Aripiprazole, Hypertension, and Confusion

Mrs. H. is an 80-year-old woman with a 15-year history of major depressive disorder without psychotic features. Previous antidepressant treatments included tricyclics, serotonin reuptake inhibitors, and serotonin-noradrenalin reuptake inhibitors. She also received augmentation strategies such as lithium, olanzapine, and dopaminergic agonists. Tolerance associated with all these therapeutics was always excellent. Unfortunately, she never achieved remission state. Ten years earlier, she underwent a coronary artery bypass graft surgery without any complications. She was treated for many years with low doses of aspirin, pravastatin, and bisoprolol for a moderate hypertension, and she was considered by cardiologists to be very well stabilized. She was treated with venlafaxine, 150 mg, without problems of hypertension related to the medication, and we decided to add aripiprazole, 5 mg, to potentiate the antidepressant effect of venlafaxine. About 48 hours after the first intake of aripiprazole, she became confused with symptoms such as loss of orientation, severe memory disturbances, and agitation. An arterial hypertension of 200/110 mmHg was measured, and the ECG was normal except for tachycardia (110 bpm). We decided to discontinue aripiprazole, and both hypertension and confusion resolved over 48 hours without treatment. The patient had never presented such symptomatology before. Over a period of 1 year, without addition of any new antihypertensive medication, and with venlafaxine treatment maintained during 4 months, the patient never experienced confusion again, and her blood pressure remained below 150/90 mmHg.

Our report tends to support the association between aripiprazole and hypertension in a geriatric patient suffering from major depression, confirming the Letter to the Editor published by Borras et al. 2 In addition, the prescription of aripiprazole also induced mental confusion, probably related to acute hypertension. 3 In the present case report, aripiprazole induced hypertension could have been induced by the preexisting cardiovascular risk factors. Another hypothesis could involve association with venlafaxine, an antidepressant known for its ability to increase blood pressure. In conclusion, we can say that particular caution is needed in the geriatric population more prone to polypharmacy and comorbid physical illnesses.