What is the best treatment approach for a client with a mood disorder, suicidal ideation, and new anxiety symptoms, currently taking lithium and Abilify (aripiprazole)?

Management of Mood Disorder with Suicidal Ideation and New Anxiety Symptoms

For a client with mood disorder, suicidal ideation, and new anxiety symptoms currently taking lithium and aripiprazole (Abilify), the optimal approach is to continue lithium therapy while carefully monitoring aripiprazole, as lithium has superior evidence for suicide prevention in mood disorders.

Current Medication Evaluation

Lithium

• Lithium is a first-line pharmacological treatment for bipolar disorder with suicidal ideation 1
• Multiple studies demonstrate lithium significantly reduces suicide risk in mood disorders:
  • Reduces recurrence of suicide attempts 8.6-fold in adults with bipolar or major affective disorders 2
  • Shows intrinsic anti-suicidal properties independent of its mood-stabilizing effects 3
  • Long-term lithium therapy provides greater benefits than short-term use for suicide prevention 3

Aripiprazole (Abilify)

• Currently prescribed at 4 mg daily for suicidal ideation
• FDA warning: Aripiprazole may increase risk of suicidality in patients under 24 years old 4
• Caution needed as aripiprazole can potentially cause:
  • Akathisia (18% of bipolar patients) 5
  • Anxiety and worsening of suicidal thoughts, particularly when combined with other medications 5
  • Requires close monitoring for emergence of agitation, irritability, or unusual behavior changes 4

Management Algorithm

1. Maintain lithium therapy

   • Continue as primary mood stabilizer due to proven anti-suicidal effects 2, 3
   • Ensure therapeutic blood levels are maintained
   • Monitor for side effects and toxicity

2. Evaluate aripiprazole's role

   • If patient is responding well without side effects, continue current dose
   • If anxiety symptoms appeared after starting/increasing aripiprazole, consider:
     • Reducing dose of aripiprazole
     • Discontinuing if anxiety or akathisia develops 5

3. Address new anxiety symptoms

   • Consider psychotherapeutic interventions:
     • Cognitive Behavioral Therapy (CBT) reduces suicidal ideation by more than 50% 1
     • Dialectical Behavior Therapy (DBT) if borderline personality features present 1
   • Avoid benzodiazepines as they may increase disinhibition 1

4. Safety measures

   • Ensure medication administration is monitored by a third party 1
   • Remove access to lethal means 1
   • Establish frequent follow-up appointments (within 24-48 hours initially) 1

Important Considerations and Pitfalls

1. Medication interactions

   • The combination of aripiprazole with other medications may increase risk of akathisia and anxiety 5
   • Monitor closely when multiple psychotropic medications are used together

2. Avoid unnecessary polypharmacy

   • "Although multiple agents are often required, care should be taken to avoid unnecessary polypharmacy" 2
   • Each additional medication increases risk of side effects and interactions

3. Monitoring for emergent symptoms

   • Watch for: anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, and mania 4
   • These symptoms may represent precursors to emerging suicidality 4

4. Age-related considerations

   • Younger patients (<24 years) have increased risk of suicidality with antipsychotics and antidepressants 4
   • Older adults may have decreased risk 4

5. Avoid relying solely on no-suicide contracts

   • Not proven effective and may give false reassurance 1
   • Comprehensive safety planning is more effective

The evidence strongly supports maintaining lithium as the cornerstone of treatment for mood disorders with suicidal ideation, while carefully evaluating the risk-benefit ratio of aripiprazole, particularly if it may be contributing to anxiety symptoms.