A 22-year-old man with a history of untreated psychosis over 2 years enters a systematic treatment algorithm.
“Mr. A” was brought to the clinic by his parents. He was cooperative and denied any history of alcohol or drug use, which his parents corroborated. His parents noted that his early milestones and medical history were uneventful. Mr. A’s academic performance was above average through high school, although he was not active socially.
Mr. A attended a local college, but during his second year, at age 20, he started hearing voices. He reported the voices to be persistent from the onset, with the predominant voice that of a female classmate “trying to hear my thoughts so she can get to know me better before starting our relationship.” At times he heard other voices warning him that the police were monitoring his activities. His academic performance suffered, and toward the end of his second year, he dropped out and became more withdrawn socially, spending days at home.
Mr. A’s score on the Brief Psychiatric Rating Scale (BPRS) was 70, and his severity subscore on the Clinical Global Impressions (CGI) scale was 6. The working diagnosis was schizophrenia, and pharmacological treatment was initiated according to the clinic’s standardized treatment algorithm, which called for two trials with second-generation antipsychotics before trying clozapine, with each trial divided into three stages based on dosage (low, full, high) and lasting up to 4 weeks per stage. After 26 weeks of treatment (olanzapine, up to 30 mg/day, for a total duration of 14 weeks; risperidone, up to 7 mg/day, for a total duration of 12 weeks), only minor improvement was observed (BPRS score, 65; CGI severity subscore, 6). Mr. A reported that leaving his house remained difficult because he felt more “bothered” by the voices when he was out.
A clozapine trial was started at week 27, and within 1 week Mr. A reported “feeling much better”; the voices had decreased in frequency and intensity to a point where he could “concentrate and think” more clearly. Mr. A’s parents reported “dramatic improvement” after 3 months (BPRS score, 40; CGI severity subscore, 3), and at 4 months Mr. A returned to school part-time. He quickly transitioned to full-time, and 1 year after the start of antipsychotic treatment (currently clozapine at 425 mg/day), he was assessed as being in full remission with very mild, transient hallucinations and unusual thought content (BPRS score, 22; CGI severity subscore, 3).