Mr. B is a 23-year-old male with a past medical history of schizophrenia and intellectual disability who presented to the emergency department via EMS after having a violent outburst at home. He broke the windows out of his house and tried to "arrest" his mother, stealing her car keys and breaking her arm. The patient was currently treated with intramuscular aripiprazole LAI 400 mg every 4 weeks and was 3 weeks post-last injection. His other home medication was divalproex delayed-release (DR) tablets 500 mg twice daily. His last inpatient psychiatric admission was a year before his presentation to the hospital. On arrival to the emergency department, he was afebrile, with HR 100, RR 15, BP 132/86, and labs were notable for a valproic acid level <10 and standard UDS positive for only THC. CMP, liver function tests (LFTs), CBC, and urinalysis (UA) were unremarkable.
The patient's mother reported that he had never been violent before, but that she had seen a change in his behavior over the previous several weeks, where he was talking and laughing to himself more, was preoccupied, and had been destroying things in his house. Patient B had been having difficulty sleeping and was self-medicating with Delta8-THC gummies for several months, which his mother reported buying him. On psychiatric exam, the patient was significantly withdrawn, disorganized, paranoid, and responding to auditory and visual hallucinations. The patient was also unkempt and malodorous, seemingly having difficulty with self-care.
The patient was admitted to inpatient psychiatry for acute care. On his first day of admission, he was maintained on his home dose of oral divalproex 500 mg twice daily and started on 6 mg of oral paliperidone daily. His aripiprazole LAI was not continued. He was still exhibiting disorganization, had visual hallucinations he was responding to, and continued to have poor hygiene. On day 3, his paliperidone was increased to 9 mg daily, and by day 6, the patient was more organized and able to hold a full conversation with the treatment team. He showed insight by recognizing that he could have hurt his mother and expressed remorse for his actions. On day 13, his paliperidone was increased to 12 mg daily, as the patient was remaining in his room and continued to have poor hygiene. By day 15, the patient was attending group therapy in the milieu and was bathing appropriately. He was given his first loading dose of intramuscular paliperidone LAI on day 16 of hospitalization, and his oral paliperidone was decreased by 3 mg daily until discontinuation. He was discharged on day 19 on a regimen of oral divalproex DR 500 mg twice daily and intramuscular paliperidone LAI 234 mg every 4 weeks (its metabolite is the same as risperidone and can be given every 4 weeks for improved adherence). On the day of discharge, he was no longer responding to internal stimuli, was not paranoid, and was performing his activities of daily living.
Patient B has continued to follow-up with his outpatient provider and has done well on this regimen in the 8 months following inpatient treatment. He has abstained from Delta8-THC use and has not had further psychiatric emergencies requiring hospitalization.