Managing Schizophrenia Medication Changes: Signs and Concerns - Psychiatry

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My family recently discussed with the doctor and switched the medication for schizophrenia treatment?


Hello Doctor, I would like to consult you about the following situation:
Main Situation: My sister, who is being treated for schizophrenia, has elevated prolactin levels.
Therefore, her medication was switched from two tablets of Risperidone to one tablet of Paliperidone.
Last Tuesday, she received a reduced dosage of her long-acting injection during her follow-up appointment.
Recently, over the past few days (from last Saturday until now), she has been experiencing more symptoms than usual.
It started when she felt that her crush had died, and she has been hearing more threatening voices, often standing still and lost in thought, feeling a bit restless, and occasionally experiencing involuntary tremors in her hands and feet (which are infrequent).
Her appetite has decreased (she wants to eat but feels bad after eating, so she refrains), and she has been indecisive (hesitating to change her food choices or activities).
However, her sleep schedule has become more regular during these days (possibly indicating she has been sleeping well?).
In the past, she occasionally experienced some symptoms (hearing voices, trembling hands when thinking about certain things, and zoning out), but this time it seems slightly more intense and concentrated.

Additionally, our father was recently hospitalized and just returned home (he was admitted last Friday, and it wasn't serious).
After this, my sister seems to have improved a bit (the symptoms appeared during our father's hospitalization, but I believe the main issue is still related to the medication change and dosage reduction).
Since my sister just saw the doctor last week, I am unsure if she needs to return for an earlier appointment or if these symptoms might be temporary due to the medication change.
About a month ago, my sister, who has been regularly treated for schizophrenia with medication and long-acting injections, discussed her elevated prolactin levels with her doctor and decided to try switching medications.
She replaced her previous two tablets of Risperidone with one tablet of Paliperidone.
During her follow-up appointment last Tuesday, her long-acting injection dosage was also reduced.
Before the medication change, my sister had been messaging a male classmate, engaging in a one-sided 'conversation' (I had previously asked you about this earlier this year).
However, since that boy had likely blocked her a long time ago, he probably didn't see her messages.
Consequently, my sister did not receive any 'clear' responses and began to infer his thoughts based on his status updates on Line (she believes he is hinting or expressing emotions through this).
This has led to her worrying about various things based on his status; for instance, if he posts something indicating heartbreak, she worries that he is suffering for some reason or that she did something wrong, causing him pain or reluctance to be with her.
My sister frequently seeks 'fortune-telling' to understand what is happening with him and what he might be thinking.
Almost every time he changes his status, she can't help but speculate about its meaning or spends her day thinking about how to send him interesting messages, which troubles her (sometimes she feels overwhelmed and tells me she doesn't know what to send and wants to give up, but after a while, she thinks he might have his struggles and that she can't just ignore him, leading her to continue messaging him).
Last Friday (a few days after her follow-up), our father was hospitalized due to bile duct inflammation, and our mother went to care for him, leaving my sister and me at home.
By Saturday night, my sister seemed to be in a worse state than usual.
She suddenly told me that she had blocked the boy she likes and had seen a vision of him dying (she knows it wasn't 'real,' but she worries it might be happening in a 'spiritual' realm).
She even asked me, "What should I do if I keep hearing threatening voices?" I told her that I would first check if what she hears aligns with reality; if there are unreasonable aspects, those voices might be what she refers to as 'low-frequency sounds' (a concept she strongly believes from her 'mind-body-spirit' course) and not real.
I wanted to reassure her that those things aren't real, but I also feared she might feel misunderstood.
Since that day, her routine has become more regular, going to bed around 10 PM and waking up around 6 AM.
However, she often seems distracted and lost in thought (possibly hearing voices?).
During this time, she has also shown indecision (for example, she initially said she wanted to eat an egg pancake for breakfast but hesitated and changed her mind to something else, appearing uncertain).
This morning, while talking to me, her foot suddenly started shaking involuntarily (not something she did on purpose), and she mentioned that sometimes her hands shake unexpectedly when she thinks about certain things.
Additionally, her appetite has decreased compared to before.
This morning, she expressed a desire to eat her favorite breakfast but felt that after a few bites, she was 'absorbing someone else's energy' (after engaging with 'mind-body-spirit' concepts, she believes this might happen.
I think the energy discussed in that course merely describes emotional states, but she interprets it as something akin to 'qi or magnetic fields.' Her strong belief in 'mind-body-spirit' is quite concerning).
Overall, her recent unusual symptoms seem more pronounced than before, coinciding with changes in weather and our father's hospitalization (thankfully, it wasn't too serious, and he was discharged this morning).
I am particularly worried that the medication change might indicate early signs of relapse, but I am uncertain if this is a temporary situation due to the dosage reduction.
I wanted to ask you about the possible scenarios and whether an earlier follow-up appointment is necessary.
Thank you for your help, Doctor!

Yangyang, 30~39 year old female. Ask Date: 2024/05/21

Dr. Qiu Junda reply Psychiatry


Hello.
Since you have just changed your medication, we can continue to observe the situation.
The symptoms described do not initially appear to indicate an acute change.
Additionally, with the long-acting injection to help stabilize your condition, there is no need to worry too much at this time.
If the time until your next appointment is more than a month away, we can consider an earlier evaluation based on the severity of your symptoms (such as if they interfere with others, etc.).
Thank you.

Reply Date: 2024/05/21

More Info


Managing medication changes in individuals with schizophrenia can be a complex and nuanced process, particularly when there are fluctuations in symptoms and external stressors. In your sister's case, it appears that she has recently undergone a medication switch from a previous antipsychotic to a new one, along with a reduction in the dosage of her long-acting injection. This kind of adjustment can often lead to a temporary exacerbation of symptoms, especially in the initial stages of the transition.

The symptoms you describe—such as increased auditory hallucinations, feelings of agitation, and changes in appetite—could indeed be linked to the recent changes in her medication regimen. It's not uncommon for patients to experience a resurgence of symptoms when their medication is altered, particularly if the new medication has not yet reached its full therapeutic effect or if the dosage reduction has led to a withdrawal effect from the previous medication.

Additionally, external factors such as your father's hospitalization could also contribute to her emotional state and symptomatology. Stressful life events can exacerbate underlying mental health conditions, and it’s possible that the combination of medication changes and familial stressors is influencing her current experience.

Regarding the specific symptoms you mentioned, such as the feeling of seeing her crush die and hearing threatening voices, these could be manifestations of her schizophrenia. The fact that she recognizes these experiences as not being grounded in reality is a positive sign, indicating some level of insight into her condition. However, it’s crucial to monitor these symptoms closely, as they can indicate a potential worsening of her condition.

In terms of whether to return for an earlier appointment, it would be prudent to consult with her psychiatrist. If her symptoms are significantly impacting her daily functioning or if there is a marked increase in distress, an earlier evaluation may be warranted. The psychiatrist can assess whether the current medication regimen is appropriate or if adjustments are necessary to better manage her symptoms.

It’s also important to maintain open lines of communication with her healthcare provider about any concerning symptoms. Documenting her experiences, including the frequency and intensity of her symptoms, can provide valuable information for her treatment team. This can help them make informed decisions about her care.

In summary, while some fluctuation in symptoms can be expected during medication changes, significant or distressing symptoms should not be overlooked. Engaging with her psychiatrist for a thorough evaluation and potential adjustment of her treatment plan is essential. Additionally, providing emotional support and understanding as she navigates these changes can be incredibly beneficial for her overall well-being.

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