Missing the Forest for the Trees: Delayed Diagnosis and Management of Treatment Resistant Schizophrenia - PubMed
5 hours ago
- #electroconvulsive therapy
- #treatment-resistant schizophrenia
- #clozapine
- Case of a 36-year-old female with schizophrenia, coronary artery disease, and type 2 diabetes hospitalized for altered mental status and persistent psychosis.
- Initial evaluation revealed myocardial infarction, pulmonary embolism, and urinary tract infection; delirium resolved but psychotic symptoms persisted.
- Brain MRI showed diffuse cortical microhemorrhages; extensive workup for vasculitis, infection, and prothrombotic syndromes was negative.
- Patient remained symptomatic despite multiple antipsychotic trials (quetiapine, risperidone, ziprasidone), with a PANSS score of 156, indicating treatment-resistant schizophrenia (TRS).
- Started on clozapine, later augmented with electroconvulsive therapy (ECT); after 10 ECT sessions and clozapine at 300 mg daily, PANSS score improved to 60.
- Highlights diagnostic complexity in medically ill psychiatric patients and risk of delayed TRS diagnosis.
- Early use of standardized tools like PANSS in general medical settings can help differentiate psychiatric from medical causes and expedite treatment.
- Clozapine is first-line for TRS, but 45-70% may not respond to monotherapy; ECT augmentation was effective in this case, though evidence remains mixed.
- Need for further research into optimal TRS augmentation strategies.