A 36-year-old man is brought to the hospital after being found wandering the streets barefoot and shouting to himself. Although he takes antipsychotic medication daily, his parents are having difficulty managing him at home. The patient believes he is fighting a conspiracy and that his thoughts are directly controlled by a device that was implanted in his brain during a prior hospitalization. Previous trials of haloperidol, quetiapine, and risperidone resulted in minimal improvement. He has no other medical problems. On mental status examination, the patient is alert, and restless with poor grooming, disheveled clothing, and flat affect. He refuses to answer most questions, accuses his parents of being part of the conspiracy, and mumbles nonsensical words. Which of the following medications would be most effective for this patient's illness?

Question

A 36-year-old man is brought to the hospital after being found wandering the streets barefoot and shouting to himself.  Although he takes antipsychotic medication daily, his parents are having difficulty managing him at home.  The patient believes he is fighting a conspiracy and that his thoughts are directly controlled by a device that was implanted in his brain during a prior hospitalization.  Previous trials of haloperidol, quetiapine, and risperidone resulted in minimal improvement.  He has no other medical problems.  On mental status examination, the patient is alert, and restless with poor grooming, disheveled clothing, and flat affect.  He refuses to answer most questions, accuses his parents of being part of the conspiracy, and mumbles nonsensical words.  Which of the following medications would be most effective for this patient's illness?

Quizplus · Accepted Answer

11ec160b_3643_b16a_9249_7b0ad89c24ab_MD0001_00 This patient likely has schizophrenia, a chronic mental illness characterized by delusions, hallucinations, disorganized speech and behavior, and negative symptoms. Antipsychotic medication is the treatment of choice. This patient is considered treatment-resistant as he has had a poor response to at least 2 antipsychotics and continues to experience multiple delusions and disorganized speech and behavior. The second-generation antipsychotic clozapine is the only medication that has consistently shown superior efficacy in treatment-resistant schizophrenia. Clozapine has an affinity for multiple dopamine and serotonin receptors, but the precise pharmacological mechanism responsible for its superior efficacy is unknown. Treatment with clozapine involves mandatory monitoring of the absolute neutrophil count due to the risk of neutropenia and life-threatening agranulocytosis. Although clozapine is associated with neutropenia, weight gain, and metabolic effects, the potential benefit of improving symptoms in treatment-resistant schizophrenia often outweighs these risks. (Choices A and G) Aripiprazole and ziprasidone are second-generation antipsychotics used in schizophrenia. However this patient has already failed 2 trials with second-generation antipsychotics (risperidone and quetiapine). Due to its superior efficacy in treatment-resistant schizophrenia, clozapine would be the preferred agent. (Choice B) Chlorpromazine is a low-potency, first-generation antipsychotic that is unlikely to be effective in treatment-resistant schizophrenia. (Choice C) Clonazepam is a benzodiazepine that can be used adjunctively to target agitation in individuals with psychosis, but it does not specifically treat psychotic symptoms. (Choice E) Haloperidol long-acting injectable would be a good strategy for a patient who is nonadherent and has a history of responding well to oral haloperidol. However, this patient is adherent and has responded poorly to haloperidol. (Choice F) Valproate is an anticonvulsant mood stabilizer used in the treatment of bipolar disorder. Educational objective: The antipsychotic clozapine is the drug of choice for treatment-resistant schizophrenia. Treatment requires monitoring of the absolute neutrophil count due to the risks of neutropenia and agranulocytosis. __________ References: Clozapine: balancing safety with superior antipsychotic efficacy. (http://www.ncbi.nlm.nih.gov/pubmed/23006238) Clozapine: a review of clinical practice guidelines and prescribing trends. (http://www.ncbi.nlm.nih.gov/pubmed/24708834)

A 36-Year-Old Man Is Brought to the Hospital After Being