Dr Phelps,
I want to know how you feel about the combination of Lamictal(50mg)and Depakote(500mg)working together to treat frequent panic attacks and mild bi-polar. My psychiatrist has me on this, but there are times at night when I have this racing feeling in my chest and feel like im suffocating. I have had many tests and been told there is nothing wrong with my heart, although it feels like it flutters during this process. The days go by at work like picket fences, as my thinking is clouded and I cant recall things that happened during the day or even what i ate yesterday.  When I complain my psych will usually raise me up to 750 depakote or drop lamictal to 25, we go back in forth for the past 1 1/2 years. I am 42 and now matter how hard i try to watch diet and stay in reasonable shape, I feel like I am headed downhill..I watched  my Dad suffer from bipolar and now he has dementia and in a nursing facility. I fear the same is in store for me. I just wish I could beat this without medication and get my life back before I forget my sons name.


 Dear Doug --

One way to interpret your description here would be to assume that you are still having manic symptoms, namely "racing thoughts", such as your vivid description about the picket fence. In that case, I think most mood specialists would agree that the solution is to find more of an anti-manic effect. Hundred milligrams of Depakote is not very much, nor even is 750 mg. In most cases it takes 1000 mg or more (where 2000 mg is the high end for most people) to get a substantial effect from this medication. You can even do a blood test to check your Depakote level. Until you push that level up to around 100 (the official top end is 125 now) you have not had "full- dose Depakote".

However, many people cannot handle full dose Depakote because they get an appetite increase and weight gain when they go beyond 1000 mg or so. That might be the reason why you and your doctor or holding back. Of course, there are many other anti-manic medications to choose from.

Another important alternative explanation for your experience that you describe your would be the possibility that Lamictal is actually responsible for some of these symptoms. This is not widely recognized, but many other mood specialists I have spoken with have recognized it, all of us independently of one another. I heard estimates that about one person in 20-30 can have a reaction to Lamictal which is rather similar to what happens when people take an antidepressant. We know from years of experience that antidepressants can cause some of the symptoms you describe, so one must ask if Lamictal could possibly be doing this. In my experience, lowering the dose can decrease such symptoms, but to really make them go away might require switching to an alternative.

So as you can see, you'll have to work with your doctor to decide whether the problem you are facing is untreated symptoms that belong to you, and require more aggressive anti-manic treatment; or perhaps whether the problem belongs in part to Lamictal, which obviously suggests a different approach.

I hope those ideas might prove to be useful. Be careful as you discuss them with your doctor, as the treatment approach you described thus far suggests that this may not be how she or he sees things. I'm just offering some ideas to consider.

Dr. Phelps



Published March, 2008