A 26-year-old woman is brought to the hospital by her family due to increasingly bizarre behavior. The patient abruptly quit her sales job 8 months ago because she believed that her coworkers and boss were poisoning her coffee and trying to kill her. Shortly thereafter, she stopped going outside the house because she was convinced that black cars were following her. The patient has been hearing multiple voices over the past month and says, "Mostly they mumble and I can't make out what they're saying, but sometimes they tell me I'm stupid and should kill myself." A comprehensive medical evaluation, including drug screen testing, is unrevealing. She is admitted, and aripiprazole is initiated with improvement in her condition. The patient is discharged 1 week later. At her 1-month follow-up, she is no longer hearing voices, is much less paranoid, and is able to go outside the house; however, she still has periods of anxiety and has been reluctant to look for work. She continues to take the medication as prescribed. Which of the following is the most appropriate treatment recommendation for this patient?
Schizophrenia | |
Diagnosis |
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Treatment |
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This patient's history of paranoid delusions, auditory hallucinations, significant functional decline, and continuous impairment for ≥6 months is consistent with schizophrenia. Although her psychotic symptoms are much improved at her 1-month follow-up, evidenced-based guidelines consistently recommend that antipsychotic medication be continued indefinitely to reduce the risk of relapse.
This recommendation applies to all patients with schizophrenia, including those experiencing a first psychotic episode, as in this case. In addition, many patients who show initial rapid improvement with antipsychotic medication experience further symptomatic and functional improvement on maintenance medication over the course of many months.
Patients with schizophrenia who discontinue medication have significantly higher rates of relapse, which often leads to rehospitalization and an overall poor outcome (Choices B and E). Cognitive-behavioral therapy is an effective adjunct treatment intervention for schizophrenia but should be used in combination with maintenance pharmacotherapy (Choice D).
(Choice A) Patients with schizophrenia frequently have anxiety, especially during and immediately following an acute psychotic episode. Psychosocial approaches (eg, reassurance, psychoeducation, social skills training, family therapy, cognitive-behavioral therapy) are preferred initial interventions due to the risk of abuse and dependence associated with benzodiazepines.
Educational objective:
Antipsychotic medication should be maintained indefinitely in patients with schizophrenia, including those with a first episode of psychosis.