What are the next steps for a 40-year-old female patient with bipolar disorder, 3 weeks post-crisis, on lithium (lithium) 150mg twice a day, Ativan (lorazepam) 0.5mg twice a day, prazosin 2mg at bedtime, and Latuda (lurasidone) 40mg at bedtime, who is still experiencing high anxiety?

Management of High Anxiety in a Bipolar Patient Post-Crisis

For a bipolar patient still experiencing high anxiety despite current medication regimen, the recommended next step is to increase the lorazepam (Ativan) dosage to 1mg twice daily.

Current Medication Assessment

• Patient is currently on lithium 150mg twice daily, lorazepam 0.5mg twice daily, prazosin 2mg at bedtime, and lurasidone (Latuda) 40mg at bedtime 1
• The current lorazepam dose is at the lower end of the therapeutic range for anxiety management 2
• Lurasidone is an appropriate choice for bipolar depression but may not adequately address severe anxiety symptoms 3, 4

Recommended Medication Adjustments

First-Line Approach:

• Increase lorazepam to 1mg twice daily as this is within the recommended dosage range for anxiety (2-6mg/day) and would provide more immediate relief for the high anxiety symptoms 2
• Benzodiazepines are appropriate for managing acute anxiety when other treatments have not provided adequate relief 5, 6

Alternative Options (if lorazepam increase is ineffective):

• Consider adding an SSRI or SNRI as these are first-line treatments for anxiety disorders, but must be used cautiously in bipolar disorder due to risk of mood destabilization 6, 7
• Consider pregabalin as a second-line agent for anxiety that has less risk of triggering mania compared to antidepressants 6

Monitoring and Follow-up

• Assess response to increased lorazepam dose after 1-2 weeks 5
• Monitor for excessive sedation, cognitive impairment, or signs of dependence 2
• Evaluate for any secondary causes of anxiety such as lithium dose inadequacy, medication side effects, or substance use 5

Long-term Considerations

• Plan for gradual tapering of benzodiazepines once anxiety is stabilized to prevent dependence 2
• Consider adding cognitive behavioral therapy (CBT) as it has strong evidence for anxiety management and can help reduce reliance on medications 6
• Evaluate lithium dose and levels, as the current dose (150mg twice daily) may be subtherapeutic for mood stabilization in bipolar disorder 1

Important Cautions

• Avoid abrupt discontinuation of lorazepam as this can precipitate withdrawal symptoms 2
• Be cautious about adding antidepressants as they may trigger manic episodes in bipolar patients 7
• Recognize that benzodiazepines are intended as a short-term solution while adjusting other medications or implementing psychotherapeutic interventions 5, 6