Lamictal augmentation for unipolar depression

[yoloswagpoop42069]

Covering for an NP today and her overall diagnoses and management is driving me f*cking insane, doing things like diagnosing BPD as bipolar, and starting Lamictal for irritability.

Have seen multiple patients of hers with MDD only today, resulting in her starting low dose Prozac, Seroquel 25 mg QHS for sleep, and Lamictal AT THE SAME TIME.

Here are 4 patients of hers I saw today, all MDD:
Patient 1: Trintellex 10 mg once daily, Ritalin 30 mg once daily, Lamictal 150 mg
Patient 2: Prozac 10 mg daily, Lamictal 100 mg daily
Patient 3: Prozac 10 mg daily, Seroquel 25 mg QHS, Lamictal 50 mg daily
Patient 4: Zoloft 50 mg and Lamictal 25 mg

I haven't seen much Lamictal augmentation for mood for unipolar depression through training, but when I took a second to think about it, I don't really see why it couldn't work, given that lithium is used for mood augmentation.

I'm assuming its not typically done or I haven't heard much about it as there does not seem to be many studies or data backing up it's use, with Star*D using lithium and other agents, and not Lamictal.

Overall prefer Lamictal over antipsychotics. Are you guys using Lamictal for mood augmentation in unipolar depression, or is there just not good data on it? I need to search the literature.

Primarily just wanted to rant about NPs. If they provided actual diagnoses and management, I would be okay. As it stands they give me suicidal thoughts.

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[SmallBird]

Lamotrigine was in my med school text book as one of the options for augmenting and there are studies but I don't use it for this purpose myself. It is actually effective for irritability and mood lability although effect sizes are smaller than for atypicals.

 

[yoloswagpoop42069]

Lamotrigine was in my med school text book as one of the options for augmenting and there are studies but I don't use it for this purpose myself. It is actually effective for irritability and mood lability although effect sizes are smaller than for atypicals.

Yeah it is effective for off-label irritability. What irks me is that irritability can be from many things, including depression and anxiety, and any normal clinician would just uptitrate the SSRI to a significant dose, before adding Lamictal.

 

[Stagg737]

I actually like lamotrigine as an MDD augmentation for BPD/"bipolar" patients when first-line options are only partially effective or when they have residual irritability/mood swings. The data for depression augmentation is worth keeping it in your back pocket. I do agree with your feelings about how this NP is prescribing though, augmentation meds should be add-ons and not initiated until single meds have failed. For straight MDD I usually only start one scheduled med and possibly short-term PRNs for anxiety or sleep.

Lamotrigine does seem to be a favorite among NPs and a lot of NPs also seem to be big fans of polypharmacy.

 

[mistafab]

I think the most frustrating part of this management is no medicine is at max dose despite being on a second med.

 

[ObsequiousAplomb]

I've used Lamictal for treatment resistant depression, whether it's bipolar or not. Sometimes in concert with an antidepressant, sometimes not. It seems to work fine when I've done it.

If you ignore the inaccurate diagnosis, would you be terribly upset by low dose prozac with low dose Lamictal? Ideally minimizing meds is great, but that combo is quite common for BPD. I don't like the Seroquel, but can't really win with some NPs. Or MDs, because while I see this very often from NPs it's also very common amongst MDs, and I assume that's because the types of MDs who trained the NPs are those.

 

[yoloswagpoop42069]

I actually like lamotrigine as an MDD augmentation for BPD/"bipolar" patients when first-line options are only partially effective or when they have residual irritability/mood swings. The data for depression augmentation is worth keeping it in your back pocket. I do agree with your feelings about how this NP is prescribing though, augmentation meds should be add-ons and not initiated until single meds have failed. For straight MDD I usually only start one scheduled med and possibly short-term PRNs for anxiety or sleep.

Lamotrigine does seem to be a favorite among NPs and a lot of NPs also seem to be big fans of polypharmacy.

I do like Lamictal off-label for BPD patients. That's one thing, but most of these patients were straight MDD, no BPD.

