Should I Reduce or Stop the Lamotrigine
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Q:  Should I Reduce or Stop the Lamotrigine

I have a 30 year history, from my mid 20s, of depressive episodes and longer periods corresponding quite closely to what is now called bipolar 2. I have tried and had some temporary success with a number of drugs including MAOIs, SSRIs, and a number of talking therapies, including psychodynamic (7 years 3 times per week) and CBT.  My best years were ages 44-47 with Prozac, follwed by poop-out and no resumption of success with other SSRIs.

I have now been in Jungian analysis (4 x per week) for 3 years, gave up medication 6 months after starting, then, in a really low suicidal state a year ago, and after great internal struggles about returning to drug help, went on lamotrigine at 200mg after the usual build-up, having read your excellent website.  I feel better now than I have ever done, but it is clear that this is in part due to my analysis. In the last year, this has transformed me, though the process of calm, steady,  insightful, reflective growth and individuation is continuing, and I think will do sofor some time to come. I am now experiencing some early wakening, without anxiety and sweating as before, but seemingly a changed sleep pattern requiring apparently 6  hours a night instead of 7 or 8, and some buzzy sensations/feelings as if inoverdrive, but not mania. The question, finally, is should I reduce or completely stop, over a period of course, the lamotrigine. My concern is less for mania than for a  return to "depression" taking the old form of self-persecution in myriad variations.

Dear Mr. D. --

Thank you for describing this interesting treatment experience. You summarized by asking if you should reduce or stop the lamotrigine. I cannot give you such a direct treatment recommendation. But allow me to offer a perspective that you could discuss with your doctor, an alternative approach of sorts.

In the history that you describe, the improvement on lamotrigine is nice to hear (as you are right, I do indeed strongly favor this medication in many circumstances for people with Bipolar II were depression is the dominant symptom, where cycling is obvious, and where antidepressants have either never worked or no longer are working). So what to do now? You are wise to be watching what is happening to your sleep, and recognizing that it might be associated with this "buzzy sensation", as it may well be. One way to approach this, then, would be to try to push your sleep back in the other direction.

For example, it is conceivable that what you are describing is a seasonal phenomenon, as lo here we are precisely at the Summer solstice. You might be reacting to the appearance of morning light with that earlier awakening -- and therefore able to address this by avoiding morning light. Options here obviously include just getting good shades on your bedroom windows, or possibly more simply, using a "sleep mask" -- one of those satin fabric things with a headband to hold the cloth over your eyes while asleep in bed. I think these are remarkably effective and underappreciated, especially since they cost about four dollars.

Alternatively, just a small bit of an anti-manic agent such as lithium or valproate (Depakote) -- although you have to be very careful of the medication interaction with the latter, which roughly doubles the lamotrigine levels -- might be sufficient to push back against this decreasing sleep. If you were having difficulty falling asleep (which you do not describe, but might be relevant to some other readers), there is even a possible way to deal with this using a non-medication approach, which I described in my somewhat lengthy essay about
Bipolar Disorder: Light and Darkness -- Treatment Implications.

Lastly, I might think about it trying a very cautious dose reduction of the lamotrigine, but I would be very concerned about the potential for increased, rather than decreased cycling of mood and energy with that move, and would be prepared to be turning it back up, particularly at the end of summer.

In any case, you will want to discuss your options with your prescriber before you undertake any changes, right? Good luck with all that.

Dr. Phelps

Published October, 2007


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