Should I add Abilify (aripiprazole) to my current regimen of Cariprazine (cariprazine) 6mg for treating anhedonia?

Should You Add Abilify to Cariprazine for Anhedonia?

No, you should not add Abilify (aripiprazole) to your current Cariprazine 6 mg regimen for anhedonia. Instead, continue optimizing your current Cariprazine therapy, as adding a second antipsychotic creates unnecessary polypharmacy risks without addressing the core issue.

Why Antipsychotic Polypharmacy Is Not Recommended Here

• Antipsychotic polypharmacy should only be considered after monotherapy trials with non-clozapine antipsychotics have failed, clozapine has been tried (if no contraindications exist), and compliance has been confirmed through long-acting injectables or blood concentration measurements 1
• Guidelines explicitly caution against antipsychotic polypharmacy as it causes more side effects than monotherapy, and monotherapy should always be the goal 1
• The combination of aripiprazole with another antipsychotic is most studied specifically with clozapine for treatment-resistant cases, not with cariprazine for anhedonia 1

Why Cariprazine Is Actually Your Best Option for Anhedonia

Cariprazine has unique anti-anhedonic properties that aripiprazole does not possess, making it superior for your specific symptom:

• Cariprazine demonstrated specific anti-anhedonic effects in patients with bipolar I depression at both 1.5 mg/day and 3 mg/day doses, with these effects preserved even after adjusting for other depressive symptoms, proving the effect was not pseudospecific 2
• Cariprazine's predominantly D3 receptor-preferring affinity contributes to its efficacy specifically against anhedonia and cognitive impairment, distinguishing it from other antipsychotics 3
• In animal models, cariprazine's antianhedonic effects are mediated specifically through dopamine D3 receptors, a mechanism that aripiprazole does not share to the same degree 4
• Cariprazine ameliorates anhedonia and cognitive deficits through D3 receptor action, representing a promising approach for treating negative symptoms that other antipsychotics fail to address 5

What You Should Do Instead

Step 1: Verify Adequate Trial Duration

• You need a systematic 6-8 week trial at adequate doses before concluding cariprazine is ineffective 6
• If you haven't been on 6 mg for at least 6-8 weeks, continue the current dose and reassess 6

Step 2: Rule Out Other Factors Reducing Treatment Effect

• Confirm medication adherence through discussion or consider blood concentration measurements if available 1
• Assess for comorbidities such as substance use disorders, anxiety disorders, or ADHD that may complicate treatment 6
• Evaluate for inadequately treated bipolar depression, as anhedonia is a core feature of the depressive pole 6

Step 3: Consider Adjunctive Strategies (Not Another Antipsychotic)

If anhedonia persists after adequate cariprazine trial:

• Add lamotrigine (not aripiprazole) as it specifically targets the depressive pole of bipolar disorder where anhedonia resides 6
• Lamotrigine is FDA-approved for maintenance therapy in bipolar disorder and is particularly effective for preventing depressive episodes 6
• Start lamotrigine with slow titration (mandatory to minimize Stevens-Johnson syndrome risk): 25 mg daily for 2 weeks, then 50 mg daily for 2 weeks, then increase by 50 mg every 1-2 weeks to target dose of 200 mg daily 6

Alternative adjunctive options:

• Consider adding an antidepressant (preferably SSRI like fluoxetine or bupropion) to cariprazine, but never use antidepressant monotherapy as it risks mood destabilization 6
• Bupropion (150-300 mg/day) may improve motivation through dopaminergic effects and has lower risk of mood destabilization compared to SSRIs 6

Step 4: Add Psychosocial Interventions

• Cognitive-behavioral therapy has strong evidence for treating anhedonia and should be combined with pharmacotherapy 6, 7
• Positive Affect Treatment (PAT) is a novel psychological intervention specifically designed to target deficits in reward sensitivity and appetitive responding that underlie anhedonia 7
• Psychoeducation about symptoms, treatment options, and medication adherence should accompany all pharmacotherapy 6

Why Aripiprazole Won't Help Your Anhedonia

• While aripiprazole is effective for acute mania and has a favorable metabolic profile, it lacks the specific D3 receptor-preferring activity that makes cariprazine uniquely effective for anhedonia 3, 5
• Aripiprazole may be useful when less sedation is desired or for reducing metabolic side effects, but these are not your primary concerns 8
• The combination of cariprazine with aripiprazole has no established evidence base and would simply add side effect burden without targeting your core symptom 1

Common Pitfalls to Avoid

• Do not add a second antipsychotic without first completing an adequate 6-8 week trial of cariprazine at therapeutic doses 1, 6
• Do not switch from cariprazine to aripiprazole, as you would lose cariprazine's unique anti-anhedonic properties 2, 3
• Do not use antidepressants as monotherapy - they must always be combined with a mood stabilizer like cariprazine to prevent mood destabilization 6
• Avoid premature discontinuation of effective medications, as withdrawal is associated with relapse rates exceeding 90% 6

Monitoring and Follow-Up

• Schedule follow-up within 1-2 weeks to reassess anhedonia symptoms, verify medication adherence, and determine if symptoms are improving 6
• Use standardized validated instruments to measure anhedonia at 4 weeks and 8 weeks 6
• If little improvement occurs after 8 weeks despite good adherence, add lamotrigine or psychological intervention rather than a second antipsychotic 6
• Monitor for metabolic side effects including BMI monthly for 3 months then quarterly, and blood pressure, fasting glucose, and lipids at 3 months then yearly 6