Do you use Lamictal augmentation for straight up MDD, no BPD?

 

[yoloswagpoop42069]

I've used Lamictal for treatment resistant depression, whether it's bipolar or not. Sometimes in concert with an antidepressant, sometimes not. It seems to work fine when I've done it.

If you ignore the inaccurate diagnosis, would you be terribly upset by low dose prozac with low dose Lamictal? Ideally minimizing meds is great, but that combo is quite common for BPD. I don't like the Seroquel, but can't really win with some NPs. Or MDs, because while I see this very often from NPs it's also very common amongst MDs, and I assume that's because the types of MDs who trained the NPs are those.

Yeah sorry, only one of these patients I had concern for BPD.
The others were straight unipolar MDD, no significant concerns for BPD. I know I phrased it wonky in the initial post that would make it seem that way.

It would bother me only in the sense that she started Lamictal when Prozac is at 10 mg daily.

 

[Stagg737]

I do like Lamictal off-label for BPD patients. That's one thing, but most of these patients were straight MDD, no BPD.

Do you use Lamictal augmentation for straight up MDD, no BPD?

You can use it for MDD augmentation without personality or other components. There's also some evidence that it may be helpful for anxiety augmentation as well though this is less studied from my knowledge. Links below, the first is a meta-analysis of lamotrigine for MDD augmentation, the second is a pretty in-depth article with links to numerous articles:

https://journals.sagepub.com/doi/full/10.1177/0269881119844199

Taking Lamictal (Lamotrigine) For Anxiety Disorders: Does It Help?

Lamotrigine is a synthetic phenyltriazine chemical with anticonvulsant and analgesic properties initially sold by GlaxoSmithKline under the brand name Lamictal.

mentalhealthdaily.com

 

[calvnandhobbs68]

I've used Lamictal for treatment resistant depression, whether it's bipolar or not. Sometimes in concert with an antidepressant, sometimes not. It seems to work fine when I've done it.

If you ignore the inaccurate diagnosis, would you be terribly upset by low dose prozac with low dose Lamictal? Ideally minimizing meds is great, but that combo is quite common for BPD.

Do you mean borderline personality disorder or bipolar disorder? I hate when people just say BPD....

Bipolar, uh no. Borderline, possibly but typically I'd like to try my best to minimize polypharmacy for borderline patients if possible and I'm also of the mindset of trying to maximize one med before we move on to another or throw more stuff on. I mean it's definitely not egregious or crazy management but not the best.

Overall prefer Lamictal over antipsychotics. Are you guys using Lamictal for mood augmentation in unipolar depression, or is there just not good data on it? I need to search the literature.

OP I would typically try an atypical for unipolar depression augmentation before lamictal though just because we have more positive data for atypicals. I get from a side effect standpoint lamictal is generally more forgiving but the other issue is it takes you a month+ to get to a real dose of lamictal.

 

[Sushirolls]

Do you use Lamictal augmentation for straight up MDD, no BPD?

No.

There are so many other better adjuncts to consider before pulling out lamictal as the adjunct.

 

[forchinet121]

No.

There are so many other better adjuncts to consider before pulling out lamictal as the adjunct.

So many better ones? What’re your main ones?

 

[Candidate2017]

Do you mean borderline personality disorder or bipolar disorder? I hate when people just say BPD....

Don't be so OCPD with acronyms. Just go with it.

Borderline and bipolar are one and the same to NPs (and to most patients, 66% of PCPs, and 33% of outpatient psychiatrists). BPD for everyone, yay! A polypharm combo of SSRI, AED, and SGA (plus bonus BZD and bonus C/DBT) has the potential to cure the entire DSM. Probably with non-inferior results compared to judicious prescribing, if we exclude side effects. Amirite?

 

[yoloswagpoop42069]

BPD = always borderline for me.

Bipolar is bipolar disorder or maybe BAD for bipolar affective disorder. Never BPD for me. BPD is sacred for those with BPD for reasons you all are aware of.

