When is Lamictal Good for Regular Old Depression?

In our striving to provide our patients with the latest, the greatest and the newest treatments for one condition or another, many psychiatrists go out on a limb to try new things.  Some of us go wwwwaaaaaayyyyy out on a limb.  There are two sides to this, of course.  You don’t want a shrink who is so “by the book” that there is no innovation and flexibility.  At the same time, there needs to be some logical, scientific and intellectually palatable explanation for what is being done.  Sometimes the docs are straight forward and forthcoming about their reasoning.  Some patients, however, come to me not having a clue as to why they were placed on one medicine or another.  

When a new treatment comes up, I am always a bit hesitant to jump on the bandwagon and start prescribing.  That is the way it was when Lamictal started to be used a number of years ago (quite a few years ago now that I think about it).  My early experiences were not positive and the risk of rash seemed so high that I rarely used it.  Over the years, as the conventional wisdom grew regarding the usefulness of Lamictal, I used it more and more as an alternative for patients who had Bipolar Disorder with significant symptoms of depression.  As my use increased, I became less concerned about the “rash” issue, even tho some of my patients developed a rash.  I even had two patients who developed Stevens-Johnson Syndrome and required a brief course of steroids to recover (which both did without any dermatologic disfigurement).  It’s usefulness clearly out-weighed the potential liabilities.  I now recommend it as a first line agent for all of my patients with significant symptoms of Bipolar Depression.

But here is where we go out on that limb . . . if it is good for Bipolar Depression, is it equally good for Unipolar Depression?  And if it is, when should it be used instead of a standard antidepressant?  There are three distinct opportunities for a medicines to be used.  It can be used as initial therapy, as a “last resort” when some one has failed multiple other trials, or as an “add on” to other therapies that have had limited or no benefit. Typically, when a new medicine is tried (or an old medicine is tried anew), it is used when other medications have failed.  Seems to me that that is a huge handicap.  Clearly, people who have failed standard treatment have more difficult pathology than those who have responded nicely to their first whiff of Prozac.  Yet, people do respond to these treatments, and that then sets the stage for trials as a first line agent or as adjunctive treatment.

So, where does Lamictal fit in at this point?  Out here in the trenches, we need to go on conventional wisdom and our own clinical experience.  The data for Lamictal is often contradictory and difficult to interpret.  There was not enough solid data for the medicine to be pushed through the FDA approval process and, since it is now generic, it never will be.  There is some data showing that it can be helpful as a first line agent, especially in patients who have more mild forms of depression.  It is rarely used for this, however, unless the patient’s history gives hints of a possible underlying Bipolar Disorder, or if there is a strong family history of Bipolar Disorder (remember, almost all Bipolar patients experience depression first and then have a later manic episode).  When reviewing the potential side effects (especially the risk of rash and Stevens-Johnson Syndrome), it is a rare patient who would pick Lamictal over a standard SSRI.  From a medical-legal perspective, can you imagine the fun a prosecuting attorney would have with a shrink who pushed use of an “off-label” medicine with a potentially deadly side effect over the standard FDA-approved medicine with no risk of deadly side effects?  I shudder to think!  If the doc is pushing for use of Lamictal in this situation, he or she better be able to explain why very clearly to you.  

The second situation would be using it as an adjunctive treatment for other agents.  My own algorithm for treating resistant unipolar depression does include using Lamictal, but only after I have tried combinations such as SSRI and Wellbutrin, or Cymbalta and Wellbutrin.  The exception here would be someone who is getting some improvement with a standard antidepressant, but has some moodiness that might lend itself to improvement with a little mood stabilization.  Even then, I often turn to Lithium to boost the effectiveness of the antidepressant.  At low doses, there is minimal side effects for most people and there is limited risk.  Blood work does not need to be done as rigorously when low doses are used.

As always, the patient must be warned about the risk of significant skin rashes and the medicine must be titrated very slowly.  Compliance is key because a period of significant non-compliance (and I count anything longer than two or three days significant) would necessitate starting back at the beginning and titrating back up again

–Dan Hartman, MD