What are the recommendations for a patient taking Lexapro (escitalopram) 20 mg and Abilify (aripiprazole) 5 mg for bipolar disorder?

Management of Bipolar Disorder with Lexapro and Abilify

Escitalopram (Lexapro) 20 mg should be discontinued and replaced with evidence-based mood stabilizers, as antidepressants are contraindicated as monotherapy in bipolar disorder due to the risk of inducing mania, mixed states, or rapid cycling. 1

Inappropriate Medication Regimen for Bipolar Disorder

The current medication regimen of escitalopram 20 mg and aripiprazole 5 mg is not optimal for bipolar disorder management for several reasons:

1. Antidepressants like escitalopram should not be used as primary treatment for bipolar disorder

   • They can trigger manic/hypomanic episodes, mixed states, or rapid cycling 1
   • Should only be considered as adjunctive therapy after establishing adequate mood stabilization 1

2. Aripiprazole (Abilify) alone is insufficient for bipolar disorder management

   • While effective for acute mania and prevention of manic episodes, evidence does not support its efficacy for bipolar depression 2, 3
   • Studies show limited therapeutic activity in bipolar depression compared to other options 4

Recommended Treatment Approach

First-line Recommendations:

1. Discontinue escitalopram with appropriate tapering to avoid discontinuation syndrome 5

2. Initiate evidence-based mood stabilizer therapy:

   • Lithium (target serum level 0.6-1.2 mEq/L) - requires baseline CBC, thyroid function, renal function, and serum calcium monitoring 1
   • Lamotrigine - particularly effective for bipolar depression with lower risk of metabolic side effects 1
   • Valproate - alternative option (use cautiously in females due to PCOS risk) 1

3. Consider optimizing antipsychotic therapy:

   • Olanzapine-fluoxetine combination (OFC) has highest efficacy for bipolar depression 1, 4
   • Quetiapine or lurasidone may be beneficial alternatives, especially for patients with anxiety 1, 4
   • If continuing aripiprazole, it should be used as adjunctive therapy with a mood stabilizer, not as monotherapy 6

Monitoring Requirements:

• Weekly assessments for the first 4 weeks after medication changes to monitor for:

  • Emergence of manic/hypomanic symptoms
  • Withdrawal symptoms from escitalopram 1
  • Potential side effects of new medications

• Regular laboratory monitoring based on chosen therapy:

  • Lithium: serum levels, thyroid function, renal function
  • Valproate: liver function, CBC, pregnancy tests
  • Atypical antipsychotics: weight, BMI, blood pressure, fasting glucose, lipid panel 1

Important Considerations and Pitfalls

1. Risk of serotonin syndrome: When changing medications, be aware of potential serotonin syndrome from drug interactions, especially if combining multiple serotonergic agents 5

   • Symptoms include mental status changes, neuromuscular hyperactivity, and autonomic hyperactivity
   • Can occur within 24-48 hours after combining medications

2. Akathisia with aripiprazole: A significant concern with aripiprazole is the development of akathisia, reported in up to 42% of patients with bipolar depression 7

   • Monitor closely for restlessness, inability to sit still, or inner feeling of restlessness

3. Limited efficacy of aripiprazole for bipolar depression: While aripiprazole is FDA approved for acute mania and maintenance therapy to prevent manic episodes, studies have not demonstrated efficacy for acute bipolar depression or prevention of depressive episodes 2, 4, 3

4. Treatment adherence challenges: Over 50% of bipolar patients are non-adherent to treatment, highlighting the need for close monitoring and support 1

5. Drug interactions: Escitalopram may have fewer drug interactions compared to other SSRIs, but still requires caution when combining with other medications 5

By implementing these evidence-based recommendations, the patient's bipolar disorder can be more effectively managed with reduced risk of mood destabilization and improved outcomes.