 

[yoloswagpoop42069]

No.

There are so many other better adjuncts to consider before pulling out lamictal as the adjunct.

Exactly. This is how I was trained for unipolar MDD hence the post.

SSRI/SNRI
+
Lithium
Remeron
Wellbutrin
Buspar
T3
Antipsychotics preferably partial agonists

Never lamictal as depression augmentation. Off label for borderline, yeah sure. Even though medications generally suck.

 

[yoloswagpoop42069]

You can use it for MDD augmentation without personality or other components. There's also some evidence that it may be helpful for anxiety augmentation as well though this is less studied from my knowledge. Links below, the first is a meta-analysis of lamotrigine for MDD augmentation, the second is a pretty in-depth article with links to numerous articles:

https://journals.sagepub.com/doi/full/10.1177/0269881119844199

Taking Lamictal (Lamotrigine) For Anxiety Disorders: Does It Help?

Lamotrigine is a synthetic phenyltriazine chemical with anticonvulsant and analgesic properties initially sold by GlaxoSmithKline under the brand name Lamictal.

mentalhealthdaily.com

Yeah I actually saw that paper on my brief search after questioning myself for lamictal augmentation for true unipolar depression without personality.

However it’s from china, and I generally do not trust papers from there for a variety of reasons.

I will look at the other source you cited but it generally does not appear to be scholarly in nature.

I will look myself at the lit as well

 

[forchinet121]

Exactly. This is how I was trained for unipolar MDD hence the post.

SSRI/SNRI
+
Lithium
Remeron
Wellbutrin
Buspar
T3
Antipsychotics preferably partial agonists

Never lamictal as depression augmentation. Off label for borderline, yeah sure. Even though medications generally suck.

I would definetly favor lamictal over lithium, any antipsychotic, and thyroid hormone

 

[uhmocksuhsillen]

Any evidence on using lamictal with antipsychotic to increase efficacy? I saw an attending combine it with clozapine for seizure prophylaxis as well as "augmentation". Thoughts on this?

 

[Sushirolls]

I would definitely favor lithium over lamictal, any antipsychotic, and thyroid hormone

Fixed that for you.

 

[yoloswagpoop42069]

I would definetly favor lamictal over lithium, any antipsychotic, and thyroid hormone

I understand. Hence my post. I have not seen attendings do that in training however.

So you are saying you routinely use Lamictal for unipolar depression augmentation?

 

[calvnandhobbs68]

I would definetly favor lamictal over lithium, any antipsychotic, and thyroid hormone

Um why? There’s way less evidence.

 

[ObsequiousAplomb]

Any evidence on using lamictal with antipsychotic to increase efficacy? I saw an attending combine it with clozapine for seizure prophylaxis as well as "augmentation". Thoughts on this?

Yeah there's good justification for Lamictal augmentation for that indication. Lamictal is far less likely than Depakote, Tegretol, or Trileptal to cause blood dyscrasia. There's also not good evidence that anticonvulsants decrease the seizure risk of clozapine, though. People still do it "just to be safe."

 

[ObsequiousAplomb]

Do you mean borderline personality disorder or bipolar disorder? I hate when people just say BPD....

Bipolar, uh no. Borderline, possibly but typically I'd like to try my best to minimize polypharmacy for borderline patients if possible and I'm also of the mindset of trying to maximize one med before we move on to another or throw more stuff on. I mean it's definitely not egregious or crazy management but not the best.



OP I would typically try an atypical for unipolar depression augmentation before lamictal though just because we have more positive data for atypicals. I get from a side effect standpoint lamictal is generally more forgiving but the other issue is it takes you a month+ to get to a real dose of lamictal.

I clearly meant BPD as borderline personality disorder. What kind of sick deviant would use three letters as an abbreviation for a two word phrase?

I always say Bipolar 1 or Bipolar II as abbreviations because throwing an extra letter in for no reason is disgusting. I've seen BAD but I don't bother with it because 3 letters isn't that far off of 7.

