Letters to the Editor
Antiaggressive Action of Combined Risperidone and Quetiapine in a Patient With Schizophrenia
Dear Editor:
Aggressive and hostile behaviours can be manifestations of schizophrenia, among other mental disorders (for example, mood disorders and dementia) (1) and contribute considerably to institutionalization (2). In patients with chronic schizophrenia, clozapine treatment has resulted in a selective improvement in aggressive behaviour, beyond the global improvement shown on the Brief Psychiatric Rating Scale (BPRS) (3,4), although this improvement did not necessarily extend to the positive symptoms of psychosis (5). Risperidone treatment showed a greater selective effect on hostility in schizophrenia patients than did haloperidol or placebo (6), although there are some contradictory data from an open trial comparing risperidone and haloperidol (7). In clinical practice, risperidone has proven very useful in treating aggression and violence in patients with chronic refractory schizophrenia (8). In a case series, olanzapine had better, but not significantly different, tranquilizing properties after 3 days of treatment, compared with haloperidol (9). Quetiapine in high dosages (up to 900 mg daily) was used successfully in 2 treatment-resistant patients with schizophrenia and concomitant aggression (10,11). In the first instance, quetiapine was added to divalproex sodium (10), and in the second, it was coadministered with risperidone (11).
In this report, we describe the case of a patient with an unremitting acute psychotic episode whose hostility and aggressive symptoms improved soon after he was given combined quetiapine and risperidone.
Case Report
A 35-year-old, unmarried man was involuntarily admitted to our clinic. He showed auditory hallucinations, delusions of persecution and reference, aggressiveness, psychomotor agitation, and restricted affect. He appeared markedly dishevelled. His score on the Brief Psychiatric Rating Scale (BPRS), in which each item is rated 1 to 7, was 57; on tension, hostility, and agitation he had a score of 6 (severe). His psychiatric problems started about 3 years ago, when he stopped working and showed total social isolation, wandering, and untriggered and unpredictable verbal outbursts. He refused any psychiatric treatment and was diagnosed with schizophrenia, paranoid type, according to DSM-IV criteria.
He refused medication and was therefore given haloperidol 30 mg daily intramuscularly for 5 days. When he subsequently consented to take medication, risperidone was gradually added while the dosage of haloperidol was slowly tapered. After 20 days, his regimen consisted only of risperidone 12 mg daily. However, he did not show any sign of improvement, and any effort to stop restraint failed. As a result, after 1 week of risperidone monotherapy, quetiapine was added and titrated to 500 mg daily in 5-day intervals. When he was evaluated 1 week later, he showed marked improvement in symptoms, scoring 36 on the BPRS; on hostility and tension, he scored 2 (very mild), and on agitation, 3 (mild). After about 40 days of hospitalization the patient was released from restriction, and 2 weeks later, he was discharged from our clinic. His risperidone was decreased to 8 mg daily; no change was made in his daily quetiapine dosage. One month after discharge, his clinical state remains the same, with no deterioration or improvement (BPRS score, 33); however, he exhibits no further aggressive or hostile behaviour. For the first time in 3 years, he visited his workplace, and he is planning to resume working.
Discussion
In our patient, aggression, hostility, and agitation were controlled in a very short time after he was given combined risperidone and quetiapine. A major factor of the superior therapeutic effects of atypical antipsychotics is 5-HT2A receptor blockade. Through this action, atypical antipsychotics may regulate prefrontal and limbic dopamine release during cognitive activity and stress. Some data also indicate that certain atypical antipsychotic drugs (clozapine, quetiapine, and ziprasidone) have important 5-HT1A receptor agonist properties (12). These effects of atypical antipsychotics may contribute to their antiaggressive action, because central serotonin deficit and prefrontal, as well as limbic system, dysfunction has been associated with aggressive behaviour (1). However, no conclusive remarks can be made for the antiaggressive action of quetiapine as monotherapy or combination therapy until more systematic studies appear in the literature.
References
1. Volavka J. The neurobiology of violence: an update. J Neuropsychiatry Clin Neurosci 1999;11:307–14.
2. White L, Parrela M, McCrystal-Simon J, Harvey PD, Masiar SJ, Davidson M. Characteristics of elderly psychiatric patients retained in a state hospital during downsizing: a prospective study with replication. Int J Geriatr Psychiatry 1997;12:474–80.
3. Volavka J, Zito JM, Vitrai J,Czobor P. Clozapine effects on hostility and aggression in schizophrenia.
J Clin Psychopharmacol 1993;13:287–9.
4. Buckley P, Bartell J, Donenwirth K, Lee S, Torigoe F, Schulz SC. Violence and schizophrenia: clozapine as a specific antiaggressive agent. Bull Am Acad Psychiatry Law 1995;23:607–11.
5. Hector RI. The use of clozapine in the treatment of aggressive schizophrenia. Can J Psychiatry 1998;43:466–72.
6. Czobor P, Volavka J, Meibach RC. Effect of risperidone on hostility in schizophrenia. J Clin Psychopharmacol 1995;15:243–9.
7. Buckley PF, Ibrahim ZY, Singer B, Orr B, Donenwirth K, Brat PS. Aggression and schizophrenia: efficacy of risperidone. J Am Acad Psychiatry Law 1997;25:173–81.
8. Vesce J, Comaty JE, Advokat C. Antiaggressive action of atypical antipsychotics in patients with schizophrenia. J Clin Psychopharmacol 2001;21:353–5.
9. Karagianis JL, Dawe IC, Thakur A, Bégin S, Raskin J, Roychowdhury SM. Rapid tranquilization with olanzapine in acute psychosis: a case series. J Clin Psychiatry 2001;62 (Suppl 2):12–6.
10. Brooks JO. Successful outcome using quetiapine in a case of treatment-resistant schizophrenia with assaultive behavior. Schizophr Res 2001;50:133–4.
11. Chue P, Welch R, Snaterse M. Combination risperidone and quetiapine therapy in refractory schizophrenia. Can J Psychiatry 2001;46:86–7.
12. Ichikawa J, Meltzer HY. Relathionship between dopaminergic and serotonergic neuronal activity in the frontal cortex and the action of typical and atypical antipsychotic drugs. Eur Arch Psychiatry Clin Neurosci 1999;249 (Suppl 4):90–8.
Vasilis P Bozikas, MD, PhD; Charoula Deseri, MD;
Stergios Pitsavas, MD, PhD; Athanasios Karavatos MD, PhD
Thessaloniki, Greece
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