Poisoned Pills

One of our psychiatry outpatients — a man in his 40s with schizophrenia — is reluctant to take his medications because they are poisoned. They aren't, of course, but he's afraid they might be.
This has been a recurring theme with him for years. Even though he's been in and out of psychiatric hospitals since his late teens, he's not certain he has a psychiatric disorder. He isn't against taking all medications; he's just afraid to take whatever pills are in his possession at any particular time because he can't trust that someone hasn't put poison in them. He doesn't seem to have other delusions or hallucinations. He's just fixated on this poisoned-pill delusion.
In spite of his unease and worry about his medications, most of the time he has trusted us and the pharmacy enough to take them. Overall, his treatment has allowed him to function fairly well living in a community group home staffed with a care provider.
He has his own bedroom and the use of several other rooms in the house. Regular meals are served to him and the other five residents. The care provider manages the medications and helps make sure everyone gets to their scheduled appointments. The residents come and go as they please.
My patient was looking pretty good when I saw him at our center a few weeks ago, although I became concerned when he again asked about switching pharmacies. And so I was disappointed, but not really surprised, when last week his care provider reported that he seemed to be doing much worse.
Now he appears distressed and distracted by things that are not apparent to anyone else. He's not sleeping well and spends hours at a time in his room talking to himself. He's no longer at ease with his housemates.
I'm worried that his persistent concern about being poisoned has once again led him to stop taking his prescribed antipsychotic medications and, as a result, that he's experiencing a return of other psychotic symptoms. Clearly, the quality of his life has deteriorated. I'm hoping we can help him recover before things get worse and he ends up being hospitalized again.
The patients themselves ultimately choose whether they take their prescribed medications; rarely are they court-ordered to do so.
Sometimes the use of orally dissolvable tablets or long-acting injections can be helpful. The dissolvable tablets prevent people from "cheeking" pills and later spitting them out. The injections can be given every two to four weeks and sometimes replace the need for pills. Still, some cooperation is necessary.
The best that health care providers can do is to educate patients about their illnesses, work with them to develop a plan that promotes a stable life, provide appropriate therapies, and inform them about the risks and benefits of any medications we recommend.