And in terms of the TRD I was mentioning earlier, I'm talking after all the other strategies people have mentioned. So after trying SSRI, SNRI, TCA, atypical antidepressants with varying augmentation by lithium, buspar, etc. I haven't done T3 because we just didn't do it that way in training. None of the attendings were remotely comfortable with it. It was a rare attending that allowed lithium for any indication.

 

[yoloswagpoop42069]

Any evidence on using lamictal with antipsychotic to increase efficacy? I saw an attending combine it with clozapine for seizure prophylaxis as well as "augmentation". Thoughts on this?

It exists for TR psychosis in the Texas algorhithm at stage 5a after clozapine.

https://ps.psychiatryonline.org/doi/10.1176/ps.50.1.69

The reasoning behind this or the true evidence for this seems minimal the last time I checked. I would need to read the algo and look at the citation if it’s included

Although I have a feeling they mean more lithium or VPA as opposed to lamictal for augmentation for psychosis

 

[forchinet121]

Um why? There’s way less evidence.

Because why would I give someone an antipsychotic that will cause them diabetes and heart disease when they could do just as well with a much more benign agent

 

[yoloswagpoop42069]

Because why would I give someone an antipsychotic that will cause them diabetes and heart disease when they could do just as well with a much more benign agent

I guess because in terms of evidence lamictal is not even approved for acute bipolar depression but maintenance for bipolar depression.

Also I’m assuming there isn’t much evidence for lamictal for acute unipolar depression or augmentation.

But I will have to do a focused detailed search. Not a Friday night thing.

Although I do understand your position in that it is more benign, aside from the risk of SJS.

 

[forchinet121]

I guess because in terms of evidence lamictal is not even approved for acute bipolar depression but maintenance for bipolar depression.

Also I’m assuming there isn’t much evidence for lamictal for acute unipolar depression or augmentation.

But I will have to do a focused detailed search. Not a Friday night thing.

Although I do understand your position in that it is more benign, aside from the risk of SJS.

I have used it with good results

 

[TheRightMedication]

I'm sorry to have to call you out but going to Lamictal as your first adjunct over Lithium/ abilify or similar / T4, is wrong.

If your individual patient finds the ADRs unacceptable, fine, but if that's your routine, you must reconsider.

 

[TheRightMedication]

I guess because in terms of evidence lamictal is not even approved for acute bipolar depression but maintenance for bipolar depression.

Also I’m assuming there isn’t much evidence for lamictal for acute unipolar depression or augmentation.

But I will have to do a focused detailed search. Not a Friday night thing.

Although I do understand your position in that it is more benign, aside from the risk of SJS.

I have been prepping for a talk on bipolar disorder and the evidence for Lamictal for acute depression in bipolar disorder is better than I thought. Check out the CANMAT 2018 guidelines, if you can stomach taking the advice of Canadians. But APA guidelines are from 2010.

Still, Lamictal for unipolar depression? No.

 

[forchinet121]

I'm sorry to have to call you out but going to Lamictal as your first adjunct over Lithium/ abilify or similar / T4, is wrong.

If your individual patient finds the ADRs unacceptable, fine, but if that's your routine, you must reconsider.

Lol I’m not going to reconsider, lamictal over antipsychotic 100 percent, no way would I start those agents over a benign drug unless lamictal doesn’t work then I’d switch and I really hope if I was an ignorant patient my psychiatrist wouldn’t jump to an antipsychotic when there are more benign options

 

[TheRightMedication]

Lol I’m not going to reconsider, lamictal over antipsychotic 100 percent, no way would I start those agents over a benign drug unless lamictal doesn’t work then I’d switch and I really hope if I was an ignorant patient my psychiatrist wouldn’t jump to an antipsychotic when there are more benign options

Ten percent of people with MDD will die by suicide. There is nothing benign in insufficient treatment.

I say this humbly as one who surely practices imperfectly, and is trying to be helpful in those rare moments when I am certain I can offer advice.

