A 35-year-old man with schizophrenia is brought to the mental health clinic by his parents. They say that his prescription for risperidone ran out, and they are worried because he is not sleeping well, is hardly eating, and has not showered for the past several weeks. The patient reluctantly admits to hearing voices telling him to "do bad things." However, he becomes guarded and refuses to elaborate when asked to describe what the voices say or whether he has followed their directives. The patient has a history of 4 psychiatric hospitalizations and a suicide attempt a year ago. He lives with his elderly parents and is unemployed. On mental status examination, the patient is noted to be unkempt and malodorous. He is highly anxious, makes no eye contact, and paces around the room. At one point, he whispers something while staring out the window. The patient's speech is tangential and sometimes difficult to follow. When asked about suicidal or homicidal ideation, he shakes his head to indicate "no." Which of the following is the most appropriate next step in management of this patient?

Question

A 35-year-old man with schizophrenia is brought to the mental health clinic by his parents.  They say that his prescription for risperidone ran out, and they are worried because he is not sleeping well, is hardly eating, and has not showered for the past several weeks.  The patient reluctantly admits to hearing voices telling him to "do bad things."  However, he becomes guarded and refuses to elaborate when asked to describe what the voices say or whether he has followed their directives.  The patient has a history of 4 psychiatric hospitalizations and a suicide attempt a year ago.  He lives with his elderly parents and is unemployed.  On mental status examination, the patient is noted to be unkempt and malodorous.  He is highly anxious, makes no eye contact, and paces around the room.  At one point, he whispers something while staring out the window.  The patient's speech is tangential and sometimes difficult to follow.  When asked about suicidal or homicidal ideation, he shakes his head to indicate "no."  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Although psychiatric treatment should take place in the least restrictive setting, safety considerations are paramount and require careful clinical judgment. This acutely psychotic patient is experiencing command auditory hallucinations. His refusal to describe the voices apart from saying that they are telling him to "do bad things" is concerning. The patient's history of multiple inpatient admissions suggests that he has a severe course of illness, and his recent history of a suicide attempt is a risk factor for repeated suicidal behavior. He is not eating well or showering, which indicates an inability to care for himself. This patient appears to be decompensating, making hospitalization the necessary course of action for safety reasons. Efforts should be made to hospitalize the patient voluntarily, but involuntary commitment should be implemented if he refuses. The legal standards specifying the criteria for civil commitment vary by state, but they generally require the presence of a mental illness, danger to self or others, and/or grave disability (inability to care for self) due to mental illness, as in this patient. (Choices A and D) The patient should be restarted on risperidone as soon as possible, but it would be unsafe to treat him as an outpatient given his current symptoms. Antipsychotics do not work immediately, and there is no way to know if he will take his medication or if his command hallucinations will resolve within the next 24 hours. Clozapine can be considered in the management of treatment-resistant schizophrenia and is a future option for this patient should his psychosis not be responsive to risperidone or another antipsychotic. (Choice C) A urine drug screen (UDS) would be helpful in determining if substances are playing a role in the patient's decompensation. However, the patient has a long history of psychotic illness and requires hospitalization, whether the UDS is positive or negative. In addition, obtaining a urine sample, especially from someone who is agitated or confused, may take time and should not delay hospitalization. (Choice E) Although converting the patient to a long-acting injectable (depot) antipsychotic would be a reasonable strategy to enhance adherence, it is not an appropriate initial intervention. Conversion to a long-acting injectable formulation could be considered once the patient is stabilized on oral antipsychotics in the hospital. Educational objective: Indications for psychiatric hospitalization include being a danger to self or others and/or grave disability. Hospitalization may be implemented on an involuntary basis if necessary. References: Command hallucinations and clinical characteristics of suicidality in patients with psychotic spectrum disorders. (http://www.ncbi.nlm.nih.gov/pubmed/23375263) Involuntary admission and treatment of patients with mental disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25595369)

A 35-Year-Old Man with Schizophrenia Is Brought to the Mental