Case Study: Severe Somnolence and Treatment Ambivalence Following Aripiprazole LAI Initiation for Bipolar I Disorder
Case at a Glance
A 23-year-old female with a recent diagnosis of Bipolar I Disorder and a history of medication non-adherence presented with severe somnolence and distress after her first dose of a long-acting injectable (LAI) antipsychotic. The case highlights the challenges of managing acute side effects, treatment ambivalence, and fragmented psychiatric care in a young adult with a serious mental illness.
Patient's Story
The patient, a 23-year-old female, presented via online correspondence seeking a method to 'get an injected antipsychotic out of her body.' She had recently received her first dose of aripiprazole long-acting injection (LAI). This followed a period of severe mania, characterized by several days of minimal sleep, and a brief inpatient psychiatric hospitalization. The transition to an LAI was a joint decision to address her history of poor adherence to oral medications. However, since the injection, she has experienced overwhelming hypersomnia, sleeping up to 15 hours a day. This has caused significant functional impairment, putting her at 'real risk' of losing her job. She described feeling depressed and disoriented, stating, 'I don’t know if it is morning or night.' The patient expressed a belief that she was 'wrongly injected' and was desperate to reverse the medication's effects, attempting to 'sweat it out' in saunas.
Initial Assessment
The patient presented with classic symptoms of severe somnolence, a known side effect of aripiprazole. Her clinical picture was complex, with several potential contributing factors: 1) A direct adverse effect of the new medication. 2) Post-manic exhaustion, where the body requires significant rest to recover from a state of high energy and sleep deprivation. 3) A switch into a depressive episode, a common occurrence in the cycling of Bipolar Disorder. Her distress was significantly amplified by a fragmented care system; her primary psychiatrist was reportedly unresponsive, and her primary care physician felt ill-equipped to manage her psychiatric needs, leaving her with limited support. The patient's perception of the treatment as a mistake indicated poor insight into her illness (anosognosia) and significant ambivalence, which are common barriers to successful management of Bipolar Disorder.
The Diagnostic Journey
The patient's history was highly suggestive of Bipolar I Disorder. A timeline constructed from her reports indicated a recent, severe manic episode that necessitated hospitalization. A history of a recent suicide attempt via acetaminophen overdose just prior to this presentation underscored the severity and high-risk nature of her condition. The clinical decision to initiate an LAI was sound, given the patient's self-admitted difficulty with adherence to a daily oral regimen ('I was good at forgetting'). The diagnostic challenge was not the underlying disorder but rather the etiology of her current debilitating symptoms. Without consistent clinical contact, it was difficult to differentiate between a severe medication side effect and the natural course of her illness (i.e., a post-manic crash or depressive episode). Her attempts to find a 'method to get the drug out' highlighted her medical misunderstanding and desperation, which was being exacerbated by her lack of access to professional guidance.
Final Diagnosis
Bipolar I Disorder, current episode unspecified, with mixed features (depressive symptoms and medication-induced hypersomnia). Significant contributing factors included medication non-adherence and limited insight into illness.
Treatment Plan
Given the inability to remove the long-acting medication from her system, the treatment plan focused on psychoeducation, side effect management, and establishing continuity of care.
Psychoeducation: The patient was informed that the medication could not be removed and that its effects would gradually wane over several weeks as it was metabolized. The rationale for the LAI (preventing relapse due to missed doses) was reinforced.
Symptom Management: The patient was strongly encouraged to utilize her available paid time off (PTO) or explore options for a formal medical leave (FMLA) to allow her body to rest and adjust without the pressure of work performance. Emphasis was placed on self-care, including hydration, nutrition, and engaging in low-energy hobbies like reading to combat depressive feelings and isolation.
Care Coordination: This was the most critical intervention. The patient was advised to immediately contact her health insurance provider to request a case manager to help navigate the system and secure timely care. She was also instructed to schedule an urgent appointment with her primary care physician to request a 'stat' referral to a new, available psychiatrist and to clearly communicate the acuity of her situation (recent hospitalization, medication side effects, employment risk) to the clinic providing the injections to facilitate an earlier follow-up.
Safety Planning: Due to her recent suicide attempt and current distress, a robust safety plan was discussed. This included identifying personal and professional supports, having crisis line information readily available, and understanding the need to present to an Emergency Department for any escalation of suicidal thoughts.
Outcome and Follow-up
Initially resistant, the patient eventually acknowledged the need for professional intervention over online advice. She agreed to contact her PCP for an urgent referral and to reach out to her insurance for a case manager. The immediate goal was to bridge the gap in her psychiatric care. The long-term follow-up plan would involve a comprehensive medication review with her new psychiatrist. This review would determine if the somnolence was dose-dependent (requiring a lower dose for the next injection) or an intolerable side effect necessitating a switch to a different LAI with a more favorable profile for her. Ongoing psychotherapy would be essential to improve her insight into her illness, develop coping strategies, and support long-term medication adherence, ultimately aiming for sustained mood stability and functional recovery.