A 37-year-old woman is brought to the hospital by the police after she was found wandering in the street. The patient is unable to provide a coherent history of recent events but mentions that she had a psychiatric hospitalization in her 20s. She has no medical history. Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 16/min. The patient is disheveled and malodorous, but physical examination is otherwise unremarkable. On mental status examination, she is alert and smiles pleasantly, but it is difficult to hold her attention. The patient gets up from her chair several times to stare at the air conditioning vent and put her ear against the wall as if listening for something. When asked about her behavior, she says, "Jingle jangle, doctor. Jingle jangle." A decision is made to admit her to the psychiatric unit. Which of the following medications is the most appropriate initial treatment for this patient?

Question

A 37-year-old woman is brought to the hospital by the police after she was found wandering in the street.  The patient is unable to provide a coherent history of recent events but mentions that she had a psychiatric hospitalization in her 20s.  She has no medical history.  Temperature is 36.7 C (98 F), blood pressure is 110/70 mm Hg, pulse is 88/min, and respirations are 16/min.  The patient is disheveled and malodorous, but physical examination is otherwise unremarkable.  On mental status examination, she is alert and smiles pleasantly, but it is difficult to hold her attention.  The patient gets up from her chair several times to stare at the air conditioning vent and put her ear against the wall as if listening for something.  When asked about her behavior, she says, "Jingle jangle, doctor.  Jingle jangle."  A decision is made to admit her to the psychiatric unit.  Which of the following medications is the most appropriate initial treatment for this patient?

Quizplus · Accepted Answer

11ec25c8_d7f9_7768_bc81_bbe31c1976c9_MD0003_00 This patient exhibits symptoms of acute psychosis (eg, grossly disorganized speech and behavior, probable hallucinations) that are most likely due to schizophrenia. Definitive diagnosis of schizophrenia requires ruling out other psychotic disorders, mood disorders with psychotic features, substance-induced psychosis, and psychosis secondary to a general medical condition. Because the patient is cooperative, initial treatment with an oral antipsychotic medication is appropriate. Medication selection depends on a patient's history of response as well as the medication side effect profile. Second-generation antipsychotics, such as aripiprazole, are often chosen due to their lower risk of extrapyramidal side effects and tardive dyskinesia compared with first-generation antipsychotics. With the exception of clozapine, there is no evidence that one antipsychotic is more effective than another. If further evaluation indicates a pattern of repeated medication nonadherence, switching to a long-acting injectable antipsychotic could be considered. However, this should be done only after the patient's ability to tolerate the oral formulation and therapeutic dosage is established, making long-acting injectable antipsychotics inappropriate choices as initial agents (Choices C and F). If this patient tolerates and responds well to oral aripiprazole then subsequently switching to a long-acting formulation of aripiprazole could be considered. (Choice B) Clozapine is a second-generation antipsychotic that is considered the gold standard for treatment-resistant schizophrenia. However, due to the risk of agranulocytosis, it is reserved for patients who have failed to respond to at least 2 antipsychotic trials. (Choice D) Lithium is a mood stabilizer used primarily in bipolar disorder. It requires gradual up-titration and is unlikely to facilitate rapid improvement in an acutely psychotic patient. Although manic episodes can present with psychotic features, there is no clear evidence of a distinct mood component to this patient's illness. (Choice E) Lorazepam is a benzodiazepine that can be used as an adjunct for agitation associated with psychosis. However, lorazepam alone is not sufficient to treat this patient's psychosis. Educational objective: Antipsychotic medications are the first-line treatment for psychosis. Long-acting injectables should be considered for nonadherence after tolerability and dosage parameters are established on oral medications. Clozapine should be considered for patients who have failed at least 2 antipsychotic trials. References: Assessing and treating the patient with acute psychotic disorders. (http://www.ncbi.nlm.nih.gov/pubmed/27229275) Management of patients presenting with acute psychotic episodes of schizophrenia. (http://www.ncbi.nlm.nih.gov/pubmed/19320529)

A 37-Year-Old Woman Is Brought to the Hospital by the Police