Can Abilify (aripiprazole) cause increasing suicidal thoughts?

Can Abilify Cause Increasing Suicidal Thoughts?

Yes, Abilify (aripiprazole) carries an FDA black-box warning for increased risk of suicidal thoughts and behaviors, particularly in children, adolescents, and young adults up to age 24, especially during the first few months of treatment and after dose changes. 1

FDA-Mandated Warning and Monitoring Requirements

The FDA requires that patients, families, and caregivers be explicitly warned about the emergence of:

• Suicidal ideation and behavior
• Anxiety, agitation, and panic attacks
• Insomnia and irritability
• Hostility, aggressiveness, and impulsivity
• Akathisia (psychomotor restlessness)
• Hypomania or mania
• Other unusual behavioral changes 1

These symptoms may appear suddenly and require immediate reporting to the prescriber, as they indicate increased risk for suicidal thinking and necessitate very close monitoring and possible medication changes. 1

Clinical Evidence and Case Reports

Multiple case reports document serious psychiatric adverse effects after starting aripiprazole:

• Five patients (ages 30-56) developed suicidal ideation or made suicide attempts after starting aripiprazole, with symptoms including troubling agitation, akathisia, insomnia, and dysphoria; none had previous suicide attempts, and suicidal thoughts resolved after discontinuing aripiprazole 2

• Two patients with mood disorders developed severe akathisia, anxiety, and suicidal ideation while using aripiprazole combined with lamotrigine and antidepressants, requiring drug discontinuation 3

• A 19-year-old patient attempted suicide after switching from risperidone to aripiprazole, with no aggressive behavior in the 18 months before or 12 months after aripiprazole use 4

Reassuring Long-Term Population Data

However, a large population-based cohort study provides important context:

• In 1,643 patients switching to or adding aripiprazole (matched 1:1 with controls), there was no increased rate of psychiatric hospitalization, self-harm, or suicide compared to other antipsychotics (HR 0.96; 95% CI, 0.68-1.36) over one year of follow-up 5

• This suggests that while individual cases of suicidal worsening can occur, population-level risk may not exceed that of other antipsychotics 5

Critical Clinical Considerations

The mechanism appears related to akathisia and severe dysphoria rather than direct suicidogenic effects. Akathisia affects approximately 18% of bipolar patients treated with aripiprazole and may worsen when combined with lamotrigine and antidepressants 3

Common pitfall: Failing to recognize akathisia as a driver of suicidal ideation—patients may describe unbearable inner restlessness that they cannot tolerate, leading to suicidal thoughts as an escape 3, 2

Practical Management Algorithm

1. Start with low doses, especially in patients with mood disorders taking multiple medications 3

2. Monitor intensively during:

   • First few months of treatment
   • After any dose increases
   • When combined with lamotrigine or antidepressants 1, 3

3. Assess specifically for:

   • Akathisia (inner restlessness, inability to sit still)
   • New or worsening anxiety
   • Sudden behavioral changes
   • Emergence of suicidal thoughts 1, 3

4. If these symptoms appear: Discontinue aripiprazole immediately—symptoms typically resolve after discontinuation 3, 4, 2

The appearance of akathisia, increased anxiety, or suicidal thoughts represents a limiting side effect requiring drug discontinuation, not dose adjustment. 3