(114) 80-Day Starvation in a Patient with Autism and Bipolar Disorder Requiring ICU Stay: Court-Ordered Treatment and Response to Aripiprazole Maintena Injection in a C-L Setting

Background/Significance: Court-ordered treatment of psychosis in the context of medical admission in patients with co-‎morbid psychiatric diagnoses requires unique treatment considerations. While psychopharmacotherapy is an important ‎component in treating psychosis-associated starvation, a biopsychosocial approach involving an interdisciplinary team of ‎psychiatrists, hospitalists, dieticians, psychologists, and family members is essential to effectively care for and treat ‎patients. Further, long-acting injectable (LAI) antipsychotics are an underutilized treatment option with potential to improve ‎patient outcomes.‎

Case: A 23-year-old male with a past psychiatric history of autism spectrum disorder, bipolar disorder, and schizophrenia ‎presented to the ED from an inpatient psychiatry unit for starvation ketoacidosis and poor PO intake for 2 weeks. He was ‎diagnosed with schizophrenia at 16, with several inpatient psychiatry admissions, and previously responded to Abilify, with ‎noted cessation of hallucinations, improved interactions, and less blunted affect. He has a history of medication non-‎adherence and recently showed increased paranoid behaviors, including excessive showering (9 times/day) and scrubbing ‎his ears until bleeding due to auditory hallucinations.‎

Hospital Course: He was admitted to the inpatient medicine service. CL psychiatry was consulted for medication ‎recommendations. Patient refused PO Abilify. Alternate medications included: various combinations of IM antipsychotics ‎‎(olanzapine, midazolam, haloperidol) with medical interventions of IV fluids and attempts at placing an NG tube, which the ‎patient consistently pulled out. He was transferred to the MICU for close monitoring.‎

A petition was filed for court-mandated treatment of an LAI antipsychotic. Aripiprazole (Abilify) LAI (400mg) was ‎administered on hospital day (HD) 44, with expected peak on HD 54-60 (Correll, 2021).‎

Response to Treatment: Patient continued to refuse PO intake, though became more engaged, noting increased ‎interactions and desire to play chess. With more frequent visits from family, engagement in hobbies, and established ‎incentive system to eat, patient ate for the first time in over 2.5 months on HD 64. Nutrition and CL teams closely ‎collaborated, which was critical in patient's eventual progress. Second Abilify LAI was administered on HD 72, with shorter ‎onset of action due to additive effect from first dose. Patient was discharged back to inpatient mental health facility on HD ‎‎78 in good health.‎

Discussion: This case addresses nuances of treating psychosis with court-ordered LAI treatment in a CL setting in a patient ‎with autism and psychosis. Recent literature suggests Abilify LAIs show improved outcomes in patients with autism and ‎psychosis (Hirsch, 2016), and are an underutilized treatment modality that can yield favorable patient outcomes (Parelleda, ‎‎2016). This case shows that a combination of pharmacotherapy, behavioral interventions, family engagement, and ‎interdisciplinary collaboration (legal, nutrition, hospitalists) are critical aspects of CL psychiatric care.‎

Conclusion/Implications: LAIs, when supplemented by several non-pharmacologic modalities, are an important component ‎in improving patient outcomes in patients who refuse PO intake.‎

References: ‎
‎1. Correll et al. Pharmacokinetic Characteristics of Long-Acting Injectable Antipsychotics for Schizophrenia CNS Drugs. ‎‎2021;35(1):39-59.‎
‎2. Hirsch LE, Pringsheim T. Aripiprazole for autism spectrum disorders (ASD). Cochrane Database Syst Rev. ‎‎2016;2016(6):CD009043.‎
‎3. Parellada E, Bioque M. Barriers to the Use of Long-Acting Injectable Antipsychotics in the Management of Schizophrenia. ‎CNS Drugs. 2016;30(8):689-701.‎