ANNALS OF CLINICAL PSYCHIATRY
LETTERS TO THE EDITOR
Obsessive-compulsive symptoms induced by long-acting injectable paliperidone in a patient with schizophrenia: A case report ANNALS OF CLINICAL PSYCHIATRY 2014;26(4):301-302
Javier Vázquez-Bourgon, MD; Pablo Rodríguez-Rodríguez, MD; Elsa Gómez-Ruíz, MS Psy; Jesús Artal, MD, PhD; Benedicto Crespo-Facorro, MD, PhD
TO THE EDITOR:
O
bsessive-compulsive symptoms (OCS) are common among patients with schizophrenia, with prevalence rates up to 30.3%.1 Although the pathophysiology underlying the presence of OCS in schizophrenia is unknown, it has been suggested their appearance may be a complication of secondgeneration antipsychotics, mainly because of these drugs' combined antagonistic action on D2 and 5-HT2 receptors. We report on a patient with psychosis who developed OCS when treated with paliperidone longacting depot injection.
Case report Mr. A, age 34, experienced his first psychotic episode 2 years ago, which was characterized by persecution delusions and disorganized behavior, and was diagnosed with paranoid schizophrenia. He initially was treated with oral risperidone, 3 mg/d, but he experienced partial response because of poor adherence. After 2 months he abandoned medication and withdrew from follow-up. One year later, he presented to a community mental health center with an exacerbation of psychotic symptoms. Because of his history of poor compliance, he was started on paliperidone long-acting injection, 100 mg/month, and within the following month, his delusional thoughts were adequately controlled. Six weeks later, he presented with distressing, obsessive thoughts about losing important documents and fre-
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quent checking compulsions that interfered with his daily functioning. Reducing the dosage of paliperidone to 75 mg/month, combined with a selective serotonin reuptake inhibitor—sertraline, 200 mg/d—gradually led to remission of his OCS.
DISCUSSION De novo emergence of OCS related to antipsychotic treatment in patients with schizophrenia has been reported. In most cases, patients who developed OCS were receiving risperidone and olanzapine,2,3 and more recently paliperidone.4 It has been suggested that the possible association between atypical antipsychotics and appearance of OCS is because of their common antagonistic activity at postsynaptic 5-HT2 and D2 receptors. Atypical anti psychotics are characterized by generally lower affinities for D2 receptors and higher affinities for 5-HT2 receptors; therefore they may, through 5-HT2 receptors, exert an inhibitory effect on the dopamine system, mostly at lower dosages.5 Paliperidone is a primary active metabolite of risperidone, with a high affinity for 5-HT2 serotonergic and D2 dopaminergic receptors. In 2011, the FDA approved the long-acting injectable formulation of paliperidone (paliperidone palmitate) for treating schizophrenia. However, to our knowledge, this is the first case report on antipsychotic-induced OCS caused by a long-acting injectable atypical antipsychotic and, in particular, paliperidone palmitate. We report a temporal relation, which may be causative, between emergence of OCS and paliperidone use, substantiated by administration of a long-acting injectable formulation. We acknowledge that OCS could have resolved faster if the patient was not receiving a long-acting injectable antipsychotic, which demonstrates the need for caution when using these drugs because it is difficult to revert treatment-emergent adverse effects. Our case supports previous findings suggesting that paliperidone might produce or exacerbate OCS in patients with psychosis; however, further investigations are needed to confirm these findings. ■
Annals of Clinical Psychiatry | Vol. 26 No. 4 | November 2014
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ANNALS OF CLINICAL PSYCHIATRY
LETTERS TO THE EDITOR The authors report no financial relationships with any company whose products are mentioned DISCLOSURE:
in this article, or with manufacturers of competing products.
REFERENCES 1. Swets M, Dekker J, van Emmerik-van Oortmerssen K, et al. The obsessive compulsive spectrum in schizophrenia, a meta-analysis and meta-regression exploring prevalence rates. Schizophr Res. 2014;152(2-3):458-468. 2. Lykouras L, Alevizos B, Michalopoulou P, et al. Obsessive-compulsive symptoms induced by atypical antipsychotics. A review of the reported cases.
Prog Neuropsychopharmacol Biol Psychiatry. 2003;27: 333-346. 3. Sareen J, Kirshner A, Lander M, et al. Do antipsychotics ameliorate or exacerbate obsessive-compulsive disorder symptoms? A systematic review. J Affect Disord. 2004;82:167-174. 4. Paparrigopoulos T, Tzavellas E, Karaiskos D, et al.
Paliperidone-induced obsessive symptoms. J Neuropsychiatry Clin Neurosci. 2011;23:E46. doi: 10.1176/appi. neuropsych.23.2.E46. 5. Ramasubbu R, Ravindron A, Lapierre Y. Serotonin and dopamine antagonism in obsessive-compulsive disorder: effect of atypical antipsychotic drugs. Pharmacopsychiatry. 2000;33:236-238.
Javier Vázquez-Bourgon, MD
Elsa Gómez-Ruíz, MS Psy
Benedicto Crespo-Facorro, MD, PhD
University Hospital Marqués de Valdecilla Institute for Training and Research (IDIVAL) Centro de Investigación Biomédica en Red de Salud Mental Santander, Spain
University Hospital Marqués de Valdecilla Institute for Training and Research (IDIVAL) Santander, Spain
University Hospital Marqués de Valdecilla Institute for Training and Research (IDIVAL) Centro de Investigación Biomédica en Red de Salud Mental Santander, Spain
Pablo Rodríguez-Rodríguez, MD University Hospital Marqués de Valdecilla Institute for Training and Research (IDIVAL) Santander, Spain
CORRESPONDENCE: Javier
Jesús Artal, MD, PhD University Hospital Marqués de Valdecilla Institute for Training and Research (IDIVAL) Santander, Spain
Vázquez-Bourgon, MD, Servicio de Psiquiatría, Hospital Universitario Marqués de Valdecilla, Avda, Valdecilla, s/n, Santander, Cantabria, 39008 Spain E-MAIL:
[email protected]
