Expert: Ivan Goldberg, M.D. - 12/12/2011

Question
Hi Dr. Goldberg,

My question is two part. My former psychiatrist left the practice and I now have a brand new psychiatrist.

First, what risks and long term complications should I be concerned about with Lamictal? I am only 33 and would like to ward off any chronic diseases that are in my control. My new psychiatrist has currently been trying to wean me off the Lamictal because he doesn't feel the benefit outweighs the risk and he isn't sure there is a bipolar component to my problem (plus he said he just doesn't like it). But crazy me, I failed to ask what the risks are (I know about the rash) and why he is so against this medication.

Second, I was first diagnosed with GAD, then dysthymia with major depressive episode, and am being evaluated for cyclothymia. My doctor truly doesn't suspect cyclothymia however I have such a good response to Lamictal. Being exhausted all the time, my doctor decided to lower my medications since I was stable to see if I could get by with less and to see if polypharmacy was playing a role in my fatigue. About 2 months ago my Lexapro was lowered from 20 mg to 10 mg. Over the past 5 weeks my Lamictal has been lowered from 200 mg to 125 mg. And I'm now feeling awful! Discontinuation or return of original problem (whatever that may be) - I have no idea and do not get much information out of the nurse when I call. My anxiety (in general and about my health as I'm having a return of "physical complaints") is back in full force along with a couple of recent panic attacks. I've been sad and crying for days - very doom and gloom about the future and life in general feels overwhelming again. Sleep is messed up. Lots of nausea and headaches.

The last two years have been a mess as prior to my first major depressive episode I'd struggled with anxiety and some sadness but on a lower level. Then my body was thrown out of whack for whatever reason and my life was forever changed.

I would never do anything against my doctors orders as the anxiety part of me makes me too afraid. :-)  But I'd like your OPINION as to what you think may be going on here and what route you would take with my two medications if I were a patient of yours.

I appreciate your opinion & your time!

Answer
Hi Wendy . . .

I have treated many patients with Lamictal some since 1987. A few developed a rash during the early stages of treatment, but most of those were able to remain on Lamictal. In no instance was the rash severe enough to require hospitalization. While I do blood counts and liver chemistries because of a remote possibility of damage to the bone marrow or liver, in no instance did any abnormalities appear. While Lamictal is often associated wit the treatment of individuals with bipolar depression, I have successfully used it to treat individuals with hard-to-treat unipolar depression.

If I saw a patient with a history of increased symptoms following a reduction in Lexapro and Lamictal, the first thing I would do would be to increase the doses of those medication to their former levels.

Best regards . . .

Ivan
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