Depression Severity May Predict Akathisia Risk With Aripiprazole Augmentation in Older Adults

Adding the antipsychotic aripiprazole to an antidepressant regimen can benefit older patients with treatment-resistant depression, but the strategy comes with risks: aripiprazole augmentation can cause extrapyramidal symptoms, such as akathisia and parkinsonism, according to a study in the Journal of Clinical Psychiatry. Thus, clinicians need to pay close attention when prescribing aripiprazole to older patients with more severe depressive symptoms.

Jonathan H. Hsu, M.D., of the University of Toronto, and colleagues analyzed data collected during a randomized, controlled trial evaluating the efficacy and safety of aripiprazole augmentation for adults aged older than 60 years with treatment-resistant depression. Patients who did not achieve remission after receiving venlafaxine extended-release (up to 300 mg/day) for 12 weeks were randomly assigned to receive aripiprazole augmentation (maximum dose 15 mg/day) or placebo for 12 weeks. Throughout the trial, the researchers assessed patients for extrapyramidal symptoms.

Forty (44%) of the 91 participants randomly assigned to aripiprazole achieved remission compared with 26 (29%) of 90 randomly assigned to placebo—a significant difference. Akathisia was the most common adverse effect of aripiprazole; 24 (26.7%) developed akathisia compared with 11 (12.2%) of participants assigned to placebo. Those who developed akathisia had higher depression severity at baseline. Aripiprazole was also associated with more parkinsonism; 15 people in the aripiprazole group (16.5%) developed parkinsonism compared with 2 (2.2%) in the placebo group. No clinical predictors or correlates for parkinsonism were identified. The researchers noted that most participants who developed akathisia improved over time, especially when aripiprazole dose was lowered.

“Fortunately, most older depressed patients who are prescribed aripiprazole will not develop akathisia, yet the emergence of these symptoms should be assessed carefully, particularly during initial dosage titration,” Hsu and colleagues concluded.

For related information, see The American Psychiatric Association Publishing Textbook of Psychopharmacology.

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Study Finds Rates of SGA-Related Neuromotor Side Effects Are Similar in Youth, Adults

Rates of extrapyramidal side effects (EPS) in young people related to use of second-generation antipsychotics (SGA) do not appear to differ from those reported in adults and are particularly low in youth taking quetiapine and olanzapine, according to a report online in the Journal of the American Academy of Child and Adolescent Psychiatry.

Christoph Correll, M.D., of Zucker Hillside Hospital in Glen Oaks, N.Y., and colleagues analyzed data from the Second-Generation Antipsychotic Treatment Indications, Effectiveness and Tolerability in Youth (SATIETY) inception cohort study. EPS was assessed at baseline and four, eight, and 12 weeks after naturalistic SGA initiation for schizophrenia, mood, disruptive behavior, and autism spectrum disorders in 342 young people (aged 4 to 19). Drug-induced parkinsonism was defined by incident mean score on the Simpson-Angus Scale (SAS) of more than 0.33, anticholinergic initiation, or an increasing SAS score of two or more in patients with baseline EPS.

Of the cohort, 15.2% developed drug-induced parkinsonism. Raw SGA-grouped drug-induced parkinsonism rates were 1.5% for patients taking quetiapine, 13.8% for olanzapine, 16.1% for risperidone, 20.0% for ziprasidone, and 27.3% for aripiprazole. SGA type, dose, higher age, and lower baseline functioning were jointly associated with drug-induced parkinsonism.

“Overall rates of drug-induced parkinsonism during second-generation antipsychotic (SGA) treatment were low, indicating that the short-term neuromotor adverse effects of SGAs during routine care are not a major clinical problem,” the researchers stated. “During naturalistic treatment, particularly low rates of drug-induced parkinsonism were found with quetiapine, indicating that youth prone to extrapyramidal adverse effects might benefit from this drug choice.

For related information, see the Psychiatric News article “More Youth Using Antipsychotics Concurrent With Other Medications.”

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