Risperidone SSRIs

Agitation (chronic) Sodium divalproex Risperidone Olanzapine SSRI Trazodone Ziprasidone Haloperidol... 

Among these choices, bnspirone is preferred if the patient is also experiencing anxiety. If the patient is depressed and agitated, a SSRI should be tried first. Second line choices inclnde carbamazepine (Tegretol) or one of the atypical antipsychot-ics—ziprasidone (Geodon), risperidone (Risperdal), olanzapine (Zyprexa), quetiap-ine (Seroquel), or aripiprazole (Abilify) can be tried. If psychotic symptoms are present, one of the atypical antipsychotics should be tried first. 

Drugs that may interact with clozapine include caffeine, SSRIs, benzodiazepines, risperidone, CYP1A2 induces/inhibitors, CYP3A4 inhibitors, phenobarbital, and ritonavir. 

Studies of the use of the specific serotonin-uptake inhibitors (SSRIs) to treat OCD suggest that, compared to non-tic-related OCD, tic-related OCD is less responsive to SSRI monotherapy (McDougle et al., 1993, 1994). Addition of a neuroleptic, such as haloperidol (McDougle et ah, 1994), risperidone (McDougle et al., 2000), or olanzapine (Bogetto et al., 2000), appears to be useful in improving treatment-resistant individuals response to a SSRI. It is unclear whether this pattern of treatment response is specifically associated with a comorbid tic disorder the pattern of obsessive compulsive symptoms characteristic of TS or yet some other predictors. 

In most cases, SSRIs are the first choice for drugs to combat OCD. Clomipramine, fluvoxamine, fluoxetine, paroxetine, sertraline, and citalopram are all SSRIs that have been proven effective in reducing OCD symptoms. However, in about 40 to 60% of patients, these drugs do not completely alleviate all the symptoms. When this is the case, a second type of drug called a neuroleptic is often added. Neuroleptic drugs, such as haloperidol, clozapine, risperidone, and chlorpromazine... 

In a report of 122 elderly patients on risperidone, hypotension was noted in 28.7% and symptomatic orthostatic hypotension was noted in 9.8%. Significant decreases in blood pressure occurred with risperidone treatment (p = 0.0001) and were common in patients with cardiovascular disease and those taking an SSRI or valproate (p = 0.03) (502). Hence, like other antipsychotics, risperidone should be prescribed cautiously for elderly patients and those with preexisting cardiac disease. Its hypotensive versus its orthostatic hypotensive effects may be an age-related pharmacodynamic response. Blood pressure, including orthostatic blood pressure, should be monitored routinely until the risperidone dosage is stabilized. Furthermore, when risperidone therapy is initiated in the elderly, dosage should be titrated from 0.25 to 0.5 mg two times a day with increments of 0.25 to 0.5 mg weekly (92). 

In an open study of 11 patients with typical borderline personality, Schulz et al. ( 253) found substantial improvement with olanzapine, particularly in psychosis, but also in anergia, hostility, and interpersonal sensitivity. Szigethy and Schulz ( 254) reported improvement in one patient whose BPRS went from 46 to 28 with risperidone. Remission of self-mutilation has also been reported in one borderline patient undergoing treatment with risperidone, as well as an SSRI, for depression (255). This patient was then able to return to a full-time job. Although one should reserve judgment until more definitive studies are completed, the more favorable side effect profile of risperidone and olanzapine suggests that these drugs may be useful when psychotic or near psychotic symptoms are present. 

A number of antidepressant drugs, particularly SSRIs, can increase plasma prolactin concentrations, although galactorrhea is uncommon. In a prescription event monitoring survey of about 65 000 patients, compared with SSRIs, moclobemide was associated with a relative risk of galactorrhea of 6.7 (95% Cl = 2.7, 15) (727). However, this was substantially less than the risk associated with the dopamine receptor antagonist risperidone (relative risk compared with SSRIs 32 95% Cl = 14, 70). 

SSRIs are often prescribed with antipsychotic drugs, and some SSRIs inhibit CYP2D6, which can lead to increased blood concentrations of the antipsychotic drug. In 13 patients aged 26-56 years with schizophrenia, stabilized on risperidone 4-6 mg/day who took sertraline 50 mg/day for 4 weeks, plasma concentrations of risperidone and its major metabolite, 9-OH-risperidone, did not change... 

Combined treatment with atypical neuroleptic drugs and SSRIs is common and case reports have suggested that SSRIs can increase risperidone concentrations and increase the risk of extrapyramidal disorders (SEDA-23, 18). 

Karki SD, Masood GR. Combination risperidone and SSRI-induced serotonin syndrome. Ann Pharmacother 2003 37 388-90. 

Several factors increase the risk of thioridazine toxicity pre-existing cardiac disease, hypokalemia, a glucose load, alcohol, exercise, and concomitant therapy with tricyclic antidepressants, erythromycin, co-trimoxazole, cisapride, risperidone, hydroxyzine, and drugs that inhibit CYP2D6 (some SSRIs, fluphenazine, and perphenazine) (11). 

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