Akathisia in Elderly Female Patient with Schizophrenia upon concurrent use of Risperidone and Sertraline

Second Generation Antipsychotics (SGAs) are used in the treatment of various psychiatric disorders. While SGAs have a risk of side effects including Extrapyramidal Symptoms (EPS)...

Second Generation Antipsychotics (SGAs) are used in the treatment of various psychiatric disorders. While SGAs have a risk of side effects including Extrapyramidal Symptoms (EPS), they are generally considered to have a lower risk than their counterparts First Generation Antipsychotics (FGA's). In the spectrum of SGAs, risperidone has the highest risk and clozapine has the lowest risk for causing EPS. Several other characteristics and steps of care may influence the development of EPS including advanced age, female sex, non-caucasian race, history of EPS, higher doses of antipsychotics, choice of antipsychotics, and presence of comorbid medical conditions. Selective Serotonin Reuptake Inhibitors (SSRIs) are also known to cause EPS, although the risk is low with sertraline having the lowest propensity amongst SSRIs. We present a case of 57-year old Hispanic female with schizophrenia who had responded favorably to 6 mg of risperidone without any side-effects but then developed akathisia on 8 mg of risperidone and 25 mg of Sertraline. This case corresponds to the current notion about the various risk factors that predispose a patient to developing EPS while using risperidone. The complicated care management of this patient with FGA's and her gender with advanced age all may have increased her propensity to develop EPS. Co-administration of risperidone with sertraline provided enough additive effect, in combination with underlying risk factors, to induce EPS in this patient.
There is also one case study where a patient had a good response to 20 mg of risperidone without any side-effects contrary to the current literature [4], and another prospective study depicted contrasting results that the prevalence of tardive dyskinesia (TD) with risperidone is similar to that of olanzapine [5]. Selective Serotonin Reuptake Inhibitors (SSRIs) are also known to cause EPS, although the risk is low. There have been a few studies and reports showing that SSRIs increase the risk of EPS especially when used concomitantly with antipsychotics in patients with additional risk factors [6,7]. Among SSRIs, fluoxetine has the highest propensity to cause EPS, and sertraline has the lowest risk. We present a case of 57-year old Hispanic female with schizophrenia who had responded favorably to 6 mg of risperidone without any sideeffects but then developed akathisia on 8 mg of risperidone and 25 mg of Sertraline. This case corresponds to the current notion about the various risk factors that predispose a patient to developing EPS while using risperidone.  [8]. This is again consistent with our clinical case. The patient had a chronic history of schizophrenia and has been trialed on various medications in the past. Additionally, as Woerner et al. [5], had suggested that previous exposure to the FGAs (especially Haloperidol) is a risk factor for the development of EPS again consistent to our patient, who was trialed on Haloperidol before switching her to Risperidone.

Conclusion
In sum, there have been numerous reported clinical cases in the past demonstrating dose related EPS from Risperidone, and as mentioned in the introduction there have also been some studies showing contrasting results. This clinical case highlights the significance of assessing the above-mentioned risk factors before prescribing higher doses of risperidone, gradually titrating the dose of risperidone, and exerting caution in concomitant use of SSRI's with antipsychotics especially in high-risk patients. This scrutiny can avoid many of the adverse effects to our patients, which can improve medication adherence which is a major concern in this patient population.

Conflicts of Interest
The authors have no conflicts or interests to declare.

Disclosures
Authors have nothing to disclose.