First-episode psychosis at 22: coordinated taper, vocational return.

Background

The patient (placeholder name R.) was seen at this practice from age 4 in CCH-002. R. is now 22, was a stable adolescent without a mood or anxiety diagnosis through age 18, and transitioned to CCH-001 at the standard handoff in 2021. R. lives at home in the Stockade District, was working at BSP Kingston in the front-of-house team, and was attending SUNY Ulster part-time. Family history is significant for a paternal grandmother with bipolar I.

R. presented to the HealthAlliance Broadway ED in February 2025 brought by family with three weeks of progressive paranoid ideation, sleep disturbance, and audiovisual hallucinations. The admission was inpatient psychiatry for 9 days; discharge diagnosis was schizophreniform disorder, on risperidone 4 mg daily, with a recommendation to follow up with psychiatry within 5 business days and a separately scheduled outpatient program at the McLean Hospital OnTrack-aligned program in Westchester. R. and family elected to receive psychiatric medication management at this practice (where R. had been seen as a child), in coordination with a regional CBT-for-psychosis-trained therapist.

Decision points

1. Receiving the post-discharge handoff

R. was scheduled for a CCH-003 new-evaluation visit on day 4 post-discharge. At intake we requested the discharge summary, the inpatient progress notes (60 pages), and the discharge medication list. The intake form was completed by R. with parent assistance.

The new-evaluation visit was 90 minutes (we extended the standard 75 because the intake notes flagged a substantial history). PHQ-9 at the visit was 11 (mild-moderate); PCL-5 was 14; AUDIT-C was 1; we used the Brief Psychiatric Rating Scale (BPRS) for baseline psychotic-symptom tracking — a score of 32 (mild residual positive symptoms) at presentation.

2. Building a working alliance and a taper plan

The first three months were maintenance and alliance-building. R. continued risperidone 4 mg with significant weight gain (5 kg over 8 weeks) and metabolic concern (fasting glucose 102, triglycerides 178). The CBT-p therapist, Mira Ostrander LCSW (independent practice in Saugerties, EBT-trained), held weekly individual sessions; R. attended every one. Family was engaged through a parent-coaching component using NAMI Family Support Group resources.

At month 3 we initiated a slow risperidone taper, with explicit shared decision-making about the tradeoff between metabolic burden and relapse risk. We discussed: the APA Practice Guideline for the Treatment of Patients with Schizophrenia recommendation for at least 12 months of antipsychotic therapy after a first episode; the meta-analysis evidence on relapse rates after dose reduction; and R.'s own values (graduate this fall, return to work, weight stability).^[01]

3. Vocational return

R. returned to BSP Kingston part-time at month 4 with explicit accommodation through the venue's HR (predictable shifts, no closing shifts initially, ear protection given residual audio sensitivity). The ACCES-VR NYS vocational rehabilitation service was engaged briefly but R. did not require their formal services.

4. Medical co-management

Maren Vanderlyn, MD, took over the metabolic monitoring at the 4-month mark per ADA 2024-aligned schedule (fasting glucose, HbA1c, lipids every 3 months during titration, every 6 months after). At month 6 the risperidone was 1.5 mg, fasting glucose 88, weight back to baseline minus 1 kg.

Outcome

At month 9 (end of this case-log period): R. is on risperidone 1 mg daily; BPRS 18 (mild, stable); PHQ-9 4; AUDIT-C 0. R. is working 30 hours/week at BSP Kingston, is two courses from completing the SUNY Ulster certificate, and is engaged to be married. The CBT-p therapy is now bi-weekly. The plan is to continue risperidone 1 mg through month 18, with a re-evaluation at that point regarding further taper or stop. R. and family understand the relapse-risk evidence; the plan is documented and signed.

What we got wrong

The first month after discharge was, in retrospect, too cautious. We held risperidone at 4 mg for 8 weeks despite the clear metabolic trajectory because we wanted "stability" before adjustment. The CMAJ's commentary on rapid metabolic complications of antipsychotic therapy could have prompted us to act sooner. We could have begun a slower taper at week 4 and likely avoided 2 of the 5 kg gain. R. has reviewed this paragraph and asked us to leave it in.