Dr Ballon Discusses Treatment of 27-Year-Old Patient With Schizophrenia

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Darius' case is a bit challenging. There's a lot of possible ways you could take this case. I wrote this case with a couple of ideas in mind, buy A, B, C, or D, with the right amount of thought, all could potentially be the right answer.

When I put this case together, I was thinking that I probably wouldn't maintain his current medication and change the dose. Yes, there is some room to go up but, at the end of the day, I'm feeling like this is a case where he's getting an adequate amount of medication. But, I'm not really sure that he's been taking it. I'm not sure, really, that this is the right medicine for him.

With that, I moved to B, C, or D. All of these are involving changing the medication, which is, frankly, what we're doing a lot of the time when a person comes into the hospital.

Yes, if a person is not taking their medication, it might mean that the medication is not working for them or that there's something about that medicine that's not appropriate, that's not working in a way that they're willing to take it.

Certainly, it means that the idea of using a long-acting injectable, as in choice B, is certainly going to be on the table. To some extent, I think that's where I would probably be leaning in this case because he was missing several doses per month.

It may have been because of difficulty with organization. It could be for any of a number of reasons. We all miss medications at some point. It's a part of the normal human condition to be somewhat forgetful, especially medicine that maybe you're not super enthused about taking or had some side effects, or is just hard to remember every day.

With that, I feel that a long-acting injectable makes a lot of sense. Now, the long-acting injectable does not guarantee that a person is going to be inherent for treatment. They still have to show up. They still have to buy in to treatment enough that they're going to come into the clinic and get what is an injection.

Ultimately, there's a certain amount of pain involved in that every month, or every two months, or every three months, depending on which formulation they're getting. It does take away that day-to-day decision-making.

Often, I find that a lot of patients are happier taking that LAI medicine because, in fact, it means that everybody that's around them knows they're taking that medicine. If they have an off day or a bad day, no one's going to come at them saying, "Did you take your medicine?" and wag a finger.

Especially for folks in this younger adult range, either in their early teens and 20s, but in this case, the mid-to-late 20s, early 30s, they have a number of people in their life who might be interested or concerned about them. It's just nice to be able to say, "Yes, I've taken my medicine. I'm following up. I'm doing the things that I need to be doing to achieve my goals."

That being said, it's not necessarily a slam-dunk that an LAI is the right option. Of course, with any of these options, it's important to check in with what is that patient, what is Darius willing to do. What does Darius think might be helpful? What is the medicine or treatment that's going to best align with Darius' goals?

Darius might say, "I was not taking my previous medicine because I gained so much weight, gained 50 pounds recently. That's just not going to work for me." Now, one option, of course, is to switch to an aripiprazole-based long-acting injectable that has a lower risk for weight gain. That might be a possibility.

In fact, maybe what Darius would rather do is try one of the newer agents on the market that tend to have a little bit less risk for weight gain, whether it's cariprazine, or any of the other newer, lower-risk agents. Metabolic side effects may be the most important thing to Darius and that might be the key that keeps him taking his medication.

Then, the other possibility -- and this one is not as favorable metabolically -- but given that Darius has had several hospitalizations recently, he's tried a few different medicines, clozapine is a very reasonable choice here.

I think with clozapine, you're going to want to make sure that his difficulty in taking his medication on a daily basis can be figured out because you don't want people who are going to be missing doses, especially more than a couple of doses where you, then, have to re-titrate. Even if it's a rapid re-titration, you have to be careful and follow up.

I would want to make sure that I'm really working with the folks who are helping Darius out to get a sense of, how can we best support Darius to take his medicine on a daily basis?

Does it mean a case manager or a family member putting pills in a box? Does it mean somebody checking in on him a little bit more frequently? We wouldn't want him to go days without taking clozapine and then, initially, go right back to the dose he was on. That could be problematic.

All of these are possibilities. I would encourage you to think about it. If you're treating somebody like Darius, there's going to be individual circumstances that are going to be beyond the scope of what I could put into a brief case synopsis that are going to help lead you in one direction or another.

For me, when I'm thinking about Darius and probably the things that I didn't even put into the case but that are informing my thoughts, I'm leaning towards choice B for an LAI at this point for him. He hasn't tried that yet. I think we can do it in a way that's metabolically relatively friendly for him.

That's where I would probably head but I can certainly see an argument can be made for B, C, or D, in particular, and even, potentially, with A as long as we're making sure that we're supporting Darius in taking his medication on a daily basis and not missing too many doses. Thank you very much.