A 29-year-old Algerian woman with a history of schizophrenia was referred to our Mental Health Center (MHC) by her primary care physician because of severe behavioral alterations and positive psychotic symptoms consisting of delusions and verbal hallucinations.
She was diagnosed with schizophrenia at age 19 in her home country due to auditory hallucinations, incoherent speech, and bizarre behavior. Haloperidol was prescribed and self-discontinued after several months of poor compliance due to non-specific adverse effects reported by the patient. No further treatments were attempted at that time. Notably, she was never admitted to a psychiatric inpatient unit. Family psychiatric history includes schizophrenia in her father. No personal or family history of substance or alcohol use was reported.
Shortly after arriving in Spain, the patient developed referential and persecutory delusions, secluding herself at home and partly destroying the furniture for fear of being watched or controlled. Subsequently, she required forced inpatient psychiatric hospitalization, and pharmacological therapy with risperidone was introduced. Due to the early appearance of EPS (muscle stiffness and distal tremor) associated with risperidone, she was switched to olanzapine up to 30mg daily with persistent symptoms of hallucinations, disorganized speech and behavior, apathy, and anhedonia, although no EPS were reported. Owing to the lack of response to olanzapine after a 14-day trial, clozapine was initiated, and the dose was uptitrated to 400 milligrams daily, achieving adequate control of her psychiatric symptoms, although she complained of drowsiness and sialorrhea. Given the improvement, the patient was discharged to the community to stay with her sister.
Approximately eight months after discharge, the patient developed intermittent episodes of mutism, isolated herself in her room, and refused to leave her apartment to attend follow-up appointments with her psychiatrist. Eventually, a year after being discharged, her sister persuaded her to go to the Mental Health Center. Psychopathological exploration revealed she was exhibiting soliloquies, incoherent speech, auditory hallucinations, and mannerisms. Additionally, during the interview, the patient appeared drowsy and slowed down, which she and her sister attributed to clozapine. On collateral information obtained from her sister, she presented bizarre behaviors at home, accompanied by social withdrawal, distrust, hostility, and aggressive outbursts.
After a year of treatment with clozapine, only partial remission of psychotic symptoms was accomplished. Additionally, the patient complained that clozapine caused her to be sedated, cognitively blunted, and apathetic. Adequate adherence was confirmed by plasma clozapine levels, ranging 375-415 ng/mL throughout the year of treatment.
In light of the recent worsening of the symptoms and limiting side effects, alternative treatment approaches were considered, and treatment with cariprazine was proposed. Switching from clozapine to cariprazine was conducted through a five-week cross-titration process. In the first week, cariprazine was started at a dose of 1.5 mg per day without any dose reduction of clozapine. Subsequently, weekly increases of 1.5 mg of cariprazine were made until reaching a dose of 6 mg daily. Simultaneously, starting on week 2, clozapine was reduced at a weekly rate of 100mg until discontinued. During the five weeks of the titration process, the patient did not exhibit worsening psychotic symptoms and experienced improvement in sedation and cognitive blunting. The only side effect reported was a mild self-limited headache during the first week after introducing cariprazine. She denied any EPS.
Four months after having completed the titration process, the patient showed a significant decrease in verbal hallucinations and mannerisms and a reduction in language and thought disorganization. Additionally, her sister described a marked improvement in functionality that could be seen in a greater tendency to relate to her relatives, frequent outdoor activities, and a better ability to collaborate with household chores. The patient also reported feeling less apathetic, and more motivated, and that she had recovered some capacity to enjoy daily activities.
In the follow-up after one year of the introduction of cariprazine, the patient reported adequate adherence to treatment as she continued to be in remission and displayed a stable functional status, which her sister corroborated.