Can I add Abilify (aripiprazole) to Lamictal (lamotrigine) for mood stabilization in a patient with bipolar disorder and a history of suicide attempts?

Adding Aripiprazole to Lamotrigine During Titration for Bipolar Disorder

Yes, you can add aripiprazole to lamotrigine during titration to provide acute mood stabilization in this patient with bipolar disorder and significant suicide risk. This combination is supported by FDA approval, clinical guidelines, and research evidence demonstrating safety and efficacy for both acute and maintenance treatment of bipolar disorder.

Rationale for Combination Therapy

Aripiprazole is FDA-approved for maintenance treatment of bipolar I disorder and can be safely combined with mood stabilizers like lamotrigine. 1 The FDA label specifically describes trials where aripiprazole was added to lithium or valproate in patients with inadequate response to mood stabilizer monotherapy, demonstrating superior efficacy in preventing mood episode relapse 1. While lamotrigine wasn't specifically studied in the FDA trials, the principle of combining aripiprazole with mood stabilizers is well-established.

The American Academy of Child and Adolescent Psychiatry guidelines support using medication combinations when treating multiple aspects of bipolar disorder, specifically noting that "medication combinations that offer unique treatment advantages for a single disorder" are appropriate 2. For bipolar disorder specifically, aripiprazole is listed as an FDA-approved agent for acute mania in adults 2.

Clinical Evidence for This Combination

Research demonstrates that aripiprazole adjunct treatment with mood stabilizers produces marked improvements in depressive symptoms and maintains stability over 2 years. 3 In a clinical study of 40 patients with bipolar disorder depression, all patients experienced significant improvements by 6 weeks when aripiprazole 5-15 mg daily was added to their mood stabilizer, with complete functional recovery by 1 year 3.

A comprehensive review confirms that combining aripiprazole with mood stabilizers offers effective and relatively well-tolerated treatment for both acute mania and long-term maintenance 4. The combination presents lower risk of metabolic side effects compared to other antipsychotic combinations, though extrapyramidal side effects require monitoring 4.

Specific Dosing Recommendations

Start aripiprazole at 5 mg daily and titrate slowly to minimize side effects, particularly akathisia. 5 Given this patient's complex psychiatric history including borderline personality disorder and suicide attempts, low initial dosing is critical. The FDA label supports starting doses of 10-15 mg with adjustments to 5-30 mg based on response 1, but clinical experience suggests starting at 5 mg in patients with mood disorders on multiple medications 5.

Continue lamotrigine titration to therapeutic dose (typically 200 mg daily for bipolar disorder) while maintaining aripiprazole 6. The combination allows aripiprazole to provide immediate mood stabilization while lamotrigine reaches therapeutic levels over several weeks.

Critical Safety Monitoring

Monitor closely for akathisia, increased anxiety, and worsening suicidal ideation when combining aripiprazole with lamotrigine. 5 A case series specifically documented that patients with mood disorders developed severe akathisia, anxiety, and suicidal ideation when using aripiprazole combined with lamotrigine and antidepressants 5. Approximately 18% of bipolar patients treated with aripiprazole experience akathisia, which may worsen with combination therapy 5.

The VA/DoD guidelines emphasize that lithium reduces suicide risk in bipolar disorder 2, but since this patient reports lamotrigine as the only effective mood stabilizer, continuing that agent while adding aripiprazole is reasonable. However, given the suicide history, consider whether lithium augmentation might be appropriate if response is inadequate.

Addressing the "Ups and Downs" During Titration

The patient's reported "ups and downs" at 100 mg lamotrigine likely reflect subtherapeutic dosing rather than treatment failure. 6 Lamotrigine typically requires 200 mg daily for bipolar disorder maintenance, and the patient is only halfway through titration. Adding aripiprazole provides immediate stabilization during the remaining titration period.

The American Academy of Child and Adolescent Psychiatry guidelines note that "multiple agents are often required" for bipolar disorder, though unnecessary polypharmacy should be avoided 2. This combination represents rational polypharmacy: one agent (lamotrigine) for long-term mood stabilization based on patient's history, and another (aripiprazole) for acute stabilization and maintenance.

Avoiding Common Pitfalls

Do not use aripiprazole as monotherapy or discontinue lamotrigine prematurely. 6 Since the patient specifically reports lamotrigine as the only medication that works for mood stabilization, maintaining this agent is essential. The combination strategy allows both medications to work synergistically.

Avoid adding antidepressants to this regimen without at least one mood stabilizer at therapeutic dose. 2 The guidelines specifically caution that antidepressants may destabilize mood or precipitate mania in bipolar disorder, and should only be used adjunctively with mood stabilizers 2.

Do not rely solely on medication for this complex patient. 2 The American Academy of Child and Adolescent Psychiatry emphasizes that prescribers who don't appreciate the need for combined psychosocial and pharmacological treatment may unnecessarily expose patients to complex medication strategies 2. Given the borderline personality disorder diagnosis and suicide history, dialectical behavior therapy (DBT) is specifically indicated, as it reduces suicidal self-directed violence in patients with borderline personality disorder 2.

Implementation Plan

1. Start aripiprazole 5 mg daily while continuing lamotrigine 100 mg daily 5
2. Continue lamotrigine titration by 25-50 mg every 1-2 weeks to target dose of 200 mg daily 6
3. Assess aripiprazole response and tolerability at 1 week, specifically screening for akathisia using objective rating scales 5
4. Increase aripiprazole to 10-15 mg daily if tolerated and needed for symptom control after 1-2 weeks 3
5. Monitor weekly during titration for mood symptoms, suicidal ideation, akathisia, and metabolic parameters 4
6. Ensure concurrent psychotherapy (preferably DBT) is in place given borderline personality disorder and suicide history 2