How I Treat: Schizophrenia With Dr Meyer Case Presentation

Sharon is a 21 year old woman of mixed African American and Mexican heritage hospitalized for the first time 2 weeks ago for schizophrenia. She was a senior in college with no prior mental health history and did not use substance or abuse alcohol, but experienced declining grades in the prior semester. In the past month overt positive symptoms were noted by her roommate (paranoid delusions, auditory hallucinations) resulting in the inpatient psychiatric stay. Sharon was given a diagnosis of schizophrenia and started initially on aripiprazole which was titrated to 20 mg QHS with limited benefit. Eventually this was stopped, Sharon responded well to risperidone 4 mg QHS and was discharged into the care of her parents who accompanied her to the first outpatient appointment. At that time the patient and her family expressed concerns about the diagnosis and also about potential adverse effects (especially metabolic issues).

Sharon's parents agreed that risperidone had been helpful, and Sharon denied side effects to date but questioned how long she would need to take medication and seemed displeased when it was suggested this might be indefinite. Sharon and her family were informed that 50% of patients with chronic illnesses such as hypertension or schizophrenia have trouble with oral medication adherence and were offered a long-acting injectable (LAI) option, noting fewer rehospitalizations in first episode schizophrenia patients on an LAI. Sharon demurred on the LAI antipsychotic for now but agreed to have periodic antipsychotic levels drawn to help monitor adherence. A 12h trough level was drawn the next morning. The lab result came back one week later with a risperidone level of 4.66 ng/ml and a 9-OH risperidone level of 23.34 ng/ml, yielding a total active moiety level of 28 ng/ml, consistent with that expected on risperidone 4 mg QHS.

Sharon was responsible for taking her medications and other aspects of treatment. She obtained monthly refills on time, came to her monthly appointments and denied issues with adherence or adverse effects, though an 8 lb. weight gain was documented; however, 4 months after the initial visit and 3 weeks after her latest visit Sharon's parents called with concern that Sharon had stopped taking the risperidone and was talking to herself and 'staring into the corners of the room,' but not agitated or hostile. An urgent telepsychiatry appointment was arranged at 8 am the next morning during which Sharon appeared bothered by auditory hallucinations, but was not suicidal. She denied that she some missed doses but agreed to go to the lab before 9 am for a risperidone level. As the risperidone level would not be back for a week, Sharon agreed to allow her parents to monitor her taking the risperidone dose each night, with a follow-up appointment scheduled 10 days later. The lab report noted an undetectable risperidone level, and a 9-OH risperidone level of 11.2 ng/ml.

At the time of the next appointment, Sharon was seen with her mother. Sharon appeared back to her baseline, and the results of the risperidone level were discussed. In nonjudgmental language it was again mentioned that many people struggle with oral medication adherence, and Sharon admitted that she wasn't happy with the weight gain, but that she was really embarrassed to report that her menstrual periods had ceased which 'freaked me out,' and this caused her to start missing doses in hopes that this would 'fix the problem.' Sharon also commented that she still isn't sure she really needs to take psychiatric medications 'forever.'