Can Abilify Be Used as Maintenance for Bipolar Disorder?
Yes, aripiprazole (Abilify) is FDA-approved and guideline-recommended as a first-line maintenance treatment for bipolar I disorder, specifically for preventing manic relapses in patients who have been stabilized on aripiprazole. 1
Evidence for Maintenance Efficacy
Aripiprazole monotherapy significantly delays time to any mood episode relapse compared to placebo in patients with bipolar I disorder who were previously stabilized on aripiprazole for at least 6 consecutive weeks. In the pivotal maintenance trial, 161 patients stabilized on aripiprazole 15-30 mg/day were randomized to continue aripiprazole or switch to placebo; aripiprazole demonstrated superior prevention of combined affective relapses (19 mood events in the aripiprazole group versus 36 in the placebo group). 1
Aripiprazole is particularly effective at preventing manic episodes during maintenance therapy. The FDA trial data show that only 6 manic episodes occurred in the aripiprazole group compared to 19 in the placebo group, while depressive episodes were similar between groups (9 versus 11). 1 This pattern indicates that aripiprazole's maintenance efficacy is primarily against manic rather than depressive recurrence. 2
Guideline Recommendations
The American Academy of Child and Adolescent Psychiatry recommends aripiprazole as a first-line option for maintenance therapy in bipolar I disorder, alongside lithium and valproate. 3 Current treatment guidelines position aripiprazole as a first-line monotherapy option for preventing recurrence of mood episodes during longer-term therapy. 4
Maintenance therapy should continue for at least 12-24 months after achieving mood stabilization, with some patients requiring indefinite treatment. 3 The median survival time (time to relapse) for aripiprazole-treated patients was not evaluable (indicating very long duration), while placebo patients relapsed at a median of 118-203 days. 2
Adjunctive Maintenance Therapy
Aripiprazole combined with lithium or valproate is recommended as a second-line maintenance option when monotherapy is insufficient. 4 In the adjunctive maintenance trial, 337 patients stabilized on aripiprazole (10-30 mg/day) plus lithium or valproate were randomized to continue combination therapy or switch to placebo plus mood stabilizer; aripiprazole adjunctive therapy prevented manic, mixed, or depressive relapses for up to 52 weeks. 1
Post-hoc analysis demonstrates that adjunctive aripiprazole significantly increases time to relapse in patients entering maintenance therapy with a manic index episode (p<0.01), but not in those with mixed episodes (p=0.59). 3
Dosing for Maintenance
The maintenance dose of aripiprazole should be the same dose (15 or 30 mg/day) that achieved stabilization during the acute phase. 1 Patients must first demonstrate clinical response and maintain stability for at least 6 consecutive weeks on aripiprazole before transitioning to maintenance therapy. 1
Tolerability Profile
Aripiprazole has a favorable metabolic profile compared to other atypical antipsychotics, with low risk of prolactin elevation, QT prolongation, and metabolic disturbances. 4 Extrapyramidal symptoms occurred in up to 28% of patients during acute treatment, but after longer-term treatment (up to 100 weeks), symptom severity did not differ significantly from placebo. 4
Baseline metabolic monitoring must include BMI, waist circumference, blood pressure, fasting glucose, and fasting lipid panel, with follow-up monitoring including BMI monthly for 3 months then quarterly, and blood pressure, glucose, and lipids at 3 months then annually. 3
Important Limitations
Aripiprazole maintenance efficacy is proven only in patients who previously responded to aripiprazole during the acute manic phase—it is not effective for patients entering maintenance from a depressive episode. 2 The efficacy during maintenance is specifically against new manic episodes, not depressive episodes. 2
Withdrawal of maintenance aripiprazole therapy dramatically increases relapse risk, with over 90% of noncompliant patients relapsing versus 37.5% of compliant patients. 3 This underscores the critical importance of medication adherence during maintenance treatment.
Common Pitfalls to Avoid
- Inadequate duration of maintenance therapy: Stopping aripiprazole before 12-24 months leads to high relapse rates. 3
- Premature discontinuation: Patients must maintain stability for at least 6 consecutive weeks before being considered appropriate candidates for maintenance therapy. 1
- Failure to monitor metabolic parameters: Regular monitoring for weight gain and metabolic effects is essential, particularly during the first 6 months. 3
- Using aripiprazole for depressive relapse prevention: Aripiprazole's maintenance efficacy is primarily against manic relapses; additional strategies are needed for depressive episode prevention. 2