Successful Transition From Covert, Involuntary Oral Medication to Consensual, Long-Acting, Injectable Antipsychotic Therapy in a Patient With Schizophrenia: A Case Report From Japan

Medication non-adherence is a primary obstacle in schizophrenia management, often leading to the involuntary or covert administration of medication by caregivers. Covert medication, the practice of administering medicine to a person without their knowledge, occurs in Japan within a complex ethical and legal landscape that lacks clear institutional frameworks, posing significant dilemmas for patients, their families, and clinicians. This report describes a case of a successful transition from such treatment to consensual, patient-centered therapy using long-acting injectable (LAI) antipsychotics. A 57-year-old Japanese man with a long history of schizophrenia experienced repeated relapses due to poor adherence to medication. For three months, his aged father covertly administered oral risperidone. This ethically unsustainable situation prompted a therapeutic shift. After engaging in shared decision-making focused on the patient's personal recovery goals, such as improving computer skills and living more independently, he consented to therapy with paliperidone palmitate LAI. The transition to LAI therapy resulted in marked clinical and functional improvements, evidenced by improved scores across all domains of the Brief Evaluation of Psychosis Symptom Domains and a significant increase in his Global Assessment of Functioning score. The patient resumed household tasks, participated in community activities, and expressed aspirations for the future, leading to dramatic improvements in quality of life and a substantial reduction in caregiver burden. This case highlights how LAIs can serve as a vital tool to resolve the ethical challenges of covert medication, respect patient autonomy, and align with principles of personal recovery. LAI antipsychotics offer an effective and ethically sound alternative to covert medication in schizophrenia. This approach can strengthen the therapeutic alliance, enhance patient autonomy, and lead to meaningful improvements in clinical symptoms and real-world functioning, providing a valuable solution within challenging sociocultural contexts.