What evaluations and investigations should be conducted for a patient with schizophrenia and substance use disorder (SUD) returning to hospital after going Absent Without Leave (AWOL)?

Evaluation and Management of Patients with Schizophrenia and Substance Use Disorder Returning After AWOL

When a patient with schizophrenia and substance use disorder returns to the hospital after going AWOL (Absent Without Leave), a comprehensive medical and psychiatric evaluation should be conducted immediately to assess for potential medical complications, substance use, and psychiatric decompensation.

Initial Medical Assessment

• Obtain vital signs, perform pulse oximetry, and conduct a focused physical examination to rule out medical emergencies and other possible etiologies (e.g., infections, metabolic disorders) 1
• Evaluate for signs of substance intoxication, withdrawal, or overdose, as substance use disorders commonly co-occur with schizophrenia and contribute to increased morbidity and mortality 1
• Assess for any physical trauma, including head injuries, that may have occurred while the patient was AWOL 1
• Review current medications and potential medication non-adherence during the AWOL period 1

Laboratory and Diagnostic Testing

• Perform urine toxicology screening to identify substances used during the AWOL period 1
• Consider selective laboratory testing based on clinical presentation rather than routine panels, as targeted testing guided by history and physical examination is more efficient and reduces false positives 1
• If the patient presents with new or changed psychiatric symptoms, consider additional testing to rule out medical causes 1
• For patients with concerning physical findings or abnormal vital signs, pursue more extensive evaluation including potential imaging studies 1

Psychiatric Evaluation

• Conduct a thorough psychiatric assessment including:

  • Current psychiatric symptoms and potential exacerbation of schizophrenia 1
  • Suicidal ideation, plans, or attempts during the AWOL period (patients with schizophrenia have a 4-10% risk of suicide) 1
  • Assessment of aggressive or violent thoughts or behaviors 1
  • Evaluation of substance use patterns, triggers, and consequences 2, 3
  • Review of medication adherence and attitudes toward treatment 1

• Use quantitative measures to identify and determine the severity of symptoms and impairments of functioning 1

Substance Use Assessment

• Evaluate the pattern, quantity, and types of substances used during the AWOL period 1, 3
• Assess for signs of substance withdrawal that may require medical management (particularly alcohol, benzodiazepines) 1
• Identify the impact of substance use on psychiatric symptoms, as substance use often exacerbates psychotic symptoms and reduces medication effectiveness 2, 4, 5
• Screen for injection drug use and associated risks (infections, blood-borne diseases) 1

Treatment Planning

• Update the patient's comprehensive treatment plan to address both schizophrenia and substance use disorder within an integrated framework 1, 4, 3

• Evaluate the need for medication adjustments or initiation of appropriate pharmacotherapy:

  • Ensure continuation of antipsychotic medication, as treatment interruption increases risk of relapse 1
  • Consider long-acting injectable antipsychotics for patients with adherence issues 1
  • For patients with alcohol use disorder, consider appropriate pharmacotherapy (e.g., naltrexone) 2

• Implement motivational and cognitive-behavioral interventions to address substance use, as these have shown effectiveness in dual-diagnosis patients 2, 3

Risk Assessment and Safety Planning

• Evaluate risk factors for future AWOL, substance use relapse, and treatment non-adherence 1
• Assess for housing stability, social support, and other psychosocial factors that may have contributed to the AWOL 1
• Screen for mental health, substance use disorders, and social care needs before planning discharge 1
• Ensure clinical stability for at least 24-48 hours before considering discharge 1

Common Pitfalls to Avoid

• Failing to integrate treatment for both schizophrenia and substance use disorder, as fragmented care leads to poorer outcomes 3
• Overlooking medical complications that may have occurred during the AWOL period 1
• Assuming all psychiatric symptoms are due to substance use without proper evaluation 1
• Neglecting to address medication non-adherence and its causes 1, 3
• Discharging patients prematurely before ensuring clinical stability and adequate follow-up plans 1