Review Question - QID 217160

This patient with a greater than 1-year history of psychiatric illness including episodes of acute psychosis (auditory hallucinations and agitated behavior) and negative symptoms (poor personal hygiene) most likely has schizophrenia. Patients experiencing command hallucinations, especially in the setting of suicidal ideation, should be hospitalized.

Patients with psychosis should have an assessment for safety risks and the level of care indicated. In general, treatment of psychosis should take place in the least restrictive environment that is still safe. Patients at risk to harm themselves (e.g., suicidal ideation with intent and plan), at risk to harm others (e.g., command hallucinations, which may tell patients to hurt others), or who are not able to secure basic needs such as food and shelter require inpatient psychiatric hospitalization. Although patients who experience command hallucinations typically ignore or appease these voices, suicidal ideation can increase the likelihood of compliance with command hallucinations. This may result in self-harm or suicide. Treatment of psychosis should generally involve antipsychotic medications and adjunctive psychosocial interventions.

Wheat et al. discuss the presentation and treatment of psychiatric emergencies, including acute psychosis. They discuss legal and medical considerations surrounding involuntary admissions. They recommend performing a debrief with all parties involved in order to ensure a therapeutic alliance.

Incorrect Answers:
Answer 1: Family therapy involving psychoeducation is an important treatment intervention that can decrease the rate of relapse. Family therapy is particularly helpful in patients, such as this patient, who have close contact with their families. However, this patient experiencing command hallucinations in the setting of suicidal ideation should be hospitalized and acutely treated first.

Answer 2: Injection of extended-release aripiprazole, an antipsychotic, can be used in the treatment of schizophrenia for patients with histories of medical non-compliance. Injected formulations may be useful for this patient in the long term; however, in the acute setting, he should first be hospitalized for safety.

Answer 4: Respecting the patient’s wishes and discharging him home to his family without medications is inappropriate in this patient with command hallucinations. Although respecting patient autonomy is important, this patient lacks decision-making capacity and should be hospitalized for command hallucinations in the setting of suicidal ideation.

Answer 5: Starting quetiapine, an antipsychotic, with outpatient psychiatry follow-up the next day is inappropriate for this patient experiencing command hallucinations and who poses a risk to others. Discharge and follow-up should only be used in cases where the patient is stable and does not pose a safety risk.

Bullet Summary:
Any patient experiencing command hallucinations, especially those with risk factors such as suicidal ideation or homicidal ideation, must be hospitalized as they pose a risk to themselves and/or others.