Expert: Ivan Goldberg, M.D. - 10/22/2010

Question
QUESTION: Hi Dr. Goldberg,

I realize this is for informational purposes only so rest assured I will not make any changes to my medications as a result of our correspondence.  I just want your opinion so that I can do further research to assist me in talking with my psychiatrist at my next appointment.

I've suffered from a low level of depression for as long as I can remember, along with anxiety.  Definite mood swings my entire life, but have only become a problem in my adult years (I'm now 31). It wasn't until earlier this year my Lexapro was increased and I seemingly flipped out, for lack of a better word.  My psychiatrist initially thought this was due to the worsening anxiety & depression and the fact that the increased Lexapro hadn't had time to take affect.  But now we're beginning to see otherwise.  I was sick as a dog, losing weight, had extremely restless depression, racing thoughts, yada yada.  I could not stand to be in my own skin.  And the benzos offered no relief.  I was off from work for several weeks.  We backed down on the Lexapro, at my request, and I was able to return to work but the depression and anxiety were still there.

I am currently on Lexapro 20mg, Wellbutrin XL 150, Klonopin as needed, and just recently put on Lamictal (it's been almost three weeks and I'm up to 50mg).  The Lamictal was added when I visited my psychiatrist a few weeks ago in "crisis".  The depression had taken it's toll on me again and we then realized I'd been hypomanic in the previous month (starting a home business I had no interest in, trading a one year old car in on a brand new one of the same make and model, etc).  So I was diagnosed with Bipolar II.  And now, learning more about it, it makes perfect sense and I believe he's hit the nail on the head after reviewing my life.

I understand it can take a long time to feel any benefit from the Lamictal since we are titrating up slowly.  But since it's been added I feel so drugged up and unreal.  I feel as if I'm in a dream and a nightmare at the same time.  I was told by a pharmacist that it probably isn't the Lamictal alone doing this, but the fact that I'm now on so many medications that affect the mind (I believe they referred to it as polypharmacy).

My psychiatrist mentioned that if the Lamictal works, he will eventually look at reducing or eliminating one of the ADs.  In your opinion, which one would you eliminate if not both?  And a second question, could the Lexapro and Wellbutrin keep the Lamictal from working as well as it could if these medications were withdrawn?  Thanks in advance!

ANSWER: Hi Wendy  . . .

I often get to see people who have been pushed into manic or hypomanic states by antidepressants. My strategy in such situations is to stop all antidepressants and to start the combination of lithium and Lamictal. Like other drugs with antidepressant activity, Lamictal can sometimes induce mania or hypomania (although it does it less often than Lexapro or Wellbutrin). Lithium protects against the development of mania or hypomania.

Best regards . . .

Ivan
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---------- FOLLOW-UP ----------

QUESTION: Quick follow-up question. My Lamictal has been titrated up to 150mg and I'm not having many lows. But I'm either having dysphoric hypomania with extreme irritability or extreme irritability alone without the hypomania. I spoke with the nurse yesterday and my psychiatrist said to discontinue the WB XL temporarily and continue the Lexapro & Klonopin (for the separate anxiety disorder) and the Lamictal. Is it possible that the Wellbutrin and not the Lexapro or Lamictal could actually be the sole culprit? Lithium has not been mentioned yet as an option. Thanks for your time.

Answer
Hi, Wendy . . .

If a patient of mine were in the situation you describe, stopping the wellbutrin is certainly one of the possible ways to go. If the dusphoric mania did not disappear within 7-20 days my next move would be to start lithium. If that was not clearly successful, I'd then, while continuing the lithium, stoop the Lexapro.

Best regards . . .

Ivan
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