{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,7]],"date-time":"2026-10-07T13:45:08Z","timestamp":1791380708639,"version":"4.3.3"},"reference-count":10,"publisher":"MedWorks Media","issue":"2","content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Psychopharmacol Bull"],"abstract":"<jats:p>We present a case of a 36-year-old female with schizophrenia, coronary artery disease, and type 2 diabetes who was hospitalized for altered mental status and persistent psychosis. Initial evaluation revealed myocardial infarction, pulmonary embolism, and urinary tract infection. While delirium resolved with treatment, psychotic symptoms persisted. Brain MRI showed diffuse cortical microhemorrhages, prompting extensive workup for vasculitis, infection, and prothrombotic syndromes, all of which were negative. Despite multiple antipsychotic trials (quetiapine, risperidone, ziprasidone), the patient remained symptomatic, with a PANSS score of 156, consistent with treatment-resistant schizophrenia (TRS). The patient was started on clozapine that was later augmented with electroconvulsive therapy (ECT). After 10 ECT sessions and clozapine titrated to 300 mg daily, her PANSS score improved significantly to 60. This case highlights the diagnostic complexity in medically ill psychiatric patients and the risk of delayed TRS diagnosis. Early use of standardized tools like PANSS in the general medical setting may be useful in differentiating psychiatric from medical causes and can expedite treatment. Though clozapine remains first-line for TRS, 45\u201370% may not respond to monotherapy.5,6,7 ECT augmentation was effective in our case, but evidence remains mixed,9 highlighting the need for further research into optimal TRS augmentation strategies.<\/jats:p>","DOI":"10.64719\/pb.16614","type":"journal-article","created":{"date-parts":[[2026,3,11]],"date-time":"2026-03-11T20:16:27Z","timestamp":1773260187000},"page":"187-190","source":"Crossref","is-referenced-by-count":0,"title":["Missing the Forest for the Trees: Delayed Diagnosis and Management of Treatment Resistant Schizophrenia"],"prefix":"10.64719","volume":"56","author":[{"given":"Irene","family":"Kuriakose","sequence":"first","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Greg","family":"Noe","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"William","family":"Montgomery","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Sahil","family":"Munjal","sequence":"additional","affiliation":[],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"54175","published-online":{"date-parts":[[2026,3,9]]},"reference":[{"key":"ref1","doi-asserted-by":"crossref","unstructured":"Bush G, Fink M, Petrides G, Dowling F, Francis A. Catatonia. I. Rating scale and standardized examination. Acta Psychiatr Scand. 1996;93(2):129\u2013136.","DOI":"10.1111\/j.1600-0447.1996.tb09814.x"},{"key":"ref2","doi-asserted-by":"crossref","unstructured":"De Hert M, Detraux J, Vancampfort D. The intriguing relationship between coronary heart disease and mental disorders. Dialogues Clin Neurosci. 2018;20(1):31\u201340.","DOI":"10.31887\/DCNS.2018.20.1\/mdehert"},{"key":"ref3","doi-asserted-by":"crossref","unstructured":"Shah P, Iwata Y, Plitman E et al. The impact of delay in clozapine initiation on treatment outcomes in patients with treatment-resistant schizophrenia: a systematic review. Psychiatry Research. 2018;268:114\u2013122.","DOI":"10.1016\/j.psychres.2018.06.070"},{"key":"ref4","doi-asserted-by":"crossref","unstructured":"Yada Y, Yoshimura B, Kishi Y. Correlation between delay in initiating clozapine and symptomatic improvement. Schizophrenia Research. 2015;168(1):585\u2013586.","DOI":"10.1016\/j.schres.2015.07.045"},{"key":"ref5","doi-asserted-by":"crossref","unstructured":"Carbon M, Correll CU. Clinical predictors of therapeutic response to antipsychotics in schizophrenia. Dialogues Clin Neurosci. 2014;16(4):505\u2013524.","DOI":"10.31887\/DCNS.2014.16.4\/mcarbon"},{"key":"ref6","doi-asserted-by":"crossref","unstructured":"Kane J, Honigfeld G, Singer J, Meltzer H. Clozapine for the treatment-resistant schizophrenic. A double-blind comparison with chlorpromazine. Arch Gen Psychiatry. 1988;45(9):789\u2013796.","DOI":"10.1001\/archpsyc.1988.01800330013001"},{"key":"ref7","doi-asserted-by":"crossref","unstructured":"Meltzer HY, Bastani B, Kwon KY, Ramirez LF, Burnett S, Sharpe J. A prospective study of clozapine in treatment-resistant schizophrenic patients. I. Preliminary report. Psychopharmacology (Berl). 1989;99 Suppl:S68\u2013S72.","DOI":"10.1007\/BF00442563"},{"key":"ref8","doi-asserted-by":"crossref","unstructured":"Petrides G, Malur C, Braga RJ et al. Electroconvulsive therapy augmentation in clozapine-resistant schizophrenia: a prospective, randomized study. Am J Psychiatry. 2015;172(1):52\u201358.","DOI":"10.1176\/appi.ajp.2014.13060787"},{"key":"ref9","doi-asserted-by":"crossref","unstructured":"Yeh TC, Correll CU, Yang FC et al. Pharmacological and nonpharmacological augmentation treatments for clozapine-resistant schizophrenia: a systematic review and network meta-analysis with normalized entropy assessment. Asian Journal of Psychiatry. 2023;79","DOI":"10.1016\/j.ajp.2022.103375"},{"key":"ref10","doi-asserted-by":"crossref","unstructured":"Melzer-Ribeiro DL, Napolitano IC, Leite SA et al. Randomized, double-blind, sham-controlled trial to evaluate the efficacy and tolerability of electroconvulsive therapy in patients with clozapine-resistant schizophrenia. Schizophr Res. 2024;268:252\u2013260.","DOI":"10.1016\/j.schres.2023.11.009"}],"container-title":["Psychopharmacology Bulletin"],"original-title":[],"deposited":{"date-parts":[[2026,10,6]],"date-time":"2026-10-06T19:36:56Z","timestamp":1791315416000},"score":1,"resource":{"primary":{"URL":"https:\/\/medworksmedia.com\/pb-article\/missing-the-forest-for-the-trees-delayed-diagnosis-and-management-of-treatment-resistant-schizophrenia\/"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,3,9]]},"references-count":10,"journal-issue":{"issue":"2","published-online":{"date-parts":[[2026,3,9]]}},"URL":"https:\/\/doi.org\/10.64719\/pb.16614","relation":{},"ISSN":["2472-2448"],"issn-type":[{"value":"2472-2448","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,3,9]]}}}