Abilify & Psychosis : Cogentin & Akathisia
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Q:  Abilify & Psychosis : Cogentin & Akathisia

I have two sort of separate questions for you, but hopefully relatively quick for you to answer.  I’m really hoping you choose to answer this as I’m desperate for help and answers.  My son is 13 and is diagnosed with Bipolar, possible schizophrenia, anxiety disorder(s), OCD, possible Aspergers.  He has been stable for nearly two years, taking 140 mg. Geodon, 1200 mg. Eskalith, and 1300 mg. Neurontin.  He experienced moderate to severe Akathesia on Geodon for which the Neurontin was added to counterbalance (and it did, along with providing some help with anxiety and stabilization I believe).  His (wonderful) psychiatrist passed away in November and I had to find another.  I’ve been happy with her, I think – that is to say I believe she’s “up” on childhood bipolar and current research, etc. (rare in my area).  Our first appointment with her in December, she asked if I would be interested in switching to Abilify – which I was.  We started gradually adding Abilify and when we had him up to 15 mg. started gradually decreasing Geodon.  It was pretty successful and we got him down to 60 mg.  The next drop (down to 40), things fell apart for him – psychosis, anxiety, etc. pretty bad.  We put him back up to 60 and now are supposed to increase his Abilify and get it up to 30 mg. before trying to back down the Geodon again.  Do you know – are you seeing – psychosis worsening or not being kept in check on Abilify?  This has been a miracle drug for us – it’s allowing my son’s personality to shine through the illness.  Something I thought was gone to the illness, but now I know better.  His affect isn’t nearly so flat, and he’s just generally more social, better hygiene, etc.  I am praying this isn’t a failure on Abilify for us.  

Second question.  Since he does suffer from Akathesia and is also somewhat rigid and stiff, she wants to prescribe Cogentin.  I have the script, but something’s been nagging me.  Now, in the back of my mind I seem to recall our last doctor saying Cogentin was really a last resort with Akathesia side effects from antipsychotics  - because it can induce psychosis.  I wouldn’t say his akathesia is extreme by any means – especially since we added Neurontin.  He’s still a little fidgety, but he’s not in constant movement like he was.  This is where I’m REALLY looking for advice.  What’s the deal with Cogentin?  Safe or not safe enough?  Psychosis is very a strong feature for my son.

Looking forward to your response.  Thank you in advance, Michele, concerned mom.

Dear Michele - 
That was a well-written summary.  Interesting course of events with those medications.  I've too little experience with Abilify so far -- haven't even prescribed it yet.  But I have seen some strong positives on the child and adolescent website (cabf.org) that may justify it's use in kids even though it's so new.  In any case apparently akathisia is a recognized problem for Abilify though in the one company-sponsored talk I heard, it was said to diminish on it's own at least somewhat. 

As for the Cogentin question:  I think I know what your former doc' was talking about, as Cogentin is an anticholinergic", antagonizing acetylcholine, and it's running low on acetylcholine that is part of the problem of Alheimer's dementia, which can basically look psychotic as it worsens.  There's not much question that anticholinergics can make elderly folks psychotic.  But, should this concern be generalized to anyone taking anticholinergics?  I've heard some speculation about that, but nothing firm. 

Therefore it's not really part of routine psychiatric care, as I understand it, to worry about Cogentin exacerbating psychosis, even though there is theoretical justification for that.  Instead, it is very routinely used with the older antipsychotics.  That's not to say we couldn't be missing something there, mind you.  

As an example of what you'll find if you search about (as you may have done already) on Cogentin and psychosis, here's an example from the RxMed website, under precautions for Cogentin:  

Mental confusion and excitement may occur with large doses, or in susceptible patients. Visual hallucinations have been reported occasionally. Furthermore, in the treatment of extrapyramidal symptoms due to CNS drugs, such as phenothiazines, and reserpine in patients with a mental disorder, occasionally there may be intensification of mental disorders. Although benztropine need not be discontinued when this occurs, the psychotogenic potential of antiparkinsonian drugs should be considered when planning the management of patients with mental disorders. Also, when using benztropine in these patients, they should be kept under careful observation especially at the beginning of treatment or if dosage is increased. In such cases, at times, increased doses of antiparkinsonian drugs can precipitate a toxic psychosis.

But again, except in the elderly, it is not routine to worry about Cogentin doing this unless it's obviously implicated (and again, that's not to say we shouldn't worry about it more; I do try to avoid having to use it, in part for this concern.  It has always seemed odd to me to commit oneself to having to add a second medication to combat the side effects of a first one.  Instead I try to use things like Trilafon, amongst the older ones; and to avoid Risperidone at doses greater than 2 mg, for example, which also brings on the muscle side effect problems that can include akathisia. 

Finally, it could be noted that Cogentin is not particularly good at treating akathisia, especially compared to other muscle side effect problems (as you may know, these are lumped under the term "extrapyramidal (literally "outside the pyramids", as the pyramidal tract is the voluntary muscle system, and this problem affects the involuntary muscle systems like posture and tone) symptoms" or EPS).  For akathisia, often beta-blockers like propanolol are used; and benzodiazepines like lorazepam.  Of course, there again is the problem of committing oneself to use an additional medication to counter the first -- but if the first is working really great....

Good luck with all that. 

Dr. Phelps

Published May, 2003


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