What medication can be added for anxiety in an adult patient with bipolar disorder taking lamictal (lamotrigine) 200mg and abilify (aripiprazole) 10mg?

Adding Medication for Anxiety in Bipolar Disorder

For a patient with bipolar disorder taking lamotrigine 200mg and aripiprazole 10mg who needs anxiety treatment, add cognitive behavioral therapy (CBT) as the primary intervention, with low-dose buspirone (5mg twice daily, maximum 20mg three times daily) as the preferred pharmacological option if CBT alone is insufficient. 1

Evidence-Based Treatment Algorithm

First-Line Approach: Non-Pharmacological Intervention

• Cognitive-behavioral therapy should be the initial treatment for comorbid anxiety in bipolar disorder, as it has strong evidence for addressing anxiety symptoms without risking mood destabilization 1
• CBT can be combined with existing pharmacotherapy and typically shows benefits within 6-12 sessions 1
• When both depression and anxiety are present, treating depressive symptoms often improves anxiety concurrently, and the current lamotrigine regimen may already be addressing this 1

Second-Line: Pharmacological Augmentation

If psychotherapy alone proves insufficient after 4-8 weeks, consider adding:

• Buspirone 5mg twice daily (titrating to maximum 20mg three times daily) is the preferred anxiolytic option 1
• Buspirone takes 2-4 weeks to become effective, so patients need counseling about delayed onset 1
• This agent avoids the mood destabilization risk associated with antidepressants and the dependence risk of benzodiazepines 1

Alternative Pharmacological Options (Use Cautiously)

PRN benzodiazepines may be appropriate for acute anxiety episodes when used at the lowest effective dose:

• Low-dose lorazepam (0.25-0.5mg PRN, not exceeding 2mg daily equivalent) can provide rapid relief 1
• Prescribe with clear frequency limitations (not more than 2-3 times weekly) to minimize tolerance and dependence risk 1
• Avoid high-dose benzodiazepines due to increased sedation risk when combined with aripiprazole 1
• Regular monitoring is essential to assess for signs of tolerance or dependence 1

Critical Pitfalls to Avoid

Never add antidepressant monotherapy or use antidepressants without adequate mood stabilizer coverage, as this can trigger manic episodes, rapid cycling, or mood destabilization 1

• The current regimen (lamotrigine + aripiprazole) provides mood stabilization, but adding an SSRI solely for anxiety carries significant risk 1
• If an antidepressant becomes necessary for severe comorbid depression with anxiety, it must always be combined with the existing mood stabilizers 1

Avoid sedating antihistamines like hydroxyzine if the patient has previously experienced excessive sedation with similar agents 1

Do not use benzodiazepines with alcohol or other CNS depressants, and establish maximum daily dosage limits upfront 1

Monitoring and Follow-Up

• Assess treatment response at 4 weeks and 8 weeks using standardized validated instruments 1
• Monitor for any signs of mood destabilization, including emerging manic symptoms or worsening depression 1
• If little improvement occurs after 8 weeks despite good adherence to CBT and buspirone, consider switching from group to individual therapy or reassessing the anxiety diagnosis 1

Special Considerations for This Regimen

• Lamotrigine provides excellent maintenance therapy for bipolar disorder, particularly effective for preventing depressive episodes, and should be continued 2, 3
• Aripiprazole has a favorable metabolic profile compared to other atypical antipsychotics and provides mood stabilization with lower weight gain risk 1, 4
• The combination of lamotrigine and aripiprazole represents appropriate maintenance therapy that should not be disrupted by anxiety treatment 1, 5
• Anticonvulsants like pregabalin or gabapentin may provide anxiolytic effects as alternative options, though evidence is less robust 1