Mood Fluctuations After Starting Buspirone and Aripiprazole for PTSD
The fluctuating "high and low" mood is most likely caused by aripiprazole's partial dopamine agonist activity, which can produce paradoxical activation and agitation in PTSD patients, particularly within the first days of treatment. 1, 2
Likely Cause of Symptoms
Aripiprazole is the primary culprit for these mood fluctuations. The medication's unique mechanism as a dopamine D2 partial agonist can cause behavioral activation, agitation, and mood instability, especially early in treatment. 1, 2
- Aripiprazole-induced activation and agitation occur in approximately 15.5% of patients, with symptoms appearing most commonly in the first 30 days of treatment. 3, 2
- The 5 mg dose is relatively low, but adverse effects from aripiprazole's partial agonist properties are documented even at lower doses and can manifest as restlessness, mood swings, and subjective feelings of being "high." 2
- Women experience aripiprazole adverse effects three times more frequently than men, which may be relevant depending on patient sex. 2
Buspirone is unlikely to be causing these specific symptoms. While buspirone can cause nervousness (4% incidence) and excitation (2% incidence), these are typically mild and do not present as fluctuating "high and low" mood states. 4
Immediate Management Steps
Discontinue aripiprazole immediately and reassess the patient's symptoms over 48-72 hours. Most aripiprazole-induced behavioral symptoms resolve within 30 days of discontinuation or dose reduction. 3
- Monitor closely for resolution of mood fluctuations after stopping aripiprazole. 3
- Continue buspirone at 5 mg if tolerated, as it has minimal adverse effects and may provide benefit for PTSD-related anxiety symptoms. 5, 4
Evidence-Based PTSD Treatment Alternatives
Neither buspirone nor low-dose aripiprazole represents guideline-based first-line treatment for PTSD. 6, 7
For core PTSD symptoms, initiate sertraline 25 mg daily, titrating to 150-200 mg over 4-6 weeks. SSRIs are the only FDA-approved medications for PTSD with proven efficacy. 7
For PTSD-related nightmares specifically:
- Start prazosin 1 mg at bedtime, titrating by 1-2 mg every few days to effective doses of 3-15 mg/day based on blood pressure tolerance. 6, 7
- Alternative options include trazodone 25-50 mg at bedtime or clonidine 0.1 mg twice daily if prazosin is ineffective or not tolerated. 6, 7
If aripiprazole was being used for nightmare treatment: The recommended dose for nightmares is 15-30 mg/day, not 5 mg, and it is considered a third-line option only after prazosin, clonidine, and risperidone have failed. 6
Critical Clinical Pitfalls
- Do not continue aripiprazole at 5 mg for PTSD. This dose is subtherapeutic for any indication and increases the risk of activation without therapeutic benefit. 6, 8
- Do not use benzodiazepines for chronic PTSD management despite patient distress, as they lack efficacy for core PTSD symptoms and carry dependence risk. 7
- Monitor for impulsive-compulsive behaviors if aripiprazole is ever reintroduced, including gambling, hypersexuality, and compulsive shopping, which can emerge within 30 days of starting treatment. 3
- Avoid combining multiple serotonergic agents (buspirone + SSRI) initially without careful monitoring for serotonin syndrome. 7