What adjustments can be made to the treatment plan for a patient with bipolar depression and anxiety who is currently taking Aripiprazole (10mg daily), Lamotrigine (150mg daily), and Buspirone (15mg daily) and is still experiencing depressive and anxious symptoms?

Treatment Adjustments for Bipolar Depression and Anxiety with Persistent Symptoms

For a patient with bipolar depression and anxiety who is experiencing persistent symptoms despite current medication regimen of Aripiprazole 10mg, Lamotrigine 150mg, and Buspirone 15mg daily, the most effective adjustment would be to optimize the Lamotrigine dose to 200mg daily and increase Buspirone to 30mg daily in divided doses.

Current Medication Analysis

The patient is currently on:

• Aripiprazole 10mg daily (atypical antipsychotic)
• Lamotrigine 150mg daily (mood stabilizer)
• Buspirone 15mg daily (anxiolytic)

Despite this regimen, they continue to experience depressive and anxiety symptoms, indicating inadequate treatment response.

Recommended Medication Adjustments

Step 1: Optimize Current Medications

• Lamotrigine: Increase from 150mg to 200mg daily

  • Lamotrigine is a first-line treatment for bipolar depression
  • The therapeutic dose range extends to 200mg daily for optimal efficacy
  • This adjustment prioritizes treating the depressive component first 1

• Buspirone: Increase from 15mg to 30mg daily in divided doses

  • Current dose is at the lower end of the therapeutic range
  • Buspirone has moderate-quality evidence for augmentation in anxiety with depression
  • Recommended therapeutic dose is 15-30mg daily in divided doses 1

Step 2: Reassess Response After 4 Weeks

• If partial improvement but still symptomatic:

  • Consider increasing Aripiprazole to 15mg daily
  • Aripiprazole has demonstrated efficacy at 15mg daily for maintenance treatment of bipolar disorder 2

• If minimal improvement:

  • Consider adding bupropion as an augmentation strategy for residual depression
  • Bupropion is recommended by the American College of Physicians for augmentation 1

Monitoring and Follow-up

• Assess treatment response at 4 and 8 weeks after medication adjustments
• Monitor for side effects, particularly with increased Lamotrigine (rash) and Buspirone (dizziness)
• Target complete remission of both depressive and anxiety symptoms
• Use standardized measures to track symptom improvement

Rationale for Recommendations

1. Treating Depression First: Guidelines recommend addressing depression first in patients with comorbid anxiety and depression 3

2. Optimizing Current Medications: Before adding new agents, optimizing the doses of current medications is preferred to minimize polypharmacy 1

3. Evidence for Lamotrigine: Lamotrigine is established as effective for bipolar depression, with 200mg being a common target dose for optimal efficacy

4. Evidence for Buspirone Augmentation: Buspirone has demonstrated efficacy as an augmentation strategy for depression with anxiety, with doses up to 30mg daily showing better response 1

5. Aripiprazole Considerations: While the current 10mg dose of Aripiprazole is within therapeutic range, studies show 15mg daily may be more effective for maintenance treatment of bipolar disorder 2

Common Pitfalls to Avoid

• Undertreating: Inadequate dosing is a common reason for treatment failure in bipolar depression and anxiety
• Premature Switching: Changing medications before optimizing doses can lead to unnecessary medication trials
• Ignoring Adherence: Ensure the patient is consistently taking their medications as prescribed
• Overlooking Psychotherapy: Consider adding Cognitive Behavioral Therapy (CBT) as an adjunct to medication management, with approximately 14 sessions over 4 months 1

If these adjustments fail to provide adequate symptom relief after 8 weeks, consider a more substantial medication change, such as adding or switching to an SNRI like venlafaxine, which is recommended by the American Psychiatric Association for mixed anxiety and depression 1.