Management of Agitation in a 14-Year-Old Female on Multiple Psychiatric Medications
The agitation and aggressive episode in this 14-year-old female is most likely related to aripiprazole, which should be discontinued and replaced with an alternative medication such as risperidone or quetiapine.
Medication Analysis and Likely Cause
The patient is currently on:
- Abilify (aripiprazole) 2mg - added 1.5 months ago
- Clonidine 0.2mg
- Divalproex (valproate) 1000mg DR
- Concerta (methylphenidate) 18mg
The timing of the aggressive episode (1.5 months after starting aripiprazole) strongly suggests aripiprazole as the culprit. This is supported by evidence that aripiprazole can paradoxically worsen agitation and aggression due to its unique partial dopamine agonist mechanism 1.
Recommended Medication Adjustments
Discontinue aripiprazole immediately
- Aripiprazole's partial dopamine agonism may increase dopaminergic activity in patients with long-term use of dopamine-blocking agents, worsening positive symptoms like agitation and aggression 1
Replace with alternative antipsychotic:
First option: Risperidone 0.5mg BID (starting dose, can be titrated)
- The American Academy of Child and Adolescent Psychiatry recommends risperidone as an effective alternative antipsychotic for children and adolescents 2
- Begin with 0.5mg twice daily and titrate based on response
Alternative option: Quetiapine 25-50mg BID (if risperidone not tolerated)
- Has less extrapyramidal side effects than risperidone
- May provide additional mood stabilization alongside divalproex
Maintain current doses of other medications:
- Continue divalproex 1000mg DR (provides mood stabilization)
- Continue clonidine 0.2mg (helps with impulsivity and agitation)
- Continue Concerta 18mg (for ADHD symptoms)
Monitoring Plan
- Schedule follow-up within 1-2 weeks to assess response to medication changes
- Monitor for:
- Resolution of agitation and aggressive behavior
- Emergence of extrapyramidal symptoms (especially with risperidone)
- Sedation (especially with quetiapine)
- Weight gain and metabolic parameters
- QTc prolongation (baseline ECG recommended with antipsychotic switch) 3
Rationale for Recommendation
Evidence for aripiprazole-induced agitation:
- Case reports document worsening agitation, anxiety, and aggression after aripiprazole initiation in patients with schizophrenia or schizoaffective disorder 1
- The timing of symptom onset (1.5 months after starting) aligns with reported cases
Evidence for alternative options:
- The American Academy of Child and Adolescent Psychiatry supports the use of alternative antipsychotics when one agent is ineffective or causes adverse effects 2
- Risperidone has established efficacy and safety in pediatric populations
- Maintaining the other medications is appropriate as they were previously effective before aripiprazole was added
Important Considerations
Avoid benzodiazepines for long-term management in adolescents due to risk of dependence, though they may be used short-term for acute agitation 2
Clonidine (which the patient is already taking) is an appropriate adjunctive agent for agitation in children and adolescents 2
Non-pharmacological approaches should be implemented alongside medication changes:
- Behavioral therapy
- Environmental modifications to reduce triggers
- Regular sleep schedule
- Stress reduction techniques
Monitor for withdrawal symptoms when discontinuing aripiprazole, though these are typically mild with this medication
If agitation persists despite these changes, consider consulting with a pediatric psychiatrist for further medication adjustments or diagnostic reassessment.