A 25-year-old man is brought to the hospital for admission by his mother. She says, "I feel badly but I couldn't manage him at home anymore. He locks himself in his bedroom and refuses to shower. Yesterday, he started screaming as if he were arguing with someone but no one was there." The patient is very guarded and makes no eye contact. He says, "The world is coming to an end and I am waiting to receive a message through the Internet indicating the exact date." He also claims that family members want to kill him because they believe the world could be saved if he were dead. The patient describes his mood as "anxious and fearful" and does not feel depressed. He has no suicidal or homicidal ideation. The patient was first hospitalized at age 19 and treated with risperidone and clonazepam. In the past 2 years, he was hospitalized 3 times for acute psychosis and treated with olanzapine. In each case he improved while in the hospital but then stopped taking the medication shortly after discharge. The patient has a history of childhood asthma and alcohol abuse. He has no known drug allergies. His sister and father have a history of anxiety disorder. Physical examination shows no abnormalities. The patient is 175 cm (5 ft 9 in) tall and weighs 120 kg (265 lb). His BMI is 39 kg/m². Urine toxicology screen is negative. His mother worries that his illness is getting worse and asks if anything else can be done. Which of the following is the most appropriate response to the mother's concerns?

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Explanation: This patient responds well to medication when hospitalized, but his history of nonadherence after discharge has resulted in frequent relapses and multiple hospital admissions. Although many antipsychotics would be effective in treating his symptoms acutely, a long-acting injectable formulation is an ideal strategy for long-term maintenance treatment. Long-acting injectable (LAI) antipsychotics eliminate the need to take oral medication daily and are administered intramuscularly every 2-4 weeks. A missed appointment for LAI antipsychotic administration can be used to identify nonadherence early on. LAI antipsychotics are an effective strategy for nonadherent patients with unstable illness and may help this patient break the cycle of repeated hospitalizations. Both first-generation antipsychotics (haloperidol and fluphenazine) and several second-generation antipsychotics are available in long-acting injectable formulations. They have comparable efficacy, and medication selection is based on patient response and tolerability to oral formulations. (Choice A) Adding clonazepam might address his anxiety acutely but would not be an optimal long-term strategy given his history of alcohol abuse. In addition, this strategy does not address the key issue of the patient's medication nonadherence. (Choice C) This patient has characteristic symptoms of schizophrenia, a typical age of onset, history of responding well to antipsychotics, noncontributory medical history, and a normal physical examination. Further diagnostic evaluation and testing are unlikely to be helpful. (Choice D) Clozapine is a second-generation antipsychotic with superior efficacy in schizophrenia, but it is reserved for treatment-resistant patients due to the risk of agranulocytosis. This patient has a history of responding well to antipsychotics and is therefore not a candidate for clozapine. (Choice E) Although this patient has a history of responding to olanzapine, he would likely be nonadherent with the oral form of this antipsychotic following discharge. In addition, the high risk of weight gain and metabolic side effects with olanzapine would be problematic in this overweight patient. Educational objective: Nonadherence with antipsychotic medication is a common cause of relapse and rehospitalization in patients with schizophrenia. Long-acting injectable antipsychotics are useful in patients who have responded well to oral antipsychotics but are chronically nonadherent. References: Antipsychotic adherence and rehospitalization in schizophrenia patients receiving oral versus long-acting injectable antipsychotics following hospital discharge. (http://www.ncbi.nlm.nih.gov/pubmed/26308223) Long-acting injectable versus oral antipsychotics in schizophrenia: a systematic review and meta-analysis of mirror-image studies. (http://www.ncbi.nlm.nih.gov/pubmed/24229745)

A 25-Year-Old Man Is Brought to the Hospital for Admission