What mood stabilizer is recommended for a patient with bipolar disorder taking Abilify (aripiprazole) and Adderall (amphetamine and dextroamphetamine)?

Recommended Mood Stabilizer for Bipolar Disorder with Abilify and Adderall

Lithium is the recommended mood stabilizer for this patient, as it provides superior long-term efficacy for preventing both manic and depressive episodes, has proven antisuicidal properties, and can be safely combined with both aripiprazole (Abilify) and stimulants once mood is stabilized. 1

Primary Recommendation: Lithium

Lithium should be the first-line mood stabilizer choice because:

• The American Academy of Child and Adolescent Psychiatry recommends lithium as having superior evidence for long-term efficacy in maintenance therapy compared to all other mood stabilizers 1
• Lithium is the only FDA-approved mood stabilizer for bipolar disorder in patients age 12 and older for both acute mania and maintenance therapy 1
• Lithium reduces suicide attempts 8.6-fold and completed suicides 9-fold, an effect independent of its mood-stabilizing properties 1
• Lithium prevents both manic and depressive episodes in non-enriched trials, unlike many alternatives that primarily prevent mania 1

Lithium Dosing and Monitoring

Start lithium with target therapeutic levels of 0.8-1.2 mEq/L for acute treatment, with maintenance levels typically 0.6-1.0 mEq/L 1, 2

Required baseline monitoring includes:

• Complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females 1

Ongoing monitoring every 3-6 months must include:

• Lithium levels, renal function, thyroid function, and urinalysis 1, 3

Single daily dosing is preferred over multiple daily doses as it reduces long-term renal damage risk and improves compliance without compromising efficacy 4

Alternative: Valproate (Divalproex)

If lithium is contraindicated or not tolerated, valproate is the second-line choice:

• The American Academy of Child and Adolescent Psychiatry recommends valproate for acute mania and maintenance therapy 1
• Valproate shows response rates of 53% in children and adolescents with mania, compared to 38% for lithium in some studies 1
• Valproate has been shown to be as effective as lithium for maintenance therapy in bipolar disorder 1

Valproate Monitoring Requirements

Baseline assessment requires:

• Liver function tests, complete blood count, and pregnancy test 1

Ongoing monitoring every 3-6 months includes:

• Serum drug levels (target 40-90 mcg/mL or 50-125 μg/mL), hepatic function, and hematological indices 1, 2

Important caveat: Valproate is associated with polycystic ovary disease in females and significant weight gain 1, 3

Critical Considerations with Current Medications

Interaction with Abilify (Aripiprazole)

Aripiprazole is already providing antipsychotic coverage and has proven efficacy as adjunctive therapy with mood stabilizers:

• FDA trials demonstrate that aripiprazole combined with lithium or valproate is superior to mood stabilizer monotherapy for preventing relapse 2
• In adjunctive maintenance trials, aripiprazole plus lithium or valproate reduced manic episodes (7 vs 19 with placebo) while depressive episodes remained similar (14 vs 18) 2
• This combination is explicitly recommended by the American Psychiatric Association as optimal long-term maintenance for bipolar I disorder 1

Interaction with Adderall (Amphetamine/Dextroamphetamine)

Stimulants should only be used after mood stabilization is achieved:

• The American Academy of Child and Adolescent Psychiatry states that for patients with comorbid ADHD, stimulant medications may be helpful once mood symptoms are adequately controlled on a mood stabilizer regimen 1
• Prioritizing mood stabilization before continuing stimulants is clinically sound, as stimulants could potentially worsen mood instability if mood is not adequately stabilized 1
• Starting with the lowest effective dose of Adderall (typically 5-10 mg daily) and titrating slowly by 5 mg increments weekly is recommended for patients with bipolar disorder 1

Treatment Duration and Maintenance

Maintenance therapy must continue for at least 12-24 months after stabilization:

• The American Academy of Child and Adolescent Psychiatry recommends continuing the regimen that effectively treated the acute episode for at least 12-24 months 1
• Some individuals may need lifelong treatment when benefits outweigh risks 1
• Withdrawal of maintenance lithium therapy is associated with increased relapse risk, especially within 6 months following discontinuation 1
• More than 90% of adolescents who were noncompliant with lithium treatment relapsed, compared to 37.5% of those who were compliant 1

Common Pitfalls to Avoid

Do not use antidepressant monotherapy or add antidepressants without adequate mood stabilizer coverage:

• Antidepressant monotherapy can trigger manic episodes or rapid cycling 1
• The American Academy of Child and Adolescent Psychiatry explicitly recommends against antidepressant monotherapy due to risk of mood destabilization 1

Do not discontinue maintenance therapy prematurely:

• Inadequate duration of maintenance therapy leads to high relapse rates 1
• Premature discontinuation is associated with relapse rates exceeding 90% in noncompliant patients 1

Do not skip regular monitoring:

• Failure to monitor for metabolic side effects of Abilify (weight gain, glucose, lipids) is a common pitfall 1
• Regular monitoring of lithium levels and organ function is essential to prevent toxicity 1, 3

Clinical Algorithm Summary

1. Initiate lithium as first-line mood stabilizer with appropriate baseline labs and target therapeutic levels 1, 3
2. Continue Abilify as adjunctive therapy to enhance mood stabilization and prevent relapse 2
3. Temporarily hold or reduce Adderall until mood is fully stabilized on lithium, then reintroduce at lowest effective dose if ADHD symptoms persist 1
4. Monitor lithium levels and organ function every 3-6 months 1, 3
5. Continue maintenance therapy for minimum 12-24 months, potentially lifelong 1
6. If lithium fails or is not tolerated, switch to valproate with appropriate monitoring 1, 3