 

[calvnandhobbs68]

Lol I’m not going to reconsider, lamictal over antipsychotic 100 percent, no way would I start those agents over a benign drug unless lamictal doesn’t work then I’d switch and I really hope if I was an ignorant patient my psychiatrist wouldn’t jump to an antipsychotic when there are more benign options

100%? Dude this is like NP level thinking. Ignore the actual evidence, I’ll just start whatever makes me feel good.

Yeah I get the concerns about side effects and I don’t love atypical antipsychotics either but it’s literally not recommended by anyone. It’s actually recommended AGAINST in uptodate for TRD.

“Treatments with little to no benefit — Randomized trials in patients with treatment-resistant depression
indicate that there is little to no benefit from buspirone, cannabis, folate, inositol, lamotrigine, magnesium,
memantine, metyrapone, pindolol, pioglitazone, riluzole, testosterone for females, or vagus nerve
stimulation.”

 

[clausewitz2]

Prosaically I end up using lamotrigine sometimes for people who do okay with an SRI but keep having very regularly recurring episodic bouts of depression. Often a very stereotyped progression of symptoms in each episode without any obvious stressors or changes in life circumstance. Sometimes also for the folks with similar response to SRIs but who also have some trouble with sleep/agitation in the spring that doesn't rise to the level of hypomania but is pretty consistent. Basically the folks who might have been put at the milder end of the MDI spectrum back in the day.

I do not have peer-reviewed literature to back this up.

EDIT: These are also usually people who hear about 'sedation' or 'weight gain' with atypicals and are firmly no sale

 

[Desired Member]

I am still a resident but have used lamictal with success for MDD patients that have failed adequate doses of 2 or more antidepressants. And when I say "failed," I mean that their depression worsened with antidepressants. These are patients that have some warning flags for bipolar (depression at a very young age, severe depression despite no particular horrible life stressor) but can't make the DSM diagnosis of bipolar. I've never seen an antidepressant augmented with lithium or thyroid hormone for MDD though I know this is part of StarD algorithm. StarD conclusions concern me because they conveniently don't mention the high rates of patient dropout and symptom relapse after achieving remission.
I kind of get what forchinet means. I get sick of trying these *** AP's e.g. abilify and rexulti for MDD, they never seem to work for depression and the patient gains 50 lbs and/or get akathisia even at low doses.

 

[TheRightMedication]

If you're working on an Akiskal style theory of bipolarity, that's fine. Indeed, if your MDD patient seems bipolarish, I'm not opposed to an AED.

But augmentation for MDD? Not lamictal.

 

[forchinet121]

100%? Dude this is like NP level thinking. Ignore the actual evidence, I’ll just start whatever makes me feel good.

Yeah I get the concerns about side effects and I don’t love atypical antipsychotics either but it’s literally not recommended by anyone. It’s actually recommended AGAINST in uptodate for TRD.

“Treatments with little to no benefit — Randomized trials in patients with treatment-resistant depression
indicate that there is little to no benefit from buspirone, cannabis, folate, inositol, lamotrigine, magnesium,
memantine, metyrapone, pindolol, pioglitazone, riluzole, testosterone for females, or vagus nerve
stimulation.”

Buspar augmentation is also recommended against..lamictal has evidence for depression augmentation I’m surprised by the response I’m getting to be honest

 

[calvnandhobbs68]

You can use it for MDD augmentation without personality or other components. There's also some evidence that it may be helpful for anxiety augmentation as well though this is less studied from my knowledge. Links below, the first is a meta-analysis of lamotrigine for MDD augmentation, the second is a pretty in-depth article with links to numerous articles:

https://journals.sagepub.com/doi/full/10.1177/0269881119844199

Taking Lamictal (Lamotrigine) For Anxiety Disorders: Does It Help?

