lesser the better

She was 26 years old. A mother of a three year old child. She was well dressed and well kempt. An old patient of ours brought her to our OPD ( out patient department ) for vague somatic complaints that she had been having for the past 2 years. She was not keen expressing her problems as well. I usually enquire regarding stressors even in a general OPD. To me young hesitant woman ususally means- domestic problems with husband or mother-in-law.

She lived in a nuclear family and her husband was very loving. As I probed into her more deeply, I realized that the patient was quite severly depressed and was also having suicidal ideation. I encouraged her attender to admit as soon as possible indicating high suicidal risk. She wanted to come the next day. A hospital admission is not that simple.

Patient’s families have to hand over their cows and hens to others to care for. They should arrange for someone to take care of their feilds. They also need to arrange for cash. Most payments are out of pocket in rural India. They need time to go and bring utensils, rice, dal and oil to cook nearby. Most importantly they should arrange for someone to stay as an attender.

She came the very next day for admission with her husband. I could see her in detail. She revealed that she had been hearing voices that others could not for the past two and a half years. She had also been suspecting few relatives of doing witchcraft against her. She was barely able to do her household work. She was managing well, due to her extremely suportive husband. Clearly her diagnosis was Paranoid Schizophrenia- continuous course.

I started her on antipsychotic Risperidone 2 mg. In the evening hours I spent time with her husband regarding her illness, its nature, course, treatment strategies, prognosis and outcomes. The voices in her ears came down within 3 days. I had planned to go up on the dose to 4 mg before discharge. I decided against it. Many a time we go up on the dose rapidly expecting results quickly. Thoogh many patients might respond at lower doses.

She bacame aware of her problem as an illness. She feels there is no reason to die if her voices go away. She has hope that treatment is helping her. Why go up on the dose? The patient is not going to run away anywhere. If she does not respond with 2 mg over 2 weeks then I would go up.

By increasing her dose to 4 mg would I not double her treatment cost? It she develops extra pyramidal side effects (tightness and rigidity), she would require medicines to control that. This would triple her cost. By being conservative in a relatively safe situation benefits are fewer medications, better compliance, lesser cost, lesser side effects and probably better effectiveness.