Medication Adherence in Schizophrenia
Mr. R, a 28-year-old man with schizophrenia, has been stable on oral risperidone 4 mg daily for 6 months. He lives in a group home and attends a day program. He complains of weight gain and sedation. He tells the nurse he has stopped taking his medication for the past week because he "feels fine" and dislikes the side effects. His family reports he has become increasingly isolative and is talking to himself. The nurse must address adherence and symptom management.
1. What is the most likely reason for Mr. R's nonadherence, and what intervention should the nurse prioritize?
Read the worked answer
The most likely reason is intolerable side effects (weight gain, sedation) and lack of insight into his illness (he feels fine). The nurse should prioritize psychoeducation about the importance of continuing medication even when feeling well, and collaborate with the provider to address side effects. Interventions include:
- Discuss dose reduction or switching to a medication with a better side effect profile (e.g., aripiprazole, lurasidone) if appropriate.
- Consider long-acting injectable (LAI) antipsychotic to improve adherence and reduce fluctuations.
- Provide education about managing weight gain (diet, exercise) and sedation (take at bedtime).
- Use motivational interviewing to explore the patient's goals and values.
- Involve family/group home staff in monitoring and support.
The nurse should not simply insist on adherence but address the patient's concerns to build trust.
2. What signs indicate Mr. R is experiencing an exacerbation of psychosis, and what immediate actions should the nurse take?
Read the worked answer
Signs of exacerbation include increased isolative behavior, self-talk (responding to internal stimuli), and functional decline. The nurse should:
- Perform a mental status examination to assess for hallucinations, delusions, and disorganization.
- Ensure safety: assess for command hallucinations or risk of harm to self/others.
- Notify the provider for medication adjustment and possible referral to intensive outpatient or inpatient care.
- Re-engage Mr. R in the day program and encourage socialization.
- Monitor for medication restart: if he resumes risperidone, watch for side effects and adherence.
- Educate family/group home staff on early warning signs and crisis contacts.
Early intervention can prevent full relapse and hospitalization.