Lamotrigine is a synthetic phenyltriazine chemical with anticonvulsant and analgesic properties initially sold by GlaxoSmithKline under the brand name Lamictal.

mentalhealthdaily.com

Okay this is why I’m always telling people to actually read the studies. Look at the actual first meta analysis paper. All the studies that showed benefit are published in Chinese journals and are literally in Chinese (like not even mainstream enough to be translated) so you can’t even look up the papers themselves on pubmed (as far as I can tell, someone feel free to prove me wrong) to see the actual info in them. I honestly rarely have faith in rando foreign articles published in rando foreign journals, many of which you can literally pay to just publish your paper. Some of these could be legit but there’s no good way to verify.

Additionally, all the studies that showed benefit seem to NOT be placebo controlled if you look at the actual table for characteristics of the studies. They conveniently skirt around this by saying “Characteristics of eight double-blinded randomized controlled trials” not PLACEBO controlled trials. The only two placebo controlled trials didn’t show benefit. Which makes sense, are patients more likely to believe the drug they’ve already been on which hasn’t been working is going to magically start working in the next 6-12 weeks?

 

[SmallBird]

Buspar augmentation is also recommended against..lamictal has evidence for depression augmentation I’m surprised by the response I’m getting to be honest

I don't understand the point - buspar augmentation is useless also, yes.

We have much better options. You can almost double response rates by adding aripiprazole to an ssri.

 

[ObsequiousAplomb]

I'm sorry to have to call you out but going to Lamictal as your first adjunct over Lithium/ abilify or similar / T4, is wrong.

If your individual patient finds the ADRs unacceptable, fine, but if that's your routine, you must reconsider.

T4? Not T3?

 

[uhmocksuhsillen]

Ten percent of people with MDD will die by suicide. There is nothing benign in insufficient treatment.

I say this humbly as one who surely practices imperfectly, and is trying to be helpful in those rare moments when I am certain I can offer advice.

This is a wonderful sentiment.

 

[splik]

I have treated a lot of patients with epilepsy. One thing I can tell you is many of them who have MDD become depressed when they are taken off their lamictal (e.g. because they grew out of it or had curative surgical treatment) and their symptoms improve when we restart the lamictal. The tapers are usually done over many months so it is not an abrupt withdrawal phenomenon. These patients are usually also on an antidepressant. The epileptologists all seem convinced that lamictal has antidepressant properties as well. Given that lamotrigine is not effective for mania/hypomania, it's not a stretch to think that it might be helpful in patients with unipolar depression as well. Personally, I do not use a lot of lamictal for antidepressant augmentation but it may be underused and certain patient populations seem to do quite well with it for mood symptoms (e.g. epilepsy pts, TBI, autoimmune encephalitis).

Also remember that unipolar vs bipolar is less relevant that single episode vs recurrent depression. Historically recurrent unipolar depression was also considered manic depressive illness and treatments such as lithium are known to effective for both.

Really, the main issue with lamotrigine in acute depressive states (whether bipolar or unipolar) is that it just takes a long time to titrate up to a therapeutic dose. The negative studies were all open label and did not continue sufficiently to see effects (e.g. 8 week study where pts were not even on 100mg until week 5 or 150mg until week 6 etc). Atypicals for all their flaws do seem to be more rapidly acting if we believe the data on their use as augmentation agents.

 

[ObsequiousAplomb]

This is a wonderful sentiment.

It would be more meaningful if there were any evidence whatsoever that antipsychotic augmentation decreased suicide risk for MDD patients.

 

[forchinet121]

I don't understand the point - buspar augmentation is useless also, yes.

We have much better options. You can almost double response rates by adding aripiprazole to an ssri.

Wasn’t buspar augmentation in stard?

 

[calvnandhobbs68]

Wasn’t buspar augmentation in stard?

STAR D was asking a totally different question than “are any of these medications any better than a sugar pills for treatment resistant depression”. It was not even setup to try to answer that question.

I have no problem with placebo effect as noted in another thread but if I’m chasing placebo effect I might as well do something other than a med someone has to be extremely consistent in taking to minimize risk of SJS (which is very rare yes) . I mean things like L Methylfolate and Omega 3s have at least some evidence over placebo anyway and are pretty benign. Another issue as splik aluded to above is that it takes over a month to even get to a real dose of lamictal.

