What medication adjustments are appropriate for an 18-year-old female with bipolar disorder and Attention Deficit Hyperactivity Disorder (ADHD) currently on Abilify (aripiprazole) 5mg and Lamictal (lamotrigine) 50mg per day, experiencing ongoing anxiety and difficulty focusing?

Medication Adjustment for 18-Year-Old Female with Bipolar Disorder, ADHD, Anxiety, and Focus Issues

For an 18-year-old female with bipolar disorder and ADHD currently on Abilify 5mg and Lamictal 50mg who is experiencing continued anxiety and problems focusing in school, the most appropriate medication adjustment would be to increase the Lamictal dose to a therapeutic level while considering the addition of a stimulant medication for ADHD symptoms.

Current Medication Assessment

• Patient is on subtherapeutic doses of both medications:
  • Abilify (aripiprazole) 5mg - low dose for bipolar disorder 1
  • Lamictal (lamotrigine) 50mg - significantly below therapeutic range for mood stabilization 1

Recommended Medication Adjustments

Primary Recommendations:

1. Increase Lamictal dose gradually:

   • Lamotrigine should be titrated to therapeutic levels (typically 200mg/day) for effective mood stabilization 1
   • Slow titration is necessary to minimize risk of serious rash:
     • Increase by 25-50mg every 1-2 weeks until reaching therapeutic dose 1

2. Consider adding a stimulant medication for ADHD symptoms:

   • Methylphenidate remains first-line for ADHD treatment even in patients with comorbid conditions 2
   • Start with low dose and titrate based on response and tolerability 2

Alternative Approaches:

1. If anxiety is the predominant symptom:

   • Consider adding an SSRI (sertraline or fluoxetine) for anxiety symptoms 2, 3
   • SSRIs have demonstrated efficacy for anxiety disorders with moderate effect sizes 3
   • Start at low doses and titrate slowly to minimize side effects 2

2. If bipolar symptoms are not well-controlled:

   • Increase Abilify dose (up to 10-15mg) 4
   • Monitor closely for akathisia, which affects approximately 18% of bipolar patients on aripiprazole 5

Monitoring and Precautions

• Drug interactions:

  • No significant interactions between lamotrigine and aripiprazole 4
  • If adding an SSRI, be aware that some (fluoxetine, paroxetine) are strong CYP2D6 inhibitors that may increase aripiprazole levels, requiring dose adjustment 4

• Side effect monitoring:

  • Watch for increased anxiety or akathisia with aripiprazole, particularly when combined with lamotrigine 5
  • Monitor for suicidal thoughts, especially during medication adjustments 5
  • Assess for rash with lamotrigine dose increases 1

Special Considerations

• Lamotrigine for ADHD with mood disorders:

  • Some evidence suggests lamotrigine may help ADHD symptoms in patients with comorbid mood disorders, supporting the recommendation to optimize this medication 6
  • In a case series, 77.5% of patients with ADHD and comorbid mood disorders improved with lamotrigine (mean dose 125.6mg) 6

• Combination therapy:

  • For anxiety disorders, combination of medication and cognitive behavioral therapy (CBT) is often more effective than either treatment alone 2, 3
  • Consider recommending CBT as an adjunct to medication management 3

• Common pitfalls to avoid:

  • Avoid rapid titration of lamotrigine due to risk of serious rash 1
  • Avoid using antidepressants as monotherapy in bipolar disorder 1
  • Be cautious with aripiprazole dose increases due to risk of akathisia 5