Q:  MAOI's & Lamictal

After years of treatment for Major Depression with antidepressants, my diagnoses was changed to Bipolar II and Panic Anxiety Disorder.  I have been on Lamictal and Ativan.  I have been told by another psychiatrist that I should never recieve antidepressants.  My doctor is pushing the Lamictal to higher doses without relief of my depression and wants to add an MAOI.  Is there any research to support this combination of therapies?  I am distressed about the food restrictions but I would try it if it would make me better.
Thank you.


Dear Ms. E' -- 
MAOI's appear to make bipolar disorder worse the least often of all antidepressants, though the margin of their advantage in this respect is not huge.  Thus if you were correctly advised by the earlier psychiatrist to avoid antidepressants, trying an MAOI is sort of a logical thing to consider if depression is the main problem.  Whether to do that with lamotrigine on board, or by itself, is a different question, and to my knowledge there is virtually no data to go on there.  I considered the combination recently for a patient and asked our hospital pharmacist if there were known contraindications to using the two together; then answer was "no, no known contraindications".  

In my view, for discussion with your psychiatrist, the worry would be that lamotrigine has been shown to have antidepressant properties.  It has not been shown to have "mood stabilizer" properties in a thoroughly reliable way such that it can be relied upon, in my view, to prevent the kind of worsening of bipolar symptoms that antidepressants can cause.  Rather, it has been shown in some cases to cause manic-side symptoms; not rarely, in my experience, although the published cases are few and the big series by Calabrese and colleagues had no cases of "induced mania" with lamotrigine (I wonder if they were only counting obvious mania, as opposed to, for example, an increase in anxiety, which can be a "manic" side symptom; more on that in a moment).  

So as you can probably gather, the bigger picture concern I'd have based on the information you've given here is that your panic attacks might indicate the presence of "manic side symptoms".  Here's my discussion of  how anxiety can be a manic symptom.  However, this is an extremely fuzzy area in our knowledge of bipolar disorder and I would have to defer to your psychiatrist on the interpretation of your symptoms.  

If you do try the MAOI, here are two very helpful articles on the food restrictions, that make it a bit more manageable, I think: 

First, a good general review of the topic; I'd urge you to use a local librarian to get a copy of the entire article.  Second, a recent bit of work that may indicate that even pepperoni pizza is safe in some circumstances -- but you must discuss this article with your doctor to decide how you two will interpret it.  

Dr. Phelps