expert correctional psychiatrist was sought to determine if the use of force, in this case, was excessive.

I am the medical director of a large city prison. Our total daily census is over 9,000 inmates and approximately 40% are receiving mental health services. My division manages the clinical care of patients with complex and severe mental health issues who require hospital-level care. I have previously served as the unit chief and associate clinical director of the forensic psychiatry division of a hospital and held clinical care responsibilities at a women's prison. All of the aforementioned clinical care settings involve the management of aggressive and/or violent patients. I have extensive direct experience in ensuring staff and patient safety when physical engagement must occur, utilizing verbal de-escalation techniques, administering and observation of intramuscular injections, and locked door seclusion or wrist/ankle restraint beds. I have served as an expert on numerous civil and criminal legal cases, some of which have included an opinion about questions raised with regard to possible failures in clinical care or malpractice.

1. Please briefly describe your work in the correctional setting. 2. What is your experience with violent or aggressive patients who have mental health issues?

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Schizophrenia Expert Witness Case Studies

Emergency Medicine Physician Neglects to Call Psychiatry Consult

Pediatric Psychiatrist Discharges Child; Results in Suicide

Psychiatry Expert Discusses Inappropriate Cessation of Wellbutrin in Schizophrenia Case

Schizophrenic Patient Suffers Psychotic Episode After Abrupt Change In Medication

Forensic Psychologist Evaluates Potentially Dangerous Patient

Correctional Officer Allegedly Uses Excessive Force On Mentally Ill Patient

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