A 24-year-old man presents to the emergency department after a suicide attempt. He is admitted to the hospital and diagnosed with schizoaffective disorder. A review of medical records reveals a history of illicit drug use, particularly cocaine and amphetamines. He is started on aripiprazole, paroxetine, and trazodone. At the time of discharge, he appeared more coherent and with a marked improvement in positive symptoms of hallucinations and delusions but still with a flat effect. During the patient’s first follow-up visit, his mother reports he has become increasingly agitated and restless despite compliance with his medications. She reports that her son’s hallucinations and delusions have stopped and he does not have suicidal ideations, but he cannot sit still and continuously taps his feet, wiggles his fingers, and paces in his room. When asked if anything is troubling him, he stands up and paces around the room. He says, “I cannot sit still. Something is happening to me.” A urine drug screen is negative. What is the next best step in the management of this patient?

Stop aripiprazole and switch to clozapine

A 20-year-old student is referred to his college's student health department because his roommates are concerned about his recent behavior. He rarely leaves his room, has not showered in several days, appears to be praying constantly even though he is not religious, and has not been studying despite previously being an extremely good student. After evaluating this patient, a physician decides to recommend initiation of pharmacological treatment. The patient's family is concerned because they heard that the drug being recommended may be associated with heart problems. Which of the following characteristics is a property of the most likely drug that was prescribed in this case?

May cause weight gain and metabolic changes

Lower risk of extrapyramidal symptoms

High affinity for serotonin 5-HT2A receptors

Generally less sedating than older antipsychotics

A 44-year-old man presents to his psychiatrist for a follow-up appointment. He is currently being treated for schizophrenia. He states that he is doing well but has experienced some odd movement of his face recently. The patient's sister is with him and states that he has been more reclusive lately and holding what seems to be conversations despite nobody being in his room with him. She has not noticed improvement in his symptoms despite changes in his medications that the psychiatrist has made at the last 3 appointments. His temperature is 99.3°F (37.4°C), blood pressure is 157/88 mmHg, pulse is 90/min, respirations are 14/min, and oxygen saturation is 98% on room air. Physical exam is notable for rhythmic movements of the patient's mouth and tongue. Which of the following is a side effect of the next best step in management?

Worsening of psychotic symptoms

Long-acting injectable antipsychotics for USMLE Step 2 CK: High-Yield Psychiatry Lessons

LAI Basics - The 'Why' & 'Who'

Primary Goal: ↑ Adherence & ↓ relapse in schizophrenia. LAIs circumvent covert non-adherence, ensuring consistent medication delivery. This leads to smoother plasma concentrations compared to oral agents, reducing breakthrough symptoms and rehospitalization rates.
Ideal Candidates:
- Patients with a documented history of poor adherence to oral antipsychotics.
- Those who express a preference for injections over daily pills.
- Patients requiring supervised medication administration.

⭐ Key Pre-requisite: Before starting an LAI, a patient MUST have already demonstrated good tolerability and response to the oral version of the same antipsychotic. This prevents "trapping" a patient with a long-acting medication they can't tolerate.

Peak-to-trough plasma concentration ratio of antipsychotics

The LAI Roster - Meet the Long Shots

Aimed at improving adherence in schizophrenia, LAIs are a crucial tool. Selection depends on the patient's prior medication tolerance, preference, and clinical factors. They are typically initiated after tolerance to oral formulations is established.

Agent	Generation	Dosing Interval	Key Features
Haloperidol decanoate	1st	q4 weeks	Requires oral overlap
Fluphenazine decanoate	1st	q2-3 weeks	Requires oral overlap
Risperdal Consta	2nd	q2 weeks	3-week oral overlap needed
Invega Sustenna	2nd	q4 weeks	No oral overlap after loading doses
Invega Trinza/Hafyera	2nd	q3/q6 months	For stable pts on Sustenna
Abilify Maintena	2nd	q4 weeks	2-week oral overlap needed
Aristada	2nd	q4-8 weeks	Flexible oral overlap options
Zyprexa Relprevv	2nd	q2-4 weeks	⚠️ REMS for PDSS

⭐ Post-injection Delirium/Sedation Syndrome (PDSS) is a rare but serious risk with Olanzapine Pamoate (Zyprexa Relprevv). Patients must be monitored at a healthcare facility for at least 3 hours post-injection.

Initiation - The Launch Sequence

Goal: Smoothly achieve and maintain therapeutic plasma levels when switching from oral antipsychotics.
Oral Bridging: Most LAIs require oral antipsychotic overlap (2-4 weeks) after the first injection.
- Confirms tolerability before committing to a long-acting formulation.
- Maintains therapeutic levels until the LAI reaches steady-state.
- Applies to: Risperdal Consta, Abilify Maintena.

⭐ Paliperidone (Invega Sustenna) and Aripiprazole Lauroxil (Aristada) can be started without an oral bridge via a loading dose strategy. Sustenna uses Day 1 (234 mg) and Day 8 (156 mg) deltoid injections.

Practical Pearls - Jabs & Jitters

Primary Indication: Improving adherence in patients with a history of relapse due to non-compliance.
Initiation Overlap: Crucial to bridge the gap until the LAI reaches therapeutic levels.
- Paliperidone (Invega Sustenna): No oral overlap needed; uses a loading dose strategy on day 1 and day 8.
- Aripiprazole (Abilify Maintena): Requires a 14-day oral overlap.
Technique: Administer via deep intramuscular injection using the Z-track method to prevent medication leakage.

⭐ Exam Favorite: Risperdal Consta (Risperidone LAI) requires a 3-week overlap with oral risperidone because the microspheres take time to release the drug.

Improves adherence and reduces relapse rates in schizophrenia, especially for patients with poor insight or frequent hospitalizations.

Requires an oral trial of the medication first to establish tolerability before initiating the long-acting formulation.

Administered every 2-12 weeks, providing stable plasma drug levels compared to fluctuating oral doses.

Key agents include paliperidone (Invega Sustenna/Trinza), aripiprazole (Abilify Maintena), and risperidone (Risperdal Consta).

Common side effects include injection site reactions; systemic side effects mirror the oral formulation.

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