Managing negative symptoms in schizophrenia
Presentation and management
This is the case of a 32-year-old male who called the Early Assessment Service for Young People with Psychosis (EASY Program) hotline due to insomnia in February 2014. The patient had no history of substance abuse, did not smoke, and did not drink alcohol. Family history was negative for mental illness. At the time of the call, he worked as a hairstylist, had one sibling, and lived in a public housing estate. He had a poor employment history, having worked at various jobs with no job lasting more than 2 years. Medical history was unremarkable.
The patient reported hearing voices, usually those of his colleagues using foul language, after returning from work. He started having paranoid delusions, with the belief that his co-workers were playing tricks on him and constantly laughing at him. He had one accident at work in which he twisted his arm, for which he believed that his colleagues were responsible. He quit his job afterwards, but he felt that his co-workers were following him on the street and eavesdropping on his phone conversations. He became increasingly irritable, developed poor sleep and appetite, and started spending considerable amounts of time watching television and playing computer games. The patient started to develop negative symptoms – avoiding social interactions, not wanting to leave home, and not expressing any volition in finding a new job.
Further interview revealed that the symptoms gradually appeared over a span of 5 to 6 years. He was diagnosed with paranoid schizophrenia and was started on oral risperidone 1 mg once a day, which was gradually increased to 1 mg twice a day after 2 weeks. However, the patient demonstrated poor insight and did not see the importance of medication and of continuing maintenance treatment. Adherence to the treatment regimen was satisfactory at first, and the patient was able to land a new job as a kitchen worker. However, the patient stopped taking his medication when the symptoms had subsided. As a result, the symptoms recurred and the patient quit his new job after only a few days. The oral antipsychotic therapy lasted from February to August 2014, with periods of poor compliance.
In August 2014, the patient was switched to zuclopenthixol 100 mg depot injection. After 4 weeks, the patient developed extrapyramidal side effects (EPS) in the form of neck rigidity and hand tremors, making him reluctant to receive another depot injection. However, he finally consented to receive paliperidone palmitate, which was given at a dose of 150 mg initially, followed by subsequent doses of 100 mg after 1 week and 50 mg 4 weeks after the second dose. Follow-up visits indicated that the patient was quite satisfied with the treatment and his mental condition. He was able to function normally and found a job as a shop assistant in a bicycle shop. The patient did not report any EPS.
In the treatment of schizophrenia, it is important to address the issue of negative symptoms as well as positive symptoms. Paliperidone palmitate, an atypical antipsychotic agent given as a depot injection, has demonstrated efficacy in reducing Positive and Negative Syndrome Scale (PANSS) scores in four short-term studies in acute schizophrenia.1 In another double-blind trial, PANSS scores for patients receiving paliperidone improved significantly after 4 days (p=0.012) and 8 days (p=0.007) compared to placebo.2 This improvement persisted (p<0.05) throughout the trial until study end (92 days).2 In addition, the patients’ Clinical Global Impressions-Severity (CGI-S) and Personal and Social Performance (PSP) scores were markedly improved.2
Another important issue in the treatment of schizophrenia is compliance, with as many as 35 percent of patients experiencing compliance problems within the first few weeks of therapy.1 In the case of this patient, poor adherence to therapy resulted in recurrence of symptoms, a problem which was addressed by using depot atypical antipsychotic injection. A study has shown that atypical long-acting injectable antipsychotic therapy is also associated with fewer rehospitalizations and emergency room visits compared to oral antipsychotics.3
Atypical antipsychotics should be considered for young patients at an early stage of schizophrenia in order to preserve their occupational potential. This can be achieved by controlling both positive and negative symptoms of schizophrenia. For this patient, it would have been beneficial to consider paliperidone palmitate depot injection right from the start, thus avoiding the adherence problems and symptom recurrence encountered during the first 6 months of antipsychotic therapy.
1. Neuropsychiatr Dis Treat 2010;6:561-572. 2. Ann Gen Psychiatr 2011;10:12.
3. BMC Psychiatry 2013;13:221.
This case study is made possible through an unrestricted educational grant from the industry.