Could Abilify and Lamictal Affect Motivation and also Ability to Think?
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Q:  Could Abilify and Lamictal Affect Motivation and also Ability to Think?

Dr. Phelps, 

I was diagnosed with bipolar disorder over a year ago. I am on 7mg abilify and 200 mg lamictal daily. For a long time, I have suspected that the drugs are affecting my ability to think clearly (I am an academic and do quite abstract thinking on a daily basis and so I would be particularly sensitive to this issue). My first question is this: could these doses be affecting my thinking, or are they too low to have that sort of effect?  

Also, since being on these drugs, I have noticed an extreme lack of motivation. Everything is forced -- eating, showering, exercising, cleaning. I don't know whether that is residual depression or whether it is due to the medication. I suspect it is the medication, since it has a completely different character from the kind of anhedonia and apathy I experience when I am depressed. Plus, more often than not, I do not have any sadness or negative mood accompanying it. I also have only ever had this kind of lack of motivation since being on the medication. So my second question is this: could the lamictal or the abilify be causing this lack of motivation?  

I ask because I have been struggling with trying to get my psychiatrist to really listen to me about this. She seems to either deny that any effect on my thinking could be significant or that the lack of motivation must be depression. But I know myself, and I definitely think the drugs are doing this. But I wanted to get another opinion. I feel that I am stuck on the current medication regime, even though I want to get off the meds, just to see if it makes any difference. However, I don't want to go against my psychiatrist's recommendations.  

Thanks for your time.


Dear Heidi --

Let's take 2 questions from this: which if either of these medications might be affecting your ability to think clearly, and your level of motivation?  And secondly, what should a person in your circumstances do, when it seems like you are having difficulty getting your psychiatrist to listen? 

First, ability to think: at 400 mg per day, lamotrigine is well known to cause a rather subtle difficulty thinking.  Often it first shows up as a difficulty in finding words (it has been dubbed "Word searching"), simple words that everyone knows -- and there you are, trying to think of the word for "table".  But some people can tell, there just is something wrong with the way they are thinking.  Sometimes one can see this effect at 300 mg.  And I have had a few patients where we were not sure, but we were wondering if it might even be there at 200 mg.  So I think it is possible that lamotrigine needs to be on the list of potential culprits. 

Likewise, aripiprazole (Abilify) can also cause a change in the way people think.  At lower doses, such as those you are taking (compared to "antipsychotic" doses, which might be more like 10-15 mg, or more), it is uncommon for people to be bothered by how the medication is affecting their thought process.  But I have seen it happen, for sure.  So it goes on the list also. 

Obviously, when you consider trying to lower or switch away from these medications, that must be done in the context of knowing your options and how likely they are to work (for example, if you have already been through many other medications, and only these were really getting good symptom control, it makes it harder to consider changing); and in the context of how severe your symptoms might be were they to recur (based on your prior experience).  And then, there are numerous other factors like cost and when you are going to make this change, relative to your current life circumstances, and so on.  That's where having a psychiatrist can you trust can really help, so there you have an opportunity to brainstorm with someone who might be able to help you evaluate all that. 

That brings us to your second question, which could be regarded as "how do I go about getting a second opinion?"  In an ideal world, you could seek that opinion from another psychiatrist who might be in a position to continue to work with you if her style and her competence seem equal to or better than your current psychiatrist.  If that's possible for you, it would be a reasonable step.  I encourage all my patients to seek a second opinion at any time.  The problem is, often it is very difficult to find another psychiatrist whom you might see, at all; sometimes because there are none, sometimes because of insurance issues, and so forth.  Finally, before you take that step, you could ask your psychiatrist to make it explicit her concerns about your making any changes in these medications.  She may have some good thoughts about why turning them down, or moving on, is not such a hot idea. 

Good luck with the process --

Dr. Phelps

Published January, 2009


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