Mr. A, a 21-year-old male with no prior psychiatric history, was brought to the emergency room by police after being found wandering outside talking to himself. On arrival, the patient was afebrile at 98.1 F, with a heart rate (HR) of 64, respiratory rate (RR) of 18, and blood pressure (BP) of 136/96. The patient's complete blood count (CBC) and complete metabolic panel (CMP) were unremarkable, and a urine drug screen (UDS) was not obtained due to the patient being uncooperative with sample collection. Computed tomography (CT) of the head was negative for acute intracranial findings. On psychiatric evaluation, the patient was noted to have psychosis, as evidenced by responding to internal stimuli, laughing inappropriately, disorganization of thought process, reports of significant paranoia, hearing voices, and visual hallucinations. His behavior displayed disorganization with psychomotor agitation and suspiciousness of medical providers. Patient A endorsed vaping Delta8-THC but denied all other drug use. The patient was admitted to inpatient psychiatry.
The family reported that there was no family history of psychiatric illness. They also reported that patient A had a decline in behavior over the 8 months preceding his hospitalization but had no formal psychiatric diagnosis or psychological disturbance before this time. He displayed aggressive, violent outbursts and once got into a physical altercation with the family's landlord, causing them to be evicted from their home. Due to the patient's unpredictable behavior, the family feared him and had not recently allowed him to live in their home.
On day 1 of admission, the patient was started on oral risperidone 0.5 mg twice daily to address continued signs of psychosis. The patient exhibited disorganization, illogical thought process, and auditory and visual hallucinations. On day 3, his risperidone was increased to 1 mg twice daily and switched to 2 mg nightly on day 5. On the 10th day of admission, the patient still had poor insight into his hospital presentation. He continued to appear confused and disorganized during the interview, with difficulties in attention and concentration, as well as signs of paranoia. His risperidone was increased to 3 mg nightly; however, the above symptoms persisted. On day 20, his risperidone was increased to 4 mg nightly. On day 22, it was suspected that the patient was cheeking his medication, and was switched to risperidone orally disintegrating tablet 4 mg. By day 28, the patient was no longer endorsing visual or auditory hallucinations, was no longer paranoid, and was participating in group therapy.
During the hospitalization, the treatment team learned that the patient started using Delta8-THC around the same time that the family reported a decline in his behavior. This is also when the patient endorsed auditory hallucinations; however, the patient was unable to give a clear history of whether he started Delta8-THC to try and prevent the voices or if the voices occurred after the Delta8-THC use. He was started on an intramuscular paliperidone long-acting injectable (LAI) on the 28th day of admission and an oral risperidone taper was begun.
Patient A was discharged on the 32nd day after admission on a regimen of intramuscular paliperidone LAI 156 mg every 4 weeks (its metabolite is the same as risperidone and can be given every 4 weeks for improved adherence). He was back to his baseline functioning at discharge and was no longer endorsing signs or symptoms of psychosis and had an organized thought process without emotional lability. He was encouraged to abstain from any cannabis products.
Patient A, unfortunately, did not follow-up for his scheduled outpatient appointment after discharge; however, he has not presented to our hospital's ER in the 7 months following discharge.