Benefits of Lamictal Outweigh Side Effects?
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Q:  Benefits of Lamictal Outweigh Side Effects?

                          
Hello Dr. Phelps,

First off, Thank You for being both knowledgeable and bold; by putting so much high quality information on web sites you have helped myself and probably thousands of others gain an orientation to the BP diagnosis and (with fabulous detail and thoughtfulness) to courses of treatment.

Enough with the flattery.

I am presently on Lamictal (see background info below) and have had minor instances of numerous side effects mentioned on your sites.  I would like your opinion as to whether the Lamictal is the culprit, and whether the combination of minor symptoms warrants revising my treatment.

Here are some of the effects that have appeared since I began the Lamictal five months ago:

1. Unusual sensitivity to normally minor skin irritations during Lamictal introduction: a case of Poison Ivy on my  wrist resulted in huge blisters and quicklyspread to other extremities and produced small rashy spots on my torso, which all subsided after three weeks; and a normal summer evening outdoors would result in 10 to 20 mosquito bites as opposed to the normal one or two I would have expected.  (Inconsequential stuff, easily explained by a patient's nervous hyper vigilance)

2. Very short-lived episodes of total disorientation.  For periods of two to five seconds I have completely and absolutely lost any sense of temporal and spatial orientation.  These are infrequent -- maybe once a month or less -- and not scary enough by themselves to warrant concern. (Perhaps this isn't relevant, but episodes always occur in small spaces like in the pantry or in the shower.)

3. Short-term memory is very diminished.  However medium and long-term memory seems unaffected.  This is accompanied by a feeling of dissociation, as reported by another of your correspondents.  On the other hand, "dissociation" from the depressive stimulus of my environment was exactly what I was hoping for!

4. Irritable-bowel syndrome, general disinterest in eating, diminished sense of taste (my mouth senses things like irritation and numbness, but I never enjoy the taste of what I eat).

5. More pronounced physical symptoms of stress such as occasional racing heart-beat and shortness of breath while at rest, and increased blood cholesterol.  Note however that at 50 years old I am an avid, competitive soccer player and do not have any heart/lung symptoms during or after 90 minutes of sprinting during a game.

BACKGROUND

{This is where I flatter myself by thinking you are interested, or even that you've read this far! :)

I am currently on a "trial diagnosis" of BP II.  I began seeing a therapist and psychiatrist two years ago to help with severe feelings of depression caused by personal tragedies:
= eldest daughter died of heroin overdose;
= oldest son suffered what used be called a nervous breakdown resulting in numerous suicide attempts and violent and destructive outbursts bordering on homicidal rage
-- ultimately diagnosed BP I and removed from our home to a group home;
= youngest son succumbed to extreme symptoms of rapid-cycling mixed mode BP I and after three other school placements is now in a residential school;
= meanwhile I was laid-off from my job as a high-tech manager and have been out of work for two-and-a-half years; and
= I have to care for my wife who suffers from severe anxiety disorder, PTSD, and agoraphobia understandably resulting from all these traumas having occurred in the space of 3 years. 

My own level of depression varied from Severe to Extreme, based on various evaluation instruments.  So I began treatment with a diagnosis of "adjustment disorder" and a suspicion of pre-existing adult ADHD.  (Btw the short- erm memory and dissociation problems could be interpreted as a strongly pronounced increase in the distractibility that was already present and was a crucial indicator for the ADHD.)

In addition to Adderall for the ADHD, my doctor put me on Celexa and subsequently Effexor.  Neither antidepressant really made a dent in my mood over the course of 18 months.  (And although I have doubts about the ADD diagnosis the Adderall has probably helped me considerably in shouldering my day-to-day burdens).

Five months ago it occurred to my psychiatrist that perhaps I have BP II.  This suspicion was based on: my lack of response to antidepressants; the family history of BP I which includes my own brother has as well as my two sons [and probably my heroin-addicted daughter]; and a perhaps liberally-interpreted personal history of life-long low- rade depression punctuated by short-lived snatches of release, happiness, and unrealistic ambition.  So the doctor reasoned that Lamictal was worth a try.

After an appropriately staggered introduction of Lamictal (in five two-week intervals up to 125mg), my feelings of depression have *completely vanished*.  Wow!  I had always thought that everyone had more or less the same degree of unhappiness that I endured my whole life, but now I realized that I've been living under a handicap!

So I'm overjoyed at the benefits of Lamictal in my case.  But there are those side effects.  Most are beneath the threshold of concern, and I might not even have linked them to Lamictal but for the references I read on your web sites.  But I'm particularly concerned that the dissociation and short-term memory loss are becoming serious impairments in my efforts to find a job.  (The flatulance might also make it tough, but I think I could make it through an interview:)  

My doctor recommends a cautious lets-just-wait-and-see approach that I agree with.  (Btw, he's also continuing the Effexor until he has another few months of run-time on the Lamictal.)  But I'd be very interested in your opinion in the meantime.

Sorry for the rambling self-indulgence (and the over-use of hyphenated words and parenthetical expressions).  It seems my "dissociation" has removed some editorial inhibitions and the self-doubt about the importance of my own words.  Even if you haven't read along this far, I thank you again for offering your ear and for providing so much stimulating and helpful information.

