Психоз при потенцировании дулоксетина арипипразолом

"Ms. L" was a 49-year-old woman with chronic depression and postoperative cellulitis following a bunion excision. She was evaluated on the medical unit. She endorsed depressive symptoms, auditory hallucinations, and suicidal thoughts. The patient had previously attempted suicide twice by drug overdose. Her most recent suicide attempt was 7 months prior. Previous responses to sertraline and citalopram were poor. At the time of assessment on the medical unit, she was receiving duloxetine (40 mg twice daily), aripiprazole (1 mg/day), clonazepam (1 mg twice daily), and amoxicillin/clavulanate (850 mg twice daily).

The patient was started on duloxetine 7 months before. Ten days prior to admission, her primary care physician had started her on aripiprazole (2 mg/day) for augmentation. She denied a history of psychotic symptoms and drug or alcohol abuse as well as a family history of psychosis.

Three days after starting aripiprazole, Ms. L reported auditory hallucinations. She was paranoid regarding her ex-husband. She described command hallucinations from the devil, who meant to harm her, and could also hear God's voice encouraging her not to listen to the devil. She experienced concurrent onset of suicidal ideation with no plan. She was fully oriented, with no evidence of confusion. Aripiprazole was reduced to 1 mg/day, which led to amelioration of her hallucinations. However, her suicidal thoughts and paranoid beliefs persisted.

The psychiatric consultant decided to discontinue aripiprazole, leading to rapid and complete resolution of the patient's psychotic symptoms and suicidal ideation. Her ongoing depression was managed with duloxetine (60 mg twice daily).

New-Onset Psychosis and Emergence of Suicidal Ideation With Aripiprazole

Индивидуальное дозирование антипсихотиков

Paralleling the preclinical evidence, are there clinical data to suggest antipsychotic tolerance with continuous treatment? Work with first-episode schizophrenia has confirmed three findings related to antipsychotic treatment: (a) response to lower doses; (b) sensitivity to side effects; and (c) comparatively high response rate.[2,21] In contrast, the more chronic stages of schizophrenia are associated with higher antipsychotic doses and diminished clinical response,[22,23] keeping in mind that the chronic population is more heterogeneous and includes a larger proportion of refractory patients who may be receiving higher doses. While antipsychotic tolerance has been raised to account for a progressive decline in response,[24] nonadherence and/or illness progression are routinely endorsed as more viable explanations. That as many as 25% of individuals on depot antipsychotic therapy relapse[25] tempers the nonadherence argument, but at the same time does not rule out alternative explanations, eg, a discrete breakthrough episode vs tolerance per se. In contrast, the preclinical description of behavioral dopamine supersensitivity closely parallels the notion of "supersensitivity psychosis" and withdrawal dyskinesias reported clinically, linked to D2 upregulation as a result of ongoing antipsychotic exposure and observed in the face of drug discontinuation.[26–28]

Antipsychotic Dosing: How Much but Also How Often?

Психозы гиперчувствительности, психозы "отдачи", поздние психозы

* Антиаритмические препараты могут провоцировать аритмии, антибиотики могут способствовоать развитию новых видов инфекций, а антипсихотические препараты могут вызывать психоз.
* Как мы можем отличить поздний психоз от шизофрении?
* Не является ли иногда резистентная шизофрения на самом деле поздним психозом?
* Снижает ли применение некоторых новых антипсихотиков вероятность развития позднего психоза?

АНТИПСИХОТИЧЕСКИЙ ПСИХОЗ