What is the best course of action for a patient experiencing increased anxiety and visual hallucinations despite taking Lithium (lithium) 450mg twice daily (BID) and Risperidone (risperidone) 1mg BID, with a planned increase to 2mg daily, and who has recently discontinued Hydroxyzine (hydroxyzine) due to lack of efficacy and started Trazodone (trazodone) for improved sleep?

From the Guidelines

The patient's decision to discontinue hydroxyzine due to lack of benefit and the planned increase in risperidone dosage to 2mg daily are appropriate steps in managing their anxiety and visual hallucinations, respectively. The patient's symptoms of feeling scatter-brained and anxiety about eating due to fear of choking need to be addressed, possibly through cognitive behavioral therapy or other non-pharmacological interventions. The improvement in sleep with Trazodone is a positive outcome, and continued use may be beneficial for sleep disturbances, as supported by guidelines for managing behavior and mood disorders 1. Key considerations in the patient's treatment plan include:

• Regular monitoring of lithium levels to ensure therapeutic efficacy and avoid toxicity, as lithium is being used for mood stabilization at a dosage of 450mg twice daily.
• The increase in risperidone dosage to 2mg daily is in line with recommendations for managing psychotic symptoms like visual hallucinations, with risperidone being an atypical antipsychotic agent that can be used at a maximum dosage of 2 to 3 mg per day, usually twice daily in divided doses, as per guidelines 1.
• The patient's history of using cannabis for self-medication and feelings of being emotional should be taken into account when adjusting their treatment plan, possibly incorporating counseling or therapy to address these aspects.
• Given the patient's visual hallucinations and the plan to increase risperidone, it's crucial to monitor for potential side effects, including extrapyramidal symptoms, which may occur at dosages of 2 mg per day or higher, as noted in the guidelines for atypical antipsychotic agents like risperidone 1.

From the FDA Drug Label

The initial dose is 0.5 mg once daily, administered as a single-daily dose in the morning or evening. The dose may be adjusted at intervals of 24 hours or greater, in increments of 0.5 mg or 1 mg per day, as tolerated, to a recommended dose of 3 mg per day. Although efficacy has been demonstrated in studies of adolescent patients with schizophrenia at doses between 1 mg to 6 mg per day, no additional benefit was observed above 3 mg per day, and higher doses were associated with more adverse events. The initial dosing is 2 mg per day. May increase the dose at intervals of 24 hours or greater, in increments of 1 to 2 mg per day, as tolerated, to a recommended dose of 4 to 8 mg per day.

The patient is currently taking Risperidone 1 mg BID but will be increased to Risperidone 2mg daily to manage the visual hallucinations.

• The dose increase is within the recommended dose range for schizophrenia, which is 4 to 8 mg per day.
• However, the patient's current dose is being increased from 2mg daily (1mg BID) to 2mg daily, which is a relatively small increase.
• It is essential to monitor the patient's response to the new dose and adjust as needed to minimize adverse events.
• The patient should be periodically reassessed to determine the need for maintenance treatment 2.

From the Research

Patient's Current Situation

• The patient has been taking hydroxyzine for approximately a week but reported an increase in anxiety and a decrease in controllability of anxiety symptoms, leading to discontinuation of the medication.
• The patient experienced sleep disturbances but reported significant improvement after starting Trazodone.
• The patient is currently taking Lithium 450mg BID for mood stabilization and is encouraged to undergo blood work to determine the lithium level.
• The patient is taking risperidone 1 mg BID, which will be increased to 2mg daily to manage visual hallucinations.

Risperidone Dosage and Tolerability

• A study published in 2000 3 investigated the safety and tolerability of a rapid oral-loading regimen for risperidone, which achieved therapeutic doses within 24 hours.
• The study found that rapid-loaded risperidone was well-tolerated in most psychiatric inpatients, with no serious extrapyramidal side effects or adverse events.
• Another study published in 2001 4 recommended a target dose of 4 mg/day for most patients, with slower titration than previously recommended.
• The patient's current dosage of 1 mg BID, which will be increased to 2mg daily, is within the recommended range.

Hydroxyzine for Anxiety

• A study published in 2010 5 reviewed the efficacy and acceptability of hydroxyzine for generalized anxiety disorder (GAD) and found that hydroxyzine was more effective than placebo, but with a high risk of bias in the included studies.
• The study suggested that hydroxyzine may be equivalent in terms of efficacy, acceptability, and tolerability compared to other anxiolytic agents, but with a higher rate of sleepiness/drowsiness.

Risperidone for Augmentation Treatment

• A study published in 2011 6 reviewed the efficacy and safety of risperidone for augmentation treatment in patients with major depressive disorder who failed to achieve adequate response to antidepressant monotherapy.
• The study found that risperidone augmentation may be effective and safe when used at low doses, with improvement on various standardized depressive symptom assessment scales.
• However, the study noted that long-term effectiveness and safety cannot be determined at this time, and an adequate trial of first-line agents from different classes and/or a combination of agents from different classes would be recommended prior to initiation of risperidone.