Dear Dr. Phelps,

I was diagnosed about two years ago with BP II and then downgraded from there to being somewhere on the Bipolar Spectrum.  I recently read your book, "Why Am I Still Depressed?" and it describes me perfectly.  I have all 11 soft signs.  Family history?  Both my brothers committed suicide, as did my grandfather.  While they suffered from severe depression, they also said that the anxiety was as debilitating or worse for them.  I started on Prozac many years ago and loved it.  My depression lifted and I felt great within 24 hours. I loved that hypomanic edge and also that I was socially comfortable for the first time in my life, though I was very ADD and OCD during the 10+ years that I took it before I crashed and burned.  I tried many other antidepressants with horrible side effects and was then was put on Lamictal.  Once I got up to 200mg I felt great, for a few days.  Then, horrible anxiety.  Fear and nervousness that caused me to withdraw even though I wasn't depressed.  I   tried everything to treat it, though I didn't allow myself to go higher than a tiny dose of a benzo because I didn't want to get addicted.  When Depakote was added I became suicidal.  I was eventually taken off Lamictal and have been on and off of several AC's...they all make me depressed.  Am I the only one who has this anxiety problem with Lamictal?  My doctor has never seen it and everyone else seems to love this drug.  I've been trying to avoid taking drugs that cause me to get fat, bald and stupid, but I'm down to Lithium being my last resort if this Trileptal doesn't work out.  Also, I am extremely sensitive to medications and I was wondering if I might get any benefit from a low dose of Lamictal...maybe 50mg.  Even though I have some anxiety isssues even when I don't take Lamictal, depression is much more of an issue so I need a mood stabilizer with an AD property.  Sorry for so many questions and the disorganization of this.  Thank you for your time.



Dear Ms. R--

Thank you for describing this reaction to Lamictal, which I have definitely seen before (oh, and before I forget, thank you for the book plug). Indeed, I spoke with a colleague who has also used a lot of lamotrigine, and realizing that he was about to describe the same thing, a kind of increased agitation anxiety, I asked him to estimate how often he has seen it. In my mind I was making my own estimate, but was surprised when he came up with the exact same figure: about one patient in 20, or one in 30. Since then, I have found numerous other prescribers who have seen the same thing. So I have little doubt that this is a real issue, and indeed I think it is relatively common.

I have a young fellow, a college student, who had this experience when he reached 75 and then 100 mg of Lamictal. He seems to be doing pretty well on 50 mg, though we have added a low dose of a "benzo" (short for benzodiazepine, the Valium family of medications, which includes lorazepam/Ativan and clonazepam/Klonopin, the most potentially useful in this regard). I have recently turned the dose of lamotrigine down in this fashion in at least two other patients within the last month.

Although lithium can potentially cause weight gain, and the proportion of patients who get it is not as high as for some other medications that we use; and getting "stupid" on it actually is really quite uncommon in my experience. A few people just hate how they feel on it, even at very low doses, but I would estimate this is less than one in 10, and might indeed be closer to the one in 20 figure above for lamotrigine and anxiety. You could easily be very pleasantly surprised by your experience on lithium. It is probably one of our most underutilized (i.e. inappropriately underutilized) strategies.

Good luck with all that --

Dr. Phelps



Published September, 2007