Aspirin as an Adjunctive Treatment for Childhood Onset Schizophrenia

Case Report

D.A. was a 13-year-old Hispanic male who presented to a psychiatric inpatient unit after increasingly bizarre behavior at school. The patient had been displaying intermittent signs of psychosis for∼1 year; for example, intermittently believing that the Mafia was coming out of the television to attack him. For several weeks prior to admission, his symptoms markedly worsened. He began standing in corners and talking to walls for hours, discussing how an invisible man was commanding him to hold his hands in various postures or to perform repetitive movements. School officials noted that he would become frightened and agitated if redirected from this activity.

On interview, he appeared frightened and confused, and was crying, saying that he was afraid that “the man” would hurt him if he did not continuously hold his hands over his face. He had delusions of being persecuted by staff and family; was very illogical in thought process; had a flat affect, prominent thought blocking, and paucity of speech; and would sit by himself on the inpatient unit, showing no motivation to interact with others. His Positive and Negative Syndrome Scale (PANSS) score on admission was 79. Magnetic resonance imaging (MRI) of the brain, electroencephalogram (EEG), microarray genetic studies, electrolytes, complete blood count (CBC), liver function tests, HIV, rapid plasma reagin (RPR), thyroid, lead, copper, and erythrocyte sedimentation rate were all unrevealing.

For treatment, he was started on aripiprazole, which was titrated over several days to 20 mg. He showed partial improvement, appearing less frightened of his hallucinations, but responding to internal stimuli with prominent negative symptoms. After 3 weeks of treatment on aripiprazole as monotherapy, his PANSS score was 59 and his clinical presentation had stabilized, with very little incremental improvement from day to day.

Given the lack of further clinical progress, he was started on aspirin 325 mg twice daily as an adjunctive treatment for psychosis. Within 2 days, he had a notable reduction in hallucinatory behavior, appearing much less distracted by internal stimuli during the interview. He also was more fluent in his speech, showed more signs of facial expression, and began to spontaneously interact with other patients on the unit. The improvement was remarkable enough that multiple unit nurses blind to the aspirin addition commented to the team about his substantial change. His PANSS score decreased over 2 days by 14 points to 45. Improvements were seen in both the positive and negative subscales.

The patient's improvement was remarkable enough that he was discharged several days later to continue with intensive in-home psychiatric services. He reported no side effects from the aspirin.

Discussion

High-dose acetylsalicylic acid was shown in one trial to be an effective adjunct in treating psychotic symptoms in adults with schizophrenia (Laan et al. 2010), and we report a case of effective use in a child.

The child in this case showed marked improvement within days, which is faster than the controlled trials in which the effects tended to emerge over a few weeks. Prior studies of the NSAID Celebrex reported more pronounced results in those with shorter disease duration (Laan et al. 2010; Muller et al. 2010), and in this case, the patient's severe psychotic deterioration was only 3 weeks old. We therefore speculate that NSAIDs may be most effective early in a psychotic break, which is of particular importance in children and adolescents, as it is often possible to begin treatment early in the course of the disease.

Childhood-onset schizophrenia carries a poor prognosis and is notoriously difficult to treat. The use of NSAIDs as an adjunctive treatment, particularly in close proximity to a first psychotic break, holds promise and warrants further investigation.