Lamictal & Manic Psychosis
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Q:  Lamictal & Manic Psychosis

My 32 yo. daughter,recently diagnosed with bp disorder has had 4 psychotic manic episodes in the last 18 months. After the last hospitalization she agreed to take the medication. She was started on depakote 1000mg and zyprexa 25mg. After 4 months she was taken off the zyprexa reduced the dapakote to 500 mgs and put on celexa. After 6 weeks she had a breakthrough of psychotic thoughts but not a complete breakthrough and with no accompanying mood elavation. She took some extra depakote and contained the "leakage" Now that she is more stable she would like to do something about the weight gaining effect of depakote. She would like to try lamectil. Her psychiatrist agreed to do it in a month. What do you you know about the effectiveness of this medication in preventing extreme manic psychosis. I am afraid of any changes that could trigger this, since her breaks were so severe and dangerous.

Thank you,
Ms. A

Dear Ms. A' -- 
Lamotrigine is looking so far like a better antidepressant-like mood stabilizer than it is a mania-controlling mood stabilizer.  So goes the current discussion in our literature.  I agree with that perspective: in my experience it's been a pretty good antidepressant but I have substantial doubts about it's reliability as a mood stabilizer, and generally don't use it by itself for that purpose as I'm too worried about recurrent mood fluctuations it might not prevent.  Just yesterday I saw two different people who have lamotrigine in their mix of medications and are better, but still cycling.  I find myself wondering, could the lamotrigine possibly be contributing to cycling?  There's no way to tell except to very slowly decrease it.  Sometimes when I do that things get better; sometimes they get worse though.  I have a few patients who've done beautifully on lamotrigine alone.  They tend to be people who had predominantly depressive symptoms, hardly any symptoms of hypomania (and in a few case of "recurrent depression" that didn't respond well to antidepressants, it's also worked beautifully).  

By contrast, your daughter's situation is nearly the opposite.  I'm surprised by the use of celexa, given that we know antidepressants can induce mania in bipolar disorder -- but sometimes, when depression is severe, there's almost no alternative but to give the antidepressant and watch out closely for emerging manic symptoms, while maintaining a fairly aggressive barrier against mania in the form of mood stabilizers and/or antipsychotics.   If the celexa's still in there I'd still have some concern about it; sometimes it's easier to address a tendency toward mania by taking out the pro-manic things rather than adding antimanic things.  However, your daughter's doctors could have good reasons for this approach that are not apparent to me based on the information we have here.  

Dr. Phelps


Published July, 2002


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