Guidelines for Using Abilify in Depression

You and your doctor may decide that a second-generation anti-psychotic (SGA) such as Abilify (aripiprazole) is a useful augmentation strategy for you. Augmentation is when a second medicine is added to an antidepressant that has helped your depression but has not helped enough.

Because the SGAs have significant side effects, detailed in the blog post “Is Abilify Safe For Depression?”, there are guidelines for following patients taking an SGA.

The TMAP depression manual recommends following the Mount Sinai Conference Guidelines: Physical Health Monitoring of Patients With Schizophrenia, Marder SR, et al. American Journal of Psychiatry 2004; 161: 1334-49). The guidelines are written for schizophrenic patients, but the TMAP authors believe that they should be applied to all patients treated with SGAs like Abilify. So the guidelines apply not just to Abilify but also to all the second-generation anti-psychotics (clozapine, risperidone, olanzepine, quetiapine, ziprasidone, paliperidone, and aripiprazole [Abilify]).

TMAP recommends that patients on therapy with an SGA have:

1. A pregnancy test as indicated
2. Body Mass Index
3. A fasting blood glucose level or a hemoglobin A1c
4. A lipid screening
5. An EKG when initiating treatment with ziprasidone and when a patient develops symptoms that could be due to QTc prolongation
6. Sexual function inquiry
7. Serum Prolactin level in some circumstances
8. Evaluation for extra-pyramidal symptoms (rigidity, tremor, akisthesia)
9. Examination for tardive dyskinesia, a movement disorder, needs to be performed periodically during treatment.
10. A vision questionnaire
11. An ocular exam [to include a slit lamp exam]

These measures need to repeated periodically during treatment—there are charts available to help you and the doctor keep track.

Although the above sounds difficult and complicated to keep up with, there are toolkits that contain forms and templates that can function as checklists and memory aids. These forms can help you and your doctor keep track of what needs to be done and when.

The STABLE Resource Toolkit is designed to help physicians caring for bipolar disorder. And it has many forms that are useful in the caring for patients with unipolar (meaning regular) depression, the most common kind. The Toolkit also contains forms that can be used for patients taking second-generation anti-psychotics for any reason and help implement the 11 TMAP recommendations.

And, also important, the authors of the STABLE Resource Toolkit have included only measures that can be used in a physician’s practice without charge. 

There are excellent instruments in the STABLE Toolkit that you and your doctor can use for depression screening, bipolar disorder screening, substance use screening and assessment, and suicide risk assessment. Without a series of questionnaires, it is easy to overlook something important in your mental health evaluation.

The Toolkit has an outstanding collection of forms for use in monitoring the side effects of the second-generation anti-psychotics.

There is an instrument called the Abnormal Involuntary Movement Scale (AIMS) that is used to detect the development of tardive dyskinesia, a movement disorder that can occur with second-generation anti-psychotic medications but at a lesser frequency than with first generation anti-psychotic medicines. There are instructions on how to complete the AIMS evaluation.

The Texas Medication Algorithm Project (TMAP) Side-effects Checklists are included in the STABLE Toolkit  and are very helpful.

The Anti-psychotic Side-effects Checklist (ASC) helps you and the doctor watch out for the common side-effects of the SGAs and is also in the Toolkit.

And the Toolkit includes forms for monitoring for the metabolic side-effects of the second-generation anti-psychotics: weight gain, diabetes, and hyperlipidemia.

Although all this may seem like a lot of extra work, once the forms are incorporated into your office visits, they will go quickly (you can fill out most of the forms before you see the doctor). And they will allow you to use your second-generation anti-psychotic medicine in a way that maximizes its effectiveness and minimizes its side-effects.

And finally, a reminder that, although the STABLE Resource Toolkit specifically addresses bipolar disorder treatment, the forms it contains are applicable to anyone taking a second-generation anti-psychotic medicine for depression.

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