Moving from Lamictal to Zoloft?

Mary writes in . . . 

I hate to say it, but I was relieved to hear that many others reported gettting acne (especially along jawline) from Lamictal. I complained about this to my Psyciatrist, but he said he never heard of that being a side effect. I, also was feeling so blah, lost my self-esteem and confidence to do my job (and quit) and could not get any endorphin release from aerobic exercise, listening to music & playing my trombone. I became so very depressed and stopped doing these activities which have been trustworthy coping strategies (am 47 yrs old). I told this to my Dr. and he insisted that I was not depressed which made me more depressed to have a Dr. who I thought understood me discount my feelings. Anyways, I have gone back to my former psychiatrist (reluctantly b/c have to pay out of pocket) b/c he has known me for almost 3 years and validated that I am depressed. I got off the 200 mg Lamictal within 1.5 weeks which gave me terrible anxiety. I tried Prozac which made it worse and went off of that. Now I have been on 50 mg of zoloft for 2 weeks & still feel depressed. I saw my Dr. today & he told me to bump the dose up to 100 mg and then to add Topomax. I fear adding a second drug especially a mood stabilizer since I had such bad experience with the Lamictal. I just want to be on one drug for now and only to be on an antidepressant for now b/c I have not been in a hypomaniac mood since January. Do you think going off the Lamictal too quickly caused me to go deeper into depression? Do you think I should wait and see if the Zoloft pulls my mood up? I am currently not working b/c of all I mentioned above and can barely take care of myself and my 5 yr. old daughter. People who know me would not recognize me b/c I have always been upbeat, positive and motivated. Now I can barely get up and take my daughter to preschool and then in another week get her off to K-grade. Oh, and yes, I have been getting talk therapy on a weekly basis for the past 4 years. Please advise…..I am in the process of trying to find a Dr. in my insurance network to get another oppinion. Thank you for your assistance….I am desperate!

Once upon a time we didn’t have Lamictal.  Hard to believe!  Seems like Lamictal has taken over the treatment for Bipolar Depression and is making inroads in the treatment of Unipolar Depression.  Despite it being a good treatment, it is far from the panacea that we would like it to be.  Failure to achieve success on Lamictal should not be viewed as a huge setback.  You still have many options!  Assuming that the diagnosis of Bipolar Disorder is correct, pharmacologic intervention needs to be done carefully, but it is hardly brain surgery.  

First and foremost, when treating Bipolar Depression with standard antidepressants, it is vitally important that a mood stabilizer be put into place.  Treatment with a standard antidepressant without a mood stabilizer in place increases the risk of precipitating hypomanic or manic symptoms.  My guess is you would not mind a little hypomania now, but in the long run it is not a good thing to foster greater mood instability.  There are many mood stabilizer options available so please explore other blarticles on the blog for those discussions.  Once the mood stabilizer is in place, the doc can treat you with standard antidepressants fairly safely.  The aggressiveness of the treatment is dependent on multiple factors, including what has worked in the past, how sensitive you are to side effects, how fragile your manic states are, etc.  It sounds like you are feeling very very depressed and in need of some fairly aggressive treatment.  It sounds like the Zoloft is being titrated fairly aggressively.  I like at least two (and preferably four) weeks in between dose changes.  Doing the math, it might be a while before you do feel better since it might take 200 mg of Zoloft to help your mood.  And if that does not do it, it might take the addition of an augmenting agent such as Wellbutrin, Lithium, or thyroid supplementation.

Now, you already mentioned that you are not happy about polypharmacy.  Sorry to hear that.  The unfortunate truth with Bipolar Disorder is that it is quite common for patients to need multiple medications to maintain stability.  The order that the meds are added must be carefully considered so as to minimize side effects, drug interactions or needless medication.  My personal preference is to get the mood stabilizer on board first in cases like this and then to add in the antidepressant medicine.  Seems like your expensive doc is adding the Topamax second.  I am not a huge fan of Topamax because I have not had great success with it as a mood stabilizing agent. It is generally well tolerated.

Lastly, could coming off the Lamictal quickly contribute to your depression.  Possibly.  I would have done it a bit slower (probably) and started the antidepressant during the taper of the Lamictal.  There is not difficulty with interactions between Lamictal and the antidepressants and, sometimes, the combination is useful in treating depression in some patients.

Remember to do all those things that are good for you . . . even if you don’t want to.  Exercise, fresh air, good food, music, vitamins and Omega 3’s (fish oil).  Even with aggressive treatment and good luck, turning this situation around might take some time.  Try to be patient.  My best wishes to you!

–Dan Hartman, MD

Comments are closed.