A 23-year-old man with schizophrenia is hospitalized in a psychiatric facility after barricading himself in his apartment for "self-defense." The patient hears voices warning about "secret government agents" who are hunting him. He is certain that a neighbor has been spying on him and listening through the wall on behalf of the government. The patient's sister reports that he had his first psychotic episode at age 19 and responded well to olanzapine. At age 21, he stopped taking olanzapine due to weight gain and was hospitalized with a psychotic relapse; he was prescribed risperidone while hospitalized. The patient has been hospitalized 3 more times in the past 2 years. Although he improves rapidly when hospitalized and taking risperidone and is then able to live independently, he typically relapses several months after discharge. On mental status examination, the patient makes poor eye contact and has a flat affect. He says, "I don't have a mental illness. Can't you see the conspiracy is real?" Which of the following is the most appropriate management for this patient?

Question

A 23-year-old man with schizophrenia is hospitalized in a psychiatric facility after barricading himself in his apartment for "self-defense."  The patient hears voices warning about "secret government agents" who are hunting him.  He is certain that a neighbor has been spying on him and listening through the wall on behalf of the government.  The patient's sister reports that he had his first psychotic episode at age 19 and responded well to olanzapine.  At age 21, he stopped taking olanzapine due to weight gain and was hospitalized with a psychotic relapse; he was prescribed risperidone while hospitalized.  The patient has been hospitalized 3 more times in the past 2 years.  Although he improves rapidly when hospitalized and taking risperidone and is then able to live independently, he typically relapses several months after discharge.  On mental status examination, the patient makes poor eye contact and has a flat affect.  He says, "I don't have a mental illness.  Can't you see the conspiracy is real?"  Which of the following is the most appropriate management for this patient?

Quizplus · Accepted Answer

This patient's psychotic symptoms rapidly improve with risperidone treatment in the hospital. However, he does not believe he has an illness, and his history of relapsing several months following discharge is suggestive of medication nonadherence. Switching to a long-acting injectable (LAI) (depot) antipsychotic is an effective strategy for breaking the cycle of repetitive hospitalization. LAI antipsychotics are administered intramuscularly every few weeks to months, eliminating the need for daily oral medication. Both first-generation (haloperidol, fluphenazine) and second-generation (risperidone, paliperidone, olanzapine, aripiprazole) antipsychotics are available in LAI formulations. Patients with unstable illness who live alone and have poor social support systems, poor insight, and frequent medication nonadherence are good candidates for LAI antipsychotics. These medications can be administered on an outpatient basis with the support of assertive community treatment programs (eg, a clinician can administer the drug in the patient's home or facilitate adherence to scheduled medication appointments). (Choices A, C, and E) This patient has a history of responding well to risperidone but relapses due to nonadherence. Augmenting risperidone with an antidepressant (eg, sertraline), switching to an alternate antipsychotic such as aripiprazole, or increasing the dosage is not indicated and would be unlikely to improve adherence. (Choice B) Social skills training and family therapy are established psychosocial interventions for schizophrenia. However, introducing such measures is not feasible until the patient's psychotic symptoms are stabilized and the cycle of frequent relapses and hospitalizations is interrupted. (Choice D) Clozapine is a second-generation antipsychotic with demonstrated superior efficacy in treatment-resistant schizophrenia. It requires routine monitoring of complete blood count due to the risk of agranulocytosis. This patient has a history of responding to first-line antipsychotic medications; therefore, he is not a candidate for clozapine. Educational objective: Antipsychotic medication nonadherence is a common cause of relapse and rehospitalization in patients with schizophrenia. Long-acting injectable antipsychotics are useful for patients who have responded to oral antipsychotics but relapse frequently due to medication nonadherence. References: The use of long-acting injectable antipsychotics in schizophrenia. (http://www.ncbi.nlm.nih.gov/pubmed/28580230) Medication adherence and discontinuation of long-acting injectable versus oral antipsychotics in patients with schizophrenia or bipolar disorder. (http://www.ncbi.nlm.nih.gov/pubmed/28895758)

A 23-Year-Old Man with Schizophrenia Is Hospitalized in a Psychiatric