Now what was it I was going to do before I decided to write you a note:?

Rgds,


p.s. If you post my note along with an answer on your site, feel free to edit it down for the benefit of your readers.
 

Dear Mr. C' -
Smart move, the flattery; it got me all the way through your letter.  Other readers are not encouraged to replicate this strategy, however (      :)   -- that's the first time I've used this little internet thingy, but I needed someway to indicate the spirit of the remark ).   The humor, however, we should all strive to replicate! 

Two prefacing remarks: one, as to diagnosis, this awful run of bipolar diagnoses in the rest of your family ought, in my opinion, to indicate that your symptoms should be regarded as bipolar until proven otherwise, rather than the other way around (as it went). Second, it is of crucial importance, in my view, to know that you have remained on Effexor with all this going on, which interestingly (I presume largely out of your wish to highlight the obvious response to lamotrigine) was almost an afterthought in your story -- see below.  

Here we go then: 

1. Unusual sensitivity to normally minor skin irritations 

...... probably the poison oak interacting with your immune system at the time of lamotrigine introduction.  I gather your skin is back to normal now?  As for the mosquito bites, well, there's this thing they didn't tell you about lamotrigine.  It makes you really attractive to mosquitoes.  And to beautiful women, too, in case you're having any trouble with that.  Sorry, kidding on both counts, darn.  Sorry, I can't even speculate on the mosquito thing.  

2., 3., 4., 5. -- 

With luck, my hunch would be right.  The Hunch:  all of these could be considered manifestations of a "high-energy" component of bipolar disorder, or an exacerbation of the bipolar disorder by an antidepressant, or both (i.e. from the illness itself, and/or from the antidepressant).   In order: dissociation -- occurs in people with bipolar disorder and post-traumatic stress disorder (PTSD), and often diminishes, usually disappears in my experience, when mood stability is achieved.  Memory:  commonly impaired as long as symptoms continue (there is a bunch of new evidence suggesting this is the effect of the mood disorder itself, but I would also be unsurprised if it worsened if an antidepressant was added to someone's mood stabilizer regimen and there were other manifestations of worsening (e.g. sleep problems; I'd bet you still have difficulty sleeping, particularly waking during the night and having difficulty getting back to sleep, perhaps waves of this being worse and then phases of it being somewhat but not completely better? (that's not diagnostic of bipolar disorder, mind you, just happens a lot with it). 

Uh, where were we, then?  Oh yes, I skipped the total spatial disorientation.  Sorry, I don't recognize that.  Unless it occurred after Effexor was recently decreased, which can produce all sorts of odd reactions somewhat like this.  I'd still hold out hope this would stop when Effexor is gone, per below. 

Next: irritable bowel:  very commonly a manifestation of the high-energy side of bipolar disorder, as well as the flatulence that goes with IBS frequently.  Next: occasional racing heart, shortness of breath at rest, in an athlete (who's had an evaluation for this by his internist?)  Easier to understand these as "high-energy" symptoms, although the way they occur briefly is puzzling unless one invokes an "ultra-rapid cycling" process, which many psychiatrists would regard as stretching "bipolar" to absurd proportions.  And yet, I've seen almost momentary symptoms seem to be part of "rapid cycling" in that they disappeared after effective mood stabilizer treatment, so its not at all outside my experience to lump these in with "bipolar" symptoms.  

Lastly, cholesterol is up.  Interesting.  Not sure what to make of that. 

Okay, here's my hunch-interpretation:  we know that antidepressants can make bipolar disorder worse.  They cause cycling, and rapid cycling in particular, and "mixed states".  In mixed states one can lose sight of "hypomanic" symptoms such as anxiety, irritability, insomnia, or profound difficulty concentrating (note that's on my website's list of hypomanic symptoms as a particular marker of hypomania, I didn't make it up for your case) because they are not "cycling" anymore, and they're all tangled up with other symptoms frequently, so it's hard to see them as part of "bipolar".  Thus it is entirely possible, and in my view likely, that the Effexor is contributing at least in part to this list of symptoms.  It's common, for example, for effective mood stabilizer treatment to decrease IBS symptoms; and to treat anxiety symptoms (here's my essay on anxiety as a bipolar symptom).  Sometimes effective treatment consists just of gradually withdrawing an antidepressant (to be discussed with your doctor, of course, as is true for any readers here). 

Therefore I would be very interested to hear back from you after the Effexor is gone (you can write me at PsychEducation; in fact, would you write me now and let me know if I can use your story, identifying information removed, to illustrate what's possible with lamotrigine?  Thanks). I'd like to know how many of these problems persist.  In case it's not your doc's usual approach, make sure you taper it extremely slowly; I've had good luck taking 4 months to taper off, roughly 25% per month, maybe a little slower at the end -- which I heard suggested by Gary Sachs, the Harvard bipolar guy.  

The short answer you may have had in mind is "no, I've never seen any of these develop in someone on 125 mg of lamotrigine, or any dose for that matter" (though I've rarely gone past 200 mg so far).  

Great that you've had such a response to lamotrigine.  I hope it just gets better from here.  

Dr. Phelps
 

Published January, 2004
 

 

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