A patient with schizophrenia who previously improved on risperidone has become non-compliant with oral medication and is now experiencing delusions of persecution. What is the most appropriate next step in management?

1. A

   Start haloperidol

2. B

   Prescribe injectable risperidone

3. C

   Initiate psychotherapy

4. D

   Switch to syrup risperidone

Appeared in: NORCET 8 Prelims-2025

Explanation

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• For patients with schizophrenia who are non-adherent to oral medication, switching to a long-acting injectable (LAI) formulation is the recommended standard of care.
• The patient had a known positive response to risperidone, so using the injectable form of the same drug (risperidone LAI) is the safest and most effective strategy, minimizing the risk of treatment failure or new side effects.
• LAIs provide consistent medication levels in the blood, which helps prevent psychotic relapses caused by missed daily doses.
• Clinicians can immediately identify non-adherence if a patient misses a scheduled injection, allowing for timely intervention.

Why Other Options Were Wrong

• Option A: Switching to a different antipsychotic, especially a first-generation one like haloperidol, is not indicated as the patient responded well to risperidone. It introduces unnecessary risks of different side effects, such as a higher incidence of extrapyramidal symptoms (EPS).
• Option C: Psychotherapy is an adjunct treatment and is not effective as a primary intervention for an acute psychotic episode caused by medication non-adherence. Pharmacological stability must be established first before the patient can meaningfully engage in therapy.
• Option D: A syrup formulation is still an oral medication that requires daily administration by the patient. It does not solve the core problem of non-compliance and is therefore unlikely to prevent future relapses.

Related Visual

• Visual 1: Chart - Comparing Oral vs. Long-Acting Injectable (LAI) Antipsychotics. This chart would show the pharmacokinetic profiles, highlighting the stable plasma concentration of LAIs versus the peaks and troughs of oral medication, visually explaining why LAIs prevent relapse from non-adherence.
• Visual 2: Infographic - Steps for Administering a Risperidone LAI. This would illustrate the correct injection sites (e.g., deltoid, gluteal), needle size, and technique, which is a key nursing skill.

Clinical Relevance

• Nursing practice connection: Use the key finding related to Management of medication non-adherence in schizophrenia to guide bedside assessment, documentation, and the next nursing action.
• Medication non-adherence is a primary driver of relapse and rehospitalization in schizophrenia, affecting up to 50% of patients. LAIs are a critical tool for improving long-term outcomes.
• Nurses play a key role in the success of LAI therapy through patient education, building therapeutic trust, administering the injections correctly, and monitoring for both therapeutic effects and adverse reactions.
• What if? If the patient had a history of poor response or intolerance to risperidone, the correct next step would be to switch to a different oral antipsychotic to establish efficacy first, before considering the LAI version of that new drug.

How to Approach the Question

• Step 1: Identify the patient's diagnosis (schizophrenia) and current clinical status (acute relapse with delusions).
• Step 2: Pinpoint the root cause of the relapse from the stem: 'non-compliant with oral medication'.
• Step 3: Note the crucial detail that the patient 'previously improved on risperidone'. This indicates the medication is effective for this specific patient.
• Step 4: Evaluate the options based on their ability to solve the core problem (non-compliance) while leveraging the known effective medication.
• Step 5: Eliminate options that fail to address non-compliance (syrup, psychotherapy) or unnecessarily change a working medication (haloperidol).
• Step 6: Conclude that the option maintaining the effective drug while ensuring adherence (injectable risperidone) is the most appropriate and evidence-based choice.

Concept Tested & Keywords

• Concept Tested: Management of medication non-adherence in schizophrenia
• Stem keywords: schizophrenia, risperidone, non-compliant, delusions of persecution
• Lead-in keywords: most appropriate next step
• Clinical cues: Patient previously improved on risperidone, which indicates the drug is effective for this individual.
• Clinical cues: Patient is non-compliant with oral medication, which is the direct cause of the current relapse.

Question ID

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