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Q: Are Wellbutrin and Lamictal a Dicey Combination?
Dear Dr. Phelps,
I am a 60 female who has struggled with severe depression, insomnia and anxiety
from childhood. Over the last 10 years I have been treated with a variety of
anti-depressants with moderate to no improvement. For the past 4 years plus my
PNP has been treating me for severe depression using some of the newer
anti-depressants in conjunction with Wellbutrin (SR and other times with
extended release). I've been taking Wellbutrin for approximately 8 years and
have not wanted to let it go because I feel that this medication helped me to
lose over 100 pounds. Recently she changed her diagnosis from severe depression
to Bipolar II disorder. She started me on Lamictal (increasing the dose slowly
until I reached 300mg.) along with the Wellbutrin (300-400mg). It was like a
MIRACLE AT FIRST.. I felt calm, happy, easy going and for the first time in my
life, I felt stable and normal. Unfortunately after about a month or two, it
seemed to lose it's effectiveness. She took a blood level and then raised the
dose to 400mg. Instead of feeling better, I actually felt worse. So she lowered
it back to 300mg of Lamictal and 400mg of Wellbutrin (the Wellbutrin at my
request because I was starting to gain weight....which is unacceptable given my
other serious orthopedic problems). I have continued to spiral downward into the
depression, mood swings, etc.. Now my cognitive abilities are being compromised
and my hands are shaking as if I had drunk gallons of coffee (I rarely drink
even a cup of coffee). I haven't slept normally for months and my weight
continues to creep up. We don't know if it is the addition of the Lamictal
causing the weight gain and addictive behavior (gambling too much). It is not
clear whether it's the medication or the lack of sleep, or both, that
aresabotaging me. I don't want to go back to the old me....depressed and a pain
in the butt. Also, to add to the mix, I am on 180mg per day of MS Contin for
pain coming from the above mentioned orthopedic problems. I take blood pressure
medication as well. I'm afraid of what is happening to me. She and I think we
are making too many changes (2-3 changes in the last couple of months) to the
dosage of my medication protocol. Now she is thinking of adding Lithium (due to
my racing thoughts) and I'm petrified what that might do to me. I know you've
said that Lamictal and anti-depressants are not the best combination. I'm just
afraid to let go of the Wellbutrin for fear of further weight gain. Are
Wellbutrin and Lamictal a dicey combination?
Dr. Phelps, I'm feeling SCARED and DESPERATE especially now that these tremors
and cognitive problems have appeared. I would appreciate any feedback you can
provide. I know you are the expert in the field of Biopolar II, and I'm certain
you will give me sound advice.
Sorry about the length of this question (I'm not thinking clearly) but.. PLEASE
DR. PHELPS HELP ME IF YOU CAN!
Sincerely and With Appreciation,
Scared and Desperate AKA Joy
Dear Joy --
I hope by the time you receive this reply that things will not be so desperate.
As you know, it is generally the nature of bipolar symptoms to change. I hope
things have gone in a better direction since you wrote this note.
As for your
question about lamotrigine (Lamictal) and bupropion (Wellbutrin): you are right,
I don't entirely trust this combination. One of the reasons for my mistrust is
that (as you probably also know) lamotrigine cannot be counted upon for
anti-manic effects. When people are not having problems with manic symptoms,
sometimes this is not a problem. However, you describe problems with sleep;
problems with gambling; and "mood swings". Having difficulty falling asleep and
staying asleep is -- in bipolar patients anyway -- more likely to be a manic
side symptom than a depression problem. Certainly problems with gambling are
generally regarded as manic symptoms. And "mood swings" suggests continued
cycling, which antidepressants are generally regarded as having the capacity to
induce.
For these
three reasons at minimum, then, we have to wonder whether the bupropion is
inducing manic symptoms or cycling that the lamotrigine is incapable of
controlling. Or perhaps lamotrigine might be able to keep those symptoms under
control, if bupropion wasn't there. Either way, you can see the obvious
conclusion: from where you are, one of the clear options is to try taking
bupropion out. Of course, you would immediately want to hope that the basis for
weight gain in the past has been associated with uncontrolled mood symptoms, so
that you have some reason to hope that without bupropion, your weight won't go
back up.
None of the
changes that you describe sound illogical to me. And I too would be thinking
about adding lithium, on the presumption that until mood symptoms are under
control, life is generally not very functional. It is also difficult to obtain
true weight stability when mood is wobbling all over the place. So I would end
up placing a priority on mood, even over weight, in the short run (because it is
hard to imagine how you can ever arrive at a really stable place if you put the
priorities the other way around; the sequence of events you describe rather
suggests that very problem?).
Once in a
while, lamotrigine is just too much like an antidepressant. Some people can't
use it, even people who look like they would be a great candidate for it. It
makes people anxious and over accelerated. But I fear that it is more likely to
cause problems like this when it is added to an antidepressant already in
place. That's why unless I'm somewhat forced into it, I tried generally not to
have lamotrigine to an antidepressant. You just can't figure out what's going
on, for sure anyway. But it is not dangerous. It just makes for puzzles like
the one you describe. I hope that you and your physician, who is make in logical
moves, will be on the get your symptoms under better control soon. (Of course
you should not make any changes except in discussion with her). And then, you
can look at the whole range of options for weight control from a better place.
Good luck with that.
Dr. Phelps
Published October, 2009
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