What is the next intervention for a 17-year-old female with bipolar type one disorder, currently taking Latuda (lurasidone) 300 mg and lithium 600 mg, with a history of self-harm and persistent depressed mood?

Next Intervention for 17-Year-Old Female with Bipolar I Disorder and Persistent Depressed Mood

Lamotrigine should be added to the current regimen as the next intervention for this 17-year-old female with bipolar I disorder experiencing persistent depressed mood despite treatment with Latuda (lurasidone) and lithium. 1

Rationale for Adding Lamotrigine

• The patient is currently on lurasidone 300 mg and lithium 600 mg without full benefit
• She has persistent depressive symptoms and a history of self-harm
• According to the American Psychiatric Association guidelines, lamotrigine is the first alternative choice for patients with bipolar disorder who do not respond to lithium, particularly for those with predominantly depressive episodes 1
• Lamotrigine has demonstrated efficacy specifically for depressive episodes in bipolar disorder and has minimal sexual and metabolic side effects 1

Dosing and Titration Plan

• Start lamotrigine at 25 mg/day and titrate slowly to a target dose of 200 mg/day 1
• Slow titration is essential to minimize the risk of serious rash, including Stevens-Johnson syndrome
• Recommended titration schedule:
  • Weeks 1-2: 25 mg once daily
  • Weeks 3-4: 50 mg once daily
  • Week 5: 100 mg once daily
  • Week 6 and beyond: 200 mg once daily

Monitoring Recommendations

• Regular monitoring of serum levels and liver function due to potential hepatotoxicity 1
• Monitor for skin rashes, particularly during the first 8 weeks of treatment
• Continue to assess mood symptoms, suicidal ideation, and self-harm behaviors
• Regular clinical assessment of medication adherence is critical, as more than 50% of patients with bipolar disorder are not adherent to treatment 2

Alternative Options to Consider

If lamotrigine is not effective or not tolerated:

1. Optimize current medications:

   • Ensure lithium dose is optimized to achieve therapeutic serum levels (0.6-1.2 mEq/L) 1
   • Consider increasing lithium dose as the current 600 mg may be subtherapeutic

2. Consider valproate:

   • Valproate (750-1500 mg/day) is another alternative, particularly effective for rapid cycling 1
   • However, use caution in females of reproductive age due to teratogenicity

Psychosocial Interventions

In addition to medication adjustment, implement:

• Family-Focused Treatment for Adolescents (FFT-A) which has demonstrated efficacy in reducing manic symptom severity and improving family relationships 1
• Dialectical Behavior Therapy for Adolescents (DBT-A) shows the most promise for reducing self-harm in young people 3
• Safety planning interventions to address the history of self-harm 3

Important Considerations and Precautions

• Comprehensive therapeutic assessment following each self-harm episode is essential 3
• Establish an empathic therapeutic relationship during assessment and interventions 3
• Greater family involvement in treatment may reduce non-adherence and improve outcomes, but must be tailored to the context and the young person's views 3
• Regular monitoring for side effects and therapeutic response is crucial
• Avoid abrupt discontinuation of any current medications

Special Considerations for This Patient

• Given her age (17), ensure close monitoring during medication transitions
• The history of self-harm requires specific attention and targeted interventions
• Persistent depressed mood despite current treatment suggests the need for more aggressive management of the depressive component of her bipolar disorder
• Regular follow-up appointments should be scheduled to assess response to the addition of lamotrigine