Should a selective serotonin reuptake inhibitor (SSRI) be added to a patient with bipolar disorder and potential Attention Deficit Hyperactivity Disorder (ADHD) who is currently taking 15 mg of aripiprazole (Abilify) and 15 mg of Adderall (amphetamine and dextroamphetamine)?

SSRI Addition to Aripiprazole and Adderall: Not Recommended in Bipolar Disorder

Adding an SSRI to a patient with bipolar disorder currently taking aripiprazole 15 mg and Adderall 15 mg is generally contraindicated and should be avoided. The primary concern is mood destabilization and precipitation of manic episodes in bipolar patients treated with antidepressants.

Key Contraindications and Risks

Bipolar Disorder-Specific Concerns

• SSRIs can destabilize mood and incite manic episodes in bipolar patients 1
• Antidepressants should only be used as adjuncts for bipolar depression when the patient is already taking at least one mood stabilizer 1
• A manic episode precipitated by an SSRI is characterized as substance-induced per DSM-IV-TR, though it may represent unmasking of the disorder or disinhibition 1
• SSRIs are not recommended or should be used with extreme caution in patients with comorbid bipolar disorder 1

Serotonin Syndrome Risk

The combination of SSRI + Adderall (amphetamine) creates significant risk:

• Combining SSRIs with stimulants (amphetamine class) requires extreme caution due to serotonin syndrome risk 1
• Serotonin syndrome symptoms include mental status changes (confusion, agitation), neuromuscular hyperactivity (tremors, clonus, hyperreflexia), and autonomic hyperactivity (hypertension, tachycardia, diaphoresis) 1
• Advanced symptoms can include fever, seizures, arrhythmias, and unconsciousness leading to fatalities 1
• When combining two non-MAOI serotonergic drugs, start at low doses, increase slowly, and monitor closely in the first 24-48 hours after dosage changes 1

Additional Considerations

• Treatment with SSRIs should be avoided in men with a history of bipolar depression due to risk of mania 1
• The current regimen (aripiprazole + stimulant) is already addressing both bipolar symptoms and ADHD without the destabilizing risk of antidepressants 1

Clinical Algorithm

If depressive symptoms are present:

1. First, optimize the current mood stabilizer (aripiprazole dose adjustment) 1
2. Consider adding a different mood stabilizer (lithium, valproate, lamotrigine) rather than an SSRI 1
3. The FDA-approved combination for bipolar depression is olanzapine plus fluoxetine - not aripiprazole plus an SSRI 1
4. Only after adequate mood stabilization should an SSRI be cautiously considered, and only if depressive symptoms remain severe and refractory 1

If anxiety symptoms are the concern:

• Address anxiety through psychosocial interventions first 1
• If pharmacotherapy is needed, consider adjusting the mood stabilizer or adding an anxiolytic that doesn't destabilize mood 1

Evidence Supporting Aripiprazole + Stimulant Without SSRI

• Aripiprazole combined with methylphenidate has demonstrated efficacy and tolerability in patients with mood dysregulation and ADHD, with significant improvements in irritability, externalizing symptoms, depression, and anxiety without requiring SSRI addition 2
• Aripiprazole is efficacious for treatment and prophylaxis of manic and mixed episodes in bipolar disorder 3

Bottom Line

The risk-benefit ratio strongly favors NOT adding an SSRI to this regimen. The combination poses dual risks: mood destabilization/mania induction from the SSRI in bipolar disorder, and serotonin syndrome from SSRI + amphetamine interaction. If additional treatment is needed for depression or anxiety, optimize the mood stabilizer first or add a second mood stabilizer rather than introducing an antidepressant 1.