Combination of escitalopram and aripiprazole causes significant improvement of negative symptoms of simple schizophrenia
Journal
Psychiatry and clinical neurosciences
Journal Volume
68
Journal Issue
7
Start Page
582
End Page
583
ISSN
1323-1316
Date Issued
2014-07
Author(s)
Abstract
Treatment of the negative symptoms of schizophrenia (NSS) is a challenging topic. Here we present a woman with simple schizophrenia, whose chronic negative symptoms improved significantly under the combination of escitalopram and aripiprazole. Mrs C is a 60-year-old woman with simple schizophrenia. Her initial presentations were social withdrawal and deteriorated self-care ability. No significant delusion, hallucination or depressed mood was noted during her treatment course. Comprehensive evaluation revealed no physical illness or substance exposure. From age 46 to 53, NSS were prominent under flupentixol 20-mg/month injection. She was bedridden most of the time, and needed assistance with the activities of daily living. At age 54, flupentixol was shifted to aripiprazole 7.5 mg/day, than titrated up to 10 mg/day at age 56. Surprisingly, after we increased the dose for several months, she was able to complete basic personal care, but its quality was barely satisfactory. Escitalopram was augmented at age 58. Several months later, she spontaneously began exercising and communicating with family members. The negative symptoms score of the Positive and Negative Syndrome Scale reduced from 45 to 30 during the treatment process. There was no overt change in Mrs C's physical condition, environment, or relation with the medical system. In the case of Mrs C, there was stepwise improvement in NSS after aripiprazole and escitalopram were prescribed. The therapeutic effect reached a maximum when she was taking escitalopram 5 mg/day and aripiprazole 10 mg/day. The response time in our case was around 6 months to 1 year. The clinical response should be attributed to the pharmacological effect, as her psychosocial status was stationary. The effect of escitalopram and aripiprazole for the treatment of NSS has been individually explored. Because of the dopaminergic activating effect in the ventral tegmental area and the frontal cortex, aripiprazole plays a role in enhancing motivation.1 Recent research indicates that a combination of antidepressant and second-generation antipsychotic may provide a better therapeutic effect for NSS.2 Although escitalopram augmentation with antipsychotics showed no significant difference to placebo,3 the efficacy of escitalopram with an individual antipsychotic has yet to be clarified. It is generally accepted that cortical dopamine increases under 5-HT1 upregulation and 5-HT2 downregulation. Besides the D2 partial agonist effect of aripiprazole, both aripiprazole and escitalopram can be viewed as 5-HT1A receptor agonists. Escitalopram increases serotonin in the synapse, while aripiprazole is a 5-HT1A partial agonist.2 Therefore, the synergic effect on 5-HT1A somatodendritic autoreceptors may reduce 5-HT2A inhibition on dopaminergic neurons, then cause significant prefrontal dopamine release.2 This case indicates that a combination of aripiprazole and escitalopram is beneficial for NSS. The clinical improvement may take several months' observation. Further study is needed to examine whether the regimens actually improve the daily function of simple schizophrenia.
Type
letter