Low-Dose Risperidone for the Irritable Medically Ill Patient

Abstract

Received June 14, 1999; accepted July 28, 1999. From the National Institutes of Health (NIH), National Institute of Mental Health, Bethesda, Maryland. Address correspondence and reprint requests to Dr. Rosenstein, Chief, NIH Psychiatry-Consultation Liaison Service, Office of the Clinical Director, Intramural Research Program, National Institute of Mental Health, 10 Center Drive, MSC 1276, Room 3N238, Bethesda, MD 20892-1276. Copyright 2000 The Academy of Psychosomatic Medicine. One of the most difficult clinical management challenges for the consultation–liaison psychiatrist is the hostile, irritable, and uncooperative medical or surgical patient. Ill and physically uncomfortable patients characteristically express feelings of mild irritability and frustration. However, overt hostility, threats of aggression, and noncompliance with medical treatment frequently result in psychiatric consultation. These mood and behavioral dyscontrol syndromes, which do not meet diagnostic criteria for psychosis or delirium, can reflect longstanding character pathology or central nervous system effects of systemic illness and polypharmacy. Typically, management of such patients includes behavioral interventions and pharmacotherapy. Unfortunately, benzodiazepines can disinhibit these patients further, conventional neuroleptics can cause dysphoria and akathisia, and antidepressants require several weeks for beneficial mood effects. One pharmacological approach to the management of the medically ill and pathologically irritable patient is the use of the atypical neuroleptic risperidone. Several studies demonstrate beneficial effects of risperidone on hostility, aggression, agitation, and affective lability in various clinical populations. Although one report describes the efficacy of risperidone for the treatment of delirium, there are no published observations on the use of risperidone for other behavioral syndromes in medical inpatients. We report three patients who demonstrated rapid improvement in symptoms of irritability, hostility, and behavioral disinhibition after treatment with low-dose risperidone.