All that being said lamictal certainly has antidepressant effects and I don’t think anyone is arguing against lamictal but rather using it as an initial augmentation agent over multiple studied augmentation agents for MDD.

Anyway, lithium and T3 augmentation were also in STAR D and lamictal wasn’t but your sentiment is go for lamictal before those options too.

 

[Celexa]

Interesting debate about lamictal. Either way though the use of lamictal is at best the second most problematic thing about the med regimens cited. The apparent inability to fully dose an SSRI is the bigger problem.

 

[forchinet121]

STAR D was asking a totally different question than “are any of these medications any better than a sugar pills for treatment resistant depression”. It was not even setup to try to answer that question.

I have no problem with placebo effect as noted in another thread but if I’m chasing placebo effect I might as well do something other than a med someone has to be extremely consistent in taking to minimize risk of SJS (which is very rare yes) . I mean things like L Methylfolate and Omega 3s have at least some evidence over placebo anyway and are pretty benign. Another issue as splik aluded to above is that it takes over a month to even get to a real dose of lamictal.

All that being said lamictal certainly has antidepressant effects and I don’t think anyone is arguing against lamictal but rather using it as an initial augmentation agent over multiple studied augmentation agents for MDD.

Anyway, lithium and T3 augmentation were also in STAR D and lamictal wasn’t but your sentiment is go for lamictal before those options too.

Yes because I’m concerned about side effects, lithium causes renal disease and a ton of side effects..why would I use an agent that will likely cause renal disease and can easily kill you if you take too much versus a benign agent, I’ve used lamictal a lot and it was heavily emphasized in my program I guess that’s the bias, I don’t have any experience with thyroid, I also don’t treat very high acuity depressed patients regularly so I’m more concerned about side effects than effect in my mind when a lot of general outpatient is less biological depression and more personality and social/psychological issues

 

[FlowRate]

I think most people are taking a balanced approach about this. FWIW Maudsley considers LTG as second line for TRD along with ketamine/esketamine, ECT, and T3. I follow a similar practice of reaching for it primarily when there are whisps of the old MDI/"bipolarish" conceptualization. A lot of my patients seriously balk at any mention of moderate/significant risk of weight gain or sedation so I end up prescribing Li/Olanz/Quetia/Mirtaz less often than would be indicated by EBM algorithms. Using T3 solely for TRD wasn't super common where I trained. I should probably do more research on it. I instead ensure we've checked TSH/FT4 and advocate for treatment of subclinical hypothyroidism if the patient has had a couple of failed MDD trials.

 

[MedMan80]

I don't like using it on non Bipolar folks due to the paucity of evidence, plus, could I ever forgive myself if a kid developed SJS and i prescribed lamictal for "anxiety"? Prob not.

 

[forchinet121]

I don't like using it on non Bipolar folks due to the paucity of evidence, plus, could I ever forgive myself if a kid developed SJS and i prescribed lamictal for "anxiety"? Prob not.

Risk is higher in kids, I don’t treat kids, the risk of serious rash is very very tiny meaning you’ll see it once a career as an adult psych

 

[tr]

Risk is higher in kids, I don’t treat kids, the risk of serious rash is very very tiny meaning you’ll see it once a career as an adult psych

Beg pardon, Lamictal rashes are not uncommon, and while statistically I understand most are benign, how do you know a priori which ones are 'serious'? If you stop the drug quickly the rash usually resolves. That doesn't mean it wouldn't have progressed to 'serious' without prompt discontinuation.

I've had several patients with very concerning skin manifestations from Lamictal (oral ulcers etc) and I'm mid-career. Doesn't stop me from using it but I wouldn't characterize ltg rash as rare.

(That said, the only patient of mine that ever ended up hospitalized for a drug rash had gotten a nasty case of DRESS from Wellbutrin, of all things. Go figure)