Is the patient's irritability caused by Abilify (aripiprazole) or sertraline?

Irritability Can Be Caused by Both Abilify (Aripiprazole) and Sertraline

Both Abilify (aripiprazole) and sertraline can cause irritability as a side effect, though sertraline is more commonly associated with this symptom.

Medication-Induced Irritability: Evidence Analysis

Sertraline and Irritability

Sertraline (Zoloft) is well-documented to cause irritability:

• The American Academy of Sleep Medicine specifically lists SSRIs including sertraline as medications that can contribute to irritability 1
• According to pediatric guidelines, SSRIs including sertraline commonly cause "crying, irritability, tremors, poor suck, feeding difficulty, hypertonia, tachypnea, sleep disturbance" with onset within hours to days after administration 1
• Sertraline-induced irritability typically begins within hours to days of starting the medication and can last 1-4 weeks 1

Aripiprazole and Irritability

Interestingly, aripiprazole (Abilify) is actually FDA-approved for treating irritability in certain conditions:

• Aripiprazole is one of only two medications approved in the USA for treating irritability associated with autism spectrum disorders 2
• However, paradoxically, aripiprazole can also cause irritability as a side effect in some patients, though this is less commonly reported than with sertraline

Differential Features of Medication-Induced Irritability

Timing Considerations

• Sertraline-induced irritability: Typically begins shortly after initiation or dose changes
• Aripiprazole-induced irritability: Less predictable timing, may develop gradually

Associated Symptoms

• Sertraline-induced irritability often presents with:

  • Sleep disturbance
  • Increased anxiety
  • Restlessness
  • Agitation
  • Tremors 1

• Aripiprazole-induced irritability may present with:

  • Akathisia (reported in 12.9% of patients in one study) 3
  • Restlessness
  • Motor restlessness

Clinical Approach to Determining the Cause

1. Temporal relationship:

   • When did irritability begin in relation to starting each medication?
   • Was there a recent dose change in either medication?

2. Pattern of symptoms:

   • Sertraline-induced irritability often includes anxiety, restlessness, and sleep disturbance
   • Aripiprazole-induced irritability is frequently associated with akathisia

3. Medication history:

   • Previous reactions to similar medications
   • Duration of treatment with each medication

Management Options

If sertraline is determined to be the cause:

• Consider dose reduction
• Switch to a different SSRI with potentially fewer side effects
• Consider adjunctive therapy to manage irritability

If aripiprazole is determined to be the cause:

• Dose reduction may help
• Consider switching to another atypical antipsychotic
• Treat akathisia if present

Special Considerations

Drug Interactions

The combination of aripiprazole and sertraline may increase the risk of adverse effects:

• One case report documented myxedema coma associated with the combination of aripiprazole and sertraline 4
• The combination may increase the risk of serotonin syndrome in sensitive individuals

Monitoring Recommendations

• Closely monitor patients on both medications for worsening irritability
• Watch for signs of akathisia, which can be mistaken for worsening anxiety or irritability
• Assess for other neuropsychiatric symptoms that might indicate a need for medication adjustment

Conclusion

When determining whether irritability is caused by aripiprazole or sertraline, the temporal relationship to medication initiation or dose changes, associated symptoms (particularly akathisia with aripiprazole), and the pattern of irritability are key factors to consider. Sertraline is more frequently associated with irritability as a side effect, while aripiprazole is actually used to treat irritability in certain conditions but can paradoxically cause it in others.