Q:  Would Lamictal be Helpful?

Dear Dr. Phelps,

I have noticed some improvement on Tegretol. The medication has worked brilliantly for sleep. I am calmer and don't get as angry. I still experience severed depressions though. I'm also on Wellbutrin. I am aware antidepressents can cause destabilization in bp, but I have been on Wellbutrin for a year now as it is the only ad i can tolerate. I believe Wellbutrin helps with ADHD symptoms.  I am currently working with the mental health clinic and have very limited communication with the doctors so it is very important for me to be well informed about my treatment. First of all can Tegretol cause depression? I have read about it causing hypothyroidism. I'm also concerned because my WBC was low.  Do you think one of the newer antipsychotics or Lamictal would be helpful? I also have mild paranoia. I am currently on 600 mg of Tegretol and 300 of Wellbutrin. I still run everyday even though i don't have as much energy.  The running has helped me more than anything I've tried.
 

Dear Ms. M' -- 
Hmm, lots of issues in there.  I'll focus on the Wellbutrin one.  You're right in the middle of a pretty big controversy in psychiatry, around whether to keep people on antidepressants with a mood stabilizer, or try to get to zero antidepressants in all cases.  The answer is "it depends", as there are clearly some people who do well for sustained periods of time with the AD combined.  Here's a summary of that antidepressant controversy, if you haven't seen it yet. 

However, in your case there's one sentence that raises the question a bit further.  You note "I still experience severe depressions, though".  I presume that means they come and go, despite the medications.  That could be interpreted as cycling, sounds like it to me.  That means you're still cycling, and I'd guess it's several ups and downs within a year easy, i.e. rapid cycling (it would be nice to be wrong, there).  In that case, there is good agreement amongst mood experts that one way to help diminish rapid cycling is to slowly taper the antidepressant, to zero if necessary to get cycling to stop. 

And there's where Lamictal does come into the picture, i.e. if you were still getting depressed (or better yet, getting and staying depressed, which would mean that sure enough, the cycling had stopped; now you have a different, and in my view easier problem to solve: to get the depression to ease without inducing cycling again.  Lamictal may indeed be good in that role, although your exercising is even better (and might, just maybe, be sufficient?  you wouldn't know until you tried it, as the "antidepressant", with a mood stabilizer or two as needed to stop cycling).  Good luck with all that. 

Dr. Phelps 

Published January, 2003