What is the best course of action for a adult patient with a history of bipolar disorder and chronic depression, currently experiencing suicidal ideations, who has previously been treated with Abilify (aripiprazole) and expresses dislike for lithium and other medications?

Immediate Management of Suicidal Ideation in Bipolar Disorder

Resume aripiprazole 5 mg immediately while simultaneously implementing urgent safety measures, including hospitalization assessment, means restriction, and close monitoring—aripiprazole has demonstrated anti-suicidal effects in bipolar disorder and is appropriate for this patient given his previous positive response. 1, 2, 3

Acute Safety Interventions (First 24-48 Hours)

Assess for immediate hospitalization based on the severity of suicidal ideation, presence of specific plan, access to means, and ability to contract for safety. 4, 5

Implement means restriction immediately:

• Engage family members to remove access to lethal medications, firearms, and other means of self-harm. 4, 1
• Prescribe aripiprazole in limited quantities (7-14 day supply maximum) with frequent refills to minimize stockpiling risk. 2
• If lithium is considered later, implement third-party medication supervision as lithium overdoses are lethal. 4, 1

Schedule follow-up within 24-72 hours to reassess suicidal ideation, verify medication adherence, and determine if symptoms are worsening or improving. 4

Pharmacological Strategy

Primary Medication: Aripiprazole

Aripiprazole 5 mg daily is an appropriate starting dose given the patient's previous positive response, which is the strongest predictor of future response. 1, 3

Titrate aripiprazole to 10-15 mg daily over 1-2 weeks if depressive symptoms and suicidal ideation persist, as this dose range demonstrates optimal efficacy for bipolar depression. 1, 3

Aripiprazole offers several advantages in this clinical scenario:

• Low lethality in overdose, making it safer than many alternatives when suicide risk is present. 1
• Demonstrated efficacy as adjunct treatment for bipolar depression with marked improvements in depressive symptoms by 6 weeks. 3
• Minimal metabolic side effects compared to olanzapine or quetiapine. 1
• FDA-approved for acute mania in adults and commonly used for bipolar depression. 1, 2

Adding a Mood Stabilizer

Consider adding lithium or lamotrigine within 1-2 weeks if depressive symptoms persist despite aripiprazole optimization. 1, 6

Lithium is the preferred mood stabilizer for patients with suicidal ideation:

• Reduces suicide attempts 8.6-fold and completed suicides 9-fold, an effect independent of its mood-stabilizing properties. 4, 1, 6
• Target therapeutic level of 0.8-1.2 mEq/L for acute treatment. 1
• Requires baseline labs: complete blood count, thyroid function tests, urinalysis, BUN, creatinine, serum calcium, and pregnancy test in females. 1
• Monitor lithium levels, renal function, and thyroid function every 3-6 months. 1

Critical lithium safety considerations:

• Lithium overdoses are lethal and require careful third-person supervision in patients with suicidal history. 4, 1
• Parents/family must secure lithium and remove access to lethal quantities. 1
• Prescribe limited quantities with frequent refills. 1

Lamotrigine is an alternative if lithium is refused:

• Particularly effective for preventing depressive episodes in bipolar disorder. 1
• Requires slow titration (start 25 mg daily, increase by 25 mg every 2 weeks) to minimize risk of Stevens-Johnson syndrome. 1
• Takes 6-8 weeks to reach therapeutic dose of 200 mg daily. 1

Medications to Avoid

Never use antidepressant monotherapy in bipolar disorder due to risk of mood destabilization, mania induction, and rapid cycling. 1, 7

Avoid SSRIs in patients with bipolar disorder and suicidal ideation unless combined with a mood stabilizer, as they carry a boxed warning for suicidal thinking and behavior through age 24. 4, 1

Do not prescribe typical antipsychotics (haloperidol) due to inferior tolerability and higher extrapyramidal symptoms risk. 1

Addressing Patient's Medication Preferences

Explore the specific reasons for disliking lithium and other medications through motivational interviewing techniques. 5

Common concerns about lithium include:

• Weight gain (occurs but less sedating than valproate). 1
• Frequent monitoring requirements (every 3-6 months). 1
• Tremor, nausea, or polyuria (dose-related side effects). 1

If lithium is categorically refused:

• Lamotrigine is the next best option for bipolar depression with suicidal ideation. 1
• Valproate is less ideal due to sedation and weight gain concerns. 1

If the patient refuses all mood stabilizers:

• Continue aripiprazole monotherapy at optimized doses (10-15 mg daily). 3
• Add intensive psychosocial interventions (see below). 1
• Reassess willingness to add mood stabilizer at each visit. 5

Psychosocial Interventions (Essential Adjuncts)

Cognitive-behavioral therapy (CBT) should begin immediately as it has strong evidence for reducing suicidal ideation and treating depressive symptoms in bipolar disorder. 1, 5

Implement family-focused therapy to help with medication supervision, early warning sign identification, and reducing access to lethal means. 1, 5

Provide psychoeducation about symptoms, course of bipolar disorder, treatment options, and critical importance of medication adherence. 1, 5

Develop a written crisis management plan outlining specific actions to take if suicidal thoughts worsen, including emergency contact numbers and steps for accessing immediate care. 5

Monitoring Protocol

Weekly visits for the first month to assess suicidal ideation, depressive symptoms, medication adherence, and emerging side effects. 4, 1

At each visit, assess:

• Severity of suicidal ideation using standardized tools (e.g., Columbia-Suicide Severity Rating Scale). 5
• Depressive symptoms using PHQ-9 or similar validated instrument. 4
• Medication adherence and barriers to taking medications. 1
• Access to means and effectiveness of safety measures. 5
• Emergence of manic symptoms or behavioral activation. 2

Increase monitoring frequency to twice weekly if symptoms worsen to prevent full relapse into severe depression or emergence of mixed features. 4

After 4-6 weeks of stability, transition to biweekly visits, then monthly once sustained remission is achieved. 4, 3

Expected Timeline for Response

Expect initial improvement in suicidal ideation within 1-2 weeks of starting aripiprazole, particularly if the patient previously responded to this medication. 3

Marked improvements in depressive symptoms should occur by 6 weeks on optimized aripiprazole doses (10-15 mg daily). 3

Complete functional recovery typically occurs by 6 months to 1 year with consistent treatment adherence. 3

Maintenance Therapy

Continue aripiprazole plus mood stabilizer for at least 12-24 months after achieving complete symptom resolution. 1, 6

Some patients require lifelong treatment, particularly those with multiple severe episodes, rapid cycling, or history of serious suicide attempts. 1, 6

Withdrawal of maintenance therapy dramatically increases relapse risk, with over 90% of noncompliant patients relapsing versus 37.5% of compliant patients. 1

Common Pitfalls to Avoid

Never delay treatment waiting for the patient to "decide" on medications—resume aripiprazole immediately given previous positive response and current suicidal ideation. 5, 3

Do not prescribe antidepressants without mood stabilizer coverage, as this can worsen suicidal ideation and trigger mixed episodes. 1, 7

Avoid premature discontinuation of effective medications—maintain treatment for minimum 12-24 months after stabilization. 1, 6

Do not underestimate the importance of psychosocial interventions—combination treatment (medication plus therapy) is superior to either alone. 1, 5

Never provide large quantities of potentially lethal medications to patients with active suicidal ideation—prescribe 7-14 day supplies maximum. 2, 5