Magazine article Clinical Psychiatry News

Lamotrigine for Depressed Phase of Bipolar Disorder

Magazine article Clinical Psychiatry News

Lamotrigine for Depressed Phase of Bipolar Disorder

Article excerpt

The Problem

You work in a group practice. One of your partners routinely prescribes lamotrigine for patients in the depressed phase of their diagnosed bipolar disorder.

The Question

Is lamotrigine efficacious in depression due to bipolar disorder?

The Analysis

We first searched the Cochrane Database of Systematic Reviews (www.cochrane.org/reviews) and found no reviews. We then searched Medline combining "bipolar" "lamotrigine" and "depression."

The Evidence

Lamotrigine is an antiepileptic drug. It is indicated for adjunctive therapy in partial seizures, generalized seizures of Lennox-Gastaut syndrome, and primary generalized tonic-clonic seizures in adults and pediatric patients (greater than or equal to 2 years) as well as for conversion to monotherapy in adults with partial seizures who are receiving treatment with carbamazepine, phenytoin, phenobarbital, primidone, or valproate. It is also indicated for the maintenance phase of bipolar I disorder.

The mechanism of action is not known, but in vitro studies suggest that lamotrigine inhibits voltage-sensitive sodium channels, thus stabilizing neuronal membranes and modulating presynaptic release of excitatory neurotransmitters such as glutamate and aspartate. Lamotrigine has been associated with several severe side effects, including life-threatening rash, acute multiorgan failure, blood dyscrasias, atrial fibrillation, thrombophlebitis, and serious central nervous system side effects.

Our search yielded a recent meta-analysis and meta-regression of five trials (Br. J. Psychiatry 2009;194:4-9). Authors looked at five randomized, controlled trials comparing lamotrigine with placebo for treatment of bipolar depression. All of the studies were sponsored by GlaxoSmithKline. Response was reported as the relative risk of response (RR) and was defined as a greater than 50% decrease in the Hamilton Rating Scale for Depression (HRSD) and Montgomery-Asberg Depression Rating Scale (MADRS).

Remission was defined as a HRSD score of less than 8 or a MADRS score of less than 12. (The HRSD rates depression on a scale from 0 to 54. Scores between 0 and 6 usually indicates a normal person, scores between 7 and 17 indicates mild depression, scores between 18 and 24 indicates moderate depression, and scores over 24 indicates severe depression. …

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