There’s a general consensus in the psychiatric community that bipolar depression is difficult to identify and differentiate from unipolar depression. It can be difficult to treat pharmacologically also. Before the advent of newer anticonvulsants and antipsychotics which are now routinely utilized in bipolar depression management, antidepressants were the mainstay of treatment, and when the SSRIs came along, they all but took over. But as time passed, it became increasingly evident that these serotonin agents were responsible for initiating cycling – sometimes rapid – to a manic state.
Lamictal (lamotrigine) is but one player in a rather crowded field of medications used in bipolar II, and is classified as an anticonvulsant. It’s joined by other anticonvulsants such as Depakote and Tegretol, as well as a host of antipsychotics (Seroquel; Latuda; Symbyax) in bipolar depression management.
Lamictal arrived on the bipolar disorder scene in 2003, when it gained FDA approval for the maintenance treatment of bipolar disorder. It delays episodes of depression, mania and hypomania, and it’s better at preventing bipolar disorder’s depressive phases, not it’s manic phases. This makes it an acceptable choice for clients with bipolar II, who, on average, typically spend half their lives in the depressive phase of the disorder, and only 4 percent of the time in a hypomanic (or mixed) phase of the disorder. It works quite well in patients with ultra-rapid mood swings that occur daily or weekly, including cyclothymia. The drug is not approved for active bouts of depression (or mania), thus it’s been nicknamed as a mood stabilizer “lite.” Its main downside is that it’s slow to act, thus it’s not a go-to when rapid action is needed – as in instances of acute depression management. Lamictal can be used as a standalone or as augmentation in conjunction with another mood stabilizer or atypical antipsychotic.
Lamictal carries a possible serious risk of Stevens-Johnson syndrome, which can be fatal if left untreated. Signs of serious rash emergence include: painful, scaling, blistering bumps involving the face, palms of the hands, feet, or mucous membranes; also fever, pharyngitis, muscle aches. Slow dosing titration can significantly reduce the risk of serious rash, but does not reduce the risk of benign rash emergence – which can be quite high at 10 percent. And there’s no surefire way to determine which rashes will advance to Stevens-Johnson. The FDA recommends stopping Lamictal at the surfacing of any rash or fever in the first 2 months. Rashes with any of the signs listed above should receive immediate medical attention.
Lamictal is also thought to cause cardiac arrhythmias in susceptible patients, particularly ventricular arrhythmias. Routine EKG’s are not currently recommended before beginning Lamictal, but any patient with cardiac conduction delays or heart disease should likely seek a consult with a cardiologist to be on the safe side. Outside of the aforementioned rashes and cardiac issues, Lamictal is well tolerated with no serious medical risk factors.
The target dose for adults is from 100-250mg per day; 50-150mg per day in older adults; and in children under the age of twelve, 50-150mg per day – although not FDA-approved.
Bipolar demands long-term management and prevention, and Lamictal’s overall tolerability profile renders it an acceptable choice primarily for preventive maintenance as monotherapy in bipolar II or as an augmenting agent in Bipolar I.
Attribution Statement:
Joe Wegmann is a licensed pharmacist & clinical social worker has presented psychopharmacology seminars to over 10,000 healthcare professionals in 46 states, and maintains an active psychotherapy practice specializing in the treatment of depression and anxiety. He is the author of Psychopharmacology: Straight Talk on Mental Health Medications, published by PESI, Inc.
To learn more about Joe’s programs, visit the Programs section of this website or contribute a question for Joe to answer in a future article: joe@thepharmatherapist.com.