Suicidality and psychotic episodes after starting aripiprazole: two case reports

Abstract

Switching antipsychotic medication must be done carefully to ensure patient safety and a successful response. Here, we present two major psychotic decompensations that occurred following a switch to aripiprazole in two patients with schizophrenia. Mr. X was treated with paliperidone and experienced residual anxiety. Thus, a switch to aripiprazole was planned with risperidone and a gradual decrease in paliperidone. Initially, an increase in aripiprazole resulted in remission of his residual symptoms. However, two weeks later, he presented an anxiety relapse with persecutory ideas which required hospitalization. Mr. Y, who was treated for many years with risperidone, presented with a treatment resistant psychotic episode. A switch to aripiprazole enhanced his clinical condition. Despite the initial improvement, soon after discharge from the hospital, the patient presented psychotic symptoms requiring home intervention. Ultimately, the patient in the midst of a delusional recrudescence, had killed himself when the health care team arrived. A strong dopamine antagonist may lead to the development of dopaminergic upregulation. The addition of a partial agonist to these hypersensitive neurotransmitter pathways could explain these episodes. We agree with previous reports and recommend careful management when switching from strong dopamine antagonists to aripiprazole.

Advances in the treatment of depression

“…For example, special care should be taken when switching from full dopamine D2 receptor antagonists to partial agonists, such as aripiprazole, because of the risk of temporary symptomatology worsening (Pae et al, 2010). A case report in this issue describes two patients who showed worsening of delusional and suicidal ideation (Meyer et al, 2022) after switching from complete to partial D2 receptor antagonists. Despite the difficulty in establishing a causal effect, because of the multidetermined nature of clinical symptoms, the cases suggest caution in this specific drug switch and the probable benefit of using a cross-tapering strategy for a few weeks.…”