Starting Dose of Aripiprazole for Depression with Psychosis
Start aripiprazole at 10 mg once daily for a patient with depression and psychosis who is already on escitalopram. 1
Rationale for 10 mg Starting Dose
The FDA-approved starting and target dose for aripiprazole is 10 or 15 mg/day administered once daily without regard to meals. 1 For your specific clinical scenario of depression with psychosis:
Depression with psychosis requires concomitant antipsychotic medication alongside the antidepressant (escitalopram/Lexapro in this case). 2
The 10 mg dose represents the lower end of the FDA-recommended starting range and is appropriate given that this patient is already on an SSRI (escitalopram), which is a moderate CYP2D6 inhibitor. 1
Evidence Supporting This Combination
The combination of escitalopram and aripiprazole has been specifically studied in psychotic major depression:
In a 7-week open trial of escitalopram combined with aripiprazole (flexibly dosed up to 30 mg/day) for psychotic major depression, the response rate was 62.5% and remission rate was 50%. 3
This combination was found to be effective and safe for treating major depressive disorder with psychotic features. 3
Dosing Considerations and Adjustments
Important factors that may require dose modification:
Do not increase the dose before 2 weeks, as this is the time needed to achieve steady-state plasma concentrations. 1
Since escitalopram has some CYP2D6 inhibitory effects (though moderate), monitor closely for side effects, particularly akathisia. 3
If akathisia develops (which occurred in 10 of 16 patients in the escitalopram-aripiprazole study), it typically resolves with dose adjustment or propranolol treatment. 3
Monitoring and Titration
Key monitoring parameters:
Assess for akathisia, which is the most common side effect requiring intervention with this combination. 3
Older or frail patients should receive lower doses to minimize risk of dizziness and unsteady gait. 4
The therapeutic dose range for aripiprazole is 10-30 mg/day, though doses higher than 10-15 mg/day have not shown superior efficacy in schizophrenia trials. 1, 5
Common Pitfall to Avoid
Do not start at 5 mg in this clinical context. While 5 mg is sometimes used in other indications or for dose adjustments, the FDA label clearly specifies 10 or 15 mg as the starting dose for psychotic conditions. 1 Starting at 5 mg would be subtherapeutic and delay treatment response in a patient with psychotic depression.