What is the best course of action for a 40-year-old female patient with a history of schizophrenia, now bed-bound and dependent on a tracheostomy ventilator, experiencing distressing hallucinations and potential seizure activity, despite treatment with aripiprazole (aripiprazole) and a recent switch to aripiprazole depot (aripiprazole), in terms of optimizing her quality of life and managing her symptoms?

From the Guidelines

The patient's current quality of life, marked by distressing hallucinations and significant physical limitations, is unacceptable and warrants a comprehensive review of her treatment plan to prioritize her best interests and improve her morbidity, mortality, and quality of life. This case involves a 40-year-old female with pre-existing schizophrenia who developed intensive care neuropathy following COVID-19 infection, resulting in tracheostomy ventilator dependence and significant communication limitations. The patient's schizophrenia symptoms persist, with reported auditory hallucinations causing distress, crying episodes, and upper limb posturing with twitching of unclear etiology. Management has been challenging, with aripiprazole 30mg via PEG proving inadequate, as indicated by the American Psychiatric Association's practice guideline for the treatment of patients with schizophrenia 1.

The clinical team's decision to initiate aripiprazole depot 400mg every 4 weeks, with a one-week bridging dose of 20mg via PEG, is in line with recommendations for patients with schizophrenia whose symptoms have improved with an antipsychotic medication to continue treatment with an antipsychotic medication 1. Mood charting is being used to assess response, though it's too early to determine efficacy. Neurological referrals have been made to investigate the posturing/potential seizure activity, which is crucial given the potential for antipsychotic therapy to cause or exacerbate neurological symptoms such as dystonia, parkinsonism, and akathisia 1.

The case raises significant ethical concerns about the patient's quality of life, as she experiences distressing hallucinations while being physically limited and bed-bound. A multidisciplinary approach involving psychologists, neuropsychiatrists, the primary consultant, and family is planned once more information about her neurological symptoms is available. This approach is appropriate as it balances addressing her psychiatric and neurological symptoms while considering the broader ethical implications of her care, in line with the American Psychiatric Association's recommendation for a person-centered treatment plan that includes evidence-based nonpharmacological and pharmacological treatments for schizophrenia 1.

Key considerations in her treatment plan should include:

• Monitoring and adjusting her antipsychotic medication to achieve optimal symptom control while minimizing side effects, as recommended by the APA 1.
• Investigating and addressing the cause of her posturing and potential seizure activity to ensure her safety and comfort.
• Providing psychosocial interventions such as cognitive-behavioral therapy for psychosis (CBTp), psychoeducation, and supported employment services, which are recommended by the APA for patients with schizophrenia 1.
• Engaging in ongoing discussions with her family and healthcare team about her best interests, quality of life, and any potential adjustments to her care plan that may be necessary to prioritize her well-being.

Ultimately, the goal of her treatment plan should be to improve her quality of life, reduce her morbidity and mortality, and ensure that her care is aligned with her best interests, as guided by the most recent and highest quality evidence available 1.

From the FDA Drug Label

A syndrome of potentially irreversible, involuntary, dyskinetic movements may develop in patients treated with antipsychotic drugs Although the prevalence of the syndrome appears to be highest among the elderly, especially elderly women, it is impossible to rely upon prevalence estimates to predict, at the inception of antipsychotic treatment, which patients are likely to develop the syndrome. The risk of developing tardive dyskinesia and the likelihood that it will become irreversible are believed to increase as the duration of treatment and the total cumulative dose of antipsychotic drugs administered to the patient increase.

The patient's treatment with aripiprazole should be carefully considered due to the risk of tardive dyskinesia, especially given her long-term treatment and high cumulative dose. The fact that she has been on aripiprazole 30mg via PEG and is now being switched to aripiprazole depot 400mg every 4 weeks increases the risk of developing this syndrome.

• The patient's age and sex also put her at a higher risk for developing tardive dyskinesia.
• It is essential to monitor the patient for signs and symptoms of tardive dyskinesia and to reassess the need for continued treatment periodically.
• If signs and symptoms of tardive dyskinesia appear, drug discontinuation should be considered 2.

From the Research

Patient Overview

• The patient is a 40-year-old female who was admitted to the Intensive Care Unit (ITU) due to Covid-19 during the first wave of infection.
• She acquired an intensive care neuropathy and is now dependent on a tracheostomy ventilator.
• She is being cared for in a specialist nursing home.
• Prior to her injury, she was diagnosed with schizophrenia and was managed by multiple community mental health teams, with various inpatient stays due to hearing persecutory voices and having hallucinations.

Current Treatment and Symptoms

• The patient is currently on aripiprazole 30mg via Percutaneous Endoscopic Gastrostomy (PEG) and has been started on an aripiprazole depot of 400mg every 4 weeks 3, 4, 5.
• She is still experiencing distressing hallucinations and is often crying.
• She has limited communication but is able to indicate yes and no using a chart.
• She has periods of distress and crying, often combined with posturing of the upper limbs and twitching, which may be behavioral or seizure activity.

Concerns and Referrals

• There are concerns about the patient's quality of life, given her physical limitations and poorly managed schizophrenia symptoms.
• She has been referred to neurology to investigate the cause of her posturing and possible seizure activity, and to the epilepsy team for further evaluation 6.
• The patient's treatment and care will be discussed with the psychologists, neuropsychiatrist, consultant, and her family to determine the best course of action.

Medication Efficacy and Safety

• Aripiprazole has been shown to be effective in treating schizophrenia, with a favorable safety profile compared to other antipsychotic medications 3, 4, 5, 7.
• The medication has a low risk of extrapyramidal symptoms, metabolic changes, and weight gain, making it a suitable option for long-term treatment.
• However, the patient's response to aripiprazole will be closely monitored, and adjustments may be made as needed to ensure optimal treatment outcomes.