Aripiprazole monotherapy in an adolescent worsens psychosis
A 16-year-old boy presented with an insidious onset illness, without any precipitating factor, continuous and progressive, of 1 year duration characterized by aloofness, anhedonia, amotivation, scholastic decline, auditory hallucinations of commanding and commenting type, delusion of reference, formal thought disorder, illogicality, fearfulness and suspiciousness. There were no depressive-cognitions, manic features or organic illness. Past or family history was insignificant. He presented to psychiatric services in mid 2011 after a suicidal attempt by consuming insecticide. Heamogram, renal-function, liver-function, electrocardiogram, computerized tomography of brain and thyroid function tests were normal. Psychiatric assessment revealed that he attempted to harm himself under the influence of the commanding auditory hallucination. His total positive and negative symptom scale score were 105 (Positive subscale score [PSS] 27, Negative subscale score [NSS] 35, General psychopathology score [GPS]-43) and clinical global impression scale score (CGIS) was 5. He was given tablet aripiprazole 15 mg/day and showed about 30% improvement in his psychopathology over the initial 4 weeks. His Total Positive and Negative Symptom Scale (TPANSS) improved to 73 (PSS 19, NSS 23, GPS-31) and CGIS to 4. In view of response, aripiprazole was increased to 20 mg/day. However, with dose increase, symptoms worsened despite good compliance, or no other psychosocial reason for worsening. By the 3rd day he reported fearfulness, somatic passivity, delusion of reference, hallucinatory behavior, formal thought disorder and poverty of content of speech. TPANSS score was 113 (PSS-29, NSS-36, GPS-48) and CGIS was 6. Extrapyramidal symptoms were not evident. Psychopathology reached near-baseline (at admission) after stopping aripiprazole. Parents were reluctant to continue with aripiprazole and resultantly the patient was given olanzapine 12.5 mg/day. By 3 weeks, overall psychopathology improved significantly and TPANSS decreased to 55 (PSS 12, NSS-18, GPS-25) and CGIS to 2. Causality assessment for adverse drug reaction (ADR) by Naranjo ADR probability scale of the index case showed a total score of +8, thereby establishing a probable causality between the drug and the ADR. For the last 8 months, the patient is maintaining well, has resumed schooling and is very near to his pre-morbid state.