NUR 7632 Module 5 Schizophrenia Relapse Case: Choosing an Antipsychotic, CATIE and Staying on Treatment Example

He Stopped Because of the Weight: Choosing an Antipsychotic a 31-Year-Old With Schizophrenia Will Keep Taking

Student Name

M.S. in Nursing, Psychiatric Mental Health Nurse Practitioner, Thomas Edison State University

NUR-7632: Advanced Assessment, Differential Diagnosis, and Management of Psychiatric Disorders: Adult Population, Part A

Mentor Name

Month Day, Year

He Stopped Because of the Weight: Choosing an Antipsychotic a 31-Year-Old With Schizophrenia Will Keep Taking

The Third Admission

Marcus, an invented patient, is 31 and lives with his mother in Trenton. He was first diagnosed with schizophrenia at 22 after a year of withdrawing from friends and hearing voices. He has been admitted twice before. For the past three years olanzapine kept him out of the hospital, and he worked part-time stocking shelves at a grocery store. Over those years he gained 40 pounds, developed prediabetes and was teased at work about his size. Four months ago he stopped the medicine on his own.

Two months later the voices returned. He stopped eating his mother's cooking, accusing the neighbors of putting chemicals in it, covered the windows with foil and lost his job. His mother called the crisis team when he had not slept for three days. In the emergency department he is guarded and frightened but not aggressive, his urine drug screen shows cannabis, and his blood sugar is 128 after fasting overnight. He says he has no wish to hurt himself or anyone else.

His mother, Gloria, is 63 and works as a school cafeteria manager. She has been his main support through each episode and keeps a notebook of the changes she sees before he becomes unwell. She is tired and frightened this time, and she asks whether he will ever be able to live on his own. Marcus, for his part, says he would rather hear the voices than be "the big guy" at work again, a statement the team records in his own words because it explains his choice.

The Diagnosis and the Relapse

The history of psychotic symptoms over nine years, with periods of recovery on treatment and a return of the same voices and fixed false beliefs after stopping medicine, fits a relapse of schizophrenia rather than a new illness. The cannabis is weighed carefully: he says he began smoking daily after the voices returned, to calm himself, and his mother confirms that the voices came first. A medical workup, including thyroid tests and a review for head injury, is unrevealing. The paper treats the relapse as an expected result of stopping an effective drug, not as a failure on his part.

Comparing the Antipsychotics

Huhn et al. (2019) combined 402 randomized trials with more than 53,000 adults with acute schizophrenia to compare 32 oral antipsychotics against placebo and against each other. All the drugs reduced overall symptoms more than placebo, though the size of the effect varied. Clozapine had the largest effect, followed by amisulpride, zotepine, olanzapine and risperidone. The drugs differed far more in their side effects than in their benefits, and weight gain was greatest with zotepine, olanzapine and sertindole, while several drugs, such as aripiprazole, lurasidone and ziprasidone, caused little weight gain.

The CATIE trial explains why those differences matter in practice. Lieberman et al. (2005) randomly assigned 1,493 people with chronic schizophrenia at 57 U.S. sites to olanzapine, perphenazine, quetiapine, risperidone or ziprasidone for up to 18 months. Most stopped their assigned drug for one reason or another, 74 percent overall. Olanzapine was stopped least often, at 64 percent, and kept people in treatment longest, but it brought more weight gain and rises in blood sugar and lipids.

Aripiprazole is chosen with Marcus. He has responded to medicine before, so clozapine is not yet needed, and his main condition for taking anything again is that it not add weight. Aripiprazole is started on the unit and raised over several days. Restlessness is watched for, since it can be mistaken for worsening psychosis.

Why Staying on Treatment Matters

Leucht et al. (2012) pooled 65 trials with 6,493 people with schizophrenia who were stable on an antipsychotic and then either continued it or were switched to placebo. Inside twelve months, relapse struck 27 percent of people kept on their antipsychotic against 64 percent switched to dummy pills, and readmissions fell from 26 percent to 10 percent. Those on medicine had more weight gain, movement problems and sedation. The authors found the benefit held across many patient groups.

For Marcus, these figures are shared plainly, as a reason to find a medicine he can keep taking. Because adherence has been the problem, a long-acting injectable form of aripiprazole is offered once he has tolerated the oral drug, which would spare him a daily reminder. He chooses to try the oral form first and to discuss the injection at his first clinic visit.

The conversation about the injection is handled with care. Long-acting forms can feel like control to people who have been hospitalized against their will, and Marcus has been twice before. He is told that the decision is his, that the dose can be adjusted and that the main benefit is steadier blood levels without a daily reminder. The paper records that he wants to talk it over with his mother first.

Monitoring the Body

His weight goes on the chart at every visit, and his waistline, blood pressure, fasting sugar and cholesterol are drawn at the start, around week twelve and each year after. His prediabetes is referred to his primary care clinician, and metformin is discussed if his glucose rises. Movement problems are checked with a structured scale at baseline and every six months. A dietitian visit is arranged, and his mother, who cooks for him, attends with his consent.

Recovery Beyond the Hospital

Discharge planning looks at his cannabis use, with motivational interviewing to explore how it affects the voices, and at his job, with a referral to supported employment that helps people with serious mental illness find and keep work. His mother is offered a family education group. A crisis plan names the early signs he and his mother have seen before relapse, such as covering windows and refusing food, and what each of them will do.

Conclusion

Marcus relapsed after stopping olanzapine because of weight gain, a reason the plan treats as valid. The 32-drug comparison shows that these medicines vary more in their burdens than in their benefits, CATIE shows that most people stop drugs they cannot tolerate, and the relapse trials show why staying on treatment matters. Aripiprazole, chosen for its lower metabolic burden, with an injectable form offered, regular metabolic and movement checks, cannabis counseling and supported employment form a plan he has a reason to continue.

References

Huhn, M., Nikolakopoulou, A., Schneider-Thoma, J., Krause, M., Samara, M., Peter, N., Arndt, T., Bäckers, L., Rothe, P., Cipriani, A., Davis, J., Salanti, G., & Leucht, S. (2019). Comparative efficacy and tolerability of 32 oral antipsychotics for the acute treatment of adults with multi-episode schizophrenia: A systematic review and network meta-analysis. The Lancet, 394(10202), 939-951. https://doi.org/10.1016/S0140-6736(19)31135-3

Leucht, S., Tardy, M., Komossa, K., Heres, S., Kissling, W., Salanti, G., & Davis, J. M. (2012). Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: A systematic review and meta-analysis. The Lancet, 379(9831), 2063-2071. https://doi.org/10.1016/S0140-6736(12)60239-6

Lieberman, J. A., Stroup, T. S., McEvoy, J. P., Swartz, M. S., Rosenheck, R. A., Perkins, D. O., Keefe, R. S. E., Davis, S. M., Davis, C. E., Lebowitz, B. D., Severe, J., & Hsiao, J. K. (2005). Effectiveness of antipsychotic drugs in patients with chronic schizophrenia. New England Journal of Medicine, 353(12), 1209-1223. https://doi.org/10.1056/NEJMoa051688