The Perfect Storm: Difficulties in the Treatment of Early-Onset Schizophrenia in Transitional Age Youth

Background: Early-onset schizophrenia (EOS) is defined as schizophrenia symptom onset occurring prior to age 18.However, due to comorbid psychiatric conditions, substance use and the nonspecific nature of early psychosis, there is often a significant delay in accurate diagnosis and treatment. In addition, services available to those within the transitional-age community, defined as youth between the ages of 16-25, are often limited, and the interface between child and adult mental health services poorly defined. This deficit directly affects the establishment of clinical programs designed to provide early intervention for psychotic disorders. Case Presentation: A 17-year old male presented with paranoia, delusional thought content and disorganized behavior. The patient had previously been diagnosed with substance-induced psychosis due to similar presentations in the setting of cannabis use. However, following a 4-month incarceration with no psychiatric care, the patient demonstrated significant decompensation and an increase in duration of psychotic symptoms. Although the patient had previously demonstrated positive response to oral Aripiprazole, and had a well-documented history of medication non-compliance, insurance declined coverage of transition to Abilify Maintena due to patient age. Subsequently, the patient was initiated on oral Haloperidol. Following several episodes of dystonia, Haloperidol was slowly titrated based on response and tolerability, and transitioned to Haloperidol-Decanoate after several weeks. The patient gradually demonstrated clinical improvement in mood, behavior and delusional thought. Outpatient services were limited by current legal status, as the patient had been tried as an adult under state law. Management generally available through Children's Division and the Juvenile Office were restricted. Following multiple meetings between both inpatient and outpatient providers, the patient was scheduled for Intensive Case Management Services through a local community behavioral health provider and subsequently discharged. Discussion: This case presents the obstacles frequently encountered in the diagnosis, treatment and outpatient management of EOS, specifically those within the transitional age community. Though services remain limited, a growingawareness of this disparity has resulted in the development of multiple early-intervention programs, as well as government-funded research initiatives designed to address the needs specific to this population.