Q:  Does Lamictal Lose Its Effectiveness in Some People?

I have rapid cycling BPII and I am on 300 mg of Lamictal.........My question to you is that I have been taking it for six months now and it does not seem to work as well as it did at first......my hypomania w/ racing thoughts and agitation and depression with suicidal ideation return every so often........do you find that Lamictal looses it's effectiveness in some people?
 

Dear Kyle -- 
Yes, seen it. Not sure whether this is better characterized as Lamictal losing its effectiveness or the bipolar being treated getting worse over time and requiring more to keep it controlled.  I tend to favor the latter; but since I don't use the same model for antidepressants when they stop working, I shouldn't be too generous in my interpretations. However, it is well known that some people's bipolar disorder gets worse over time. The implication has been that each episode of illness, in those who have widely separated manic phases and depressed phases, seems to make the progression accelerate and episodes more severe. On that basis I tend to think that's what's going on in situations such as you describe: the condition is getting worse in the background, and that's what leads to the need for additional treatment. This reasoning also leads the possibility that the progression might be slowed or even halted if the episodes, even "micro-episodes", are completely controlled. 

There are ways to approach this other than adding more medication, of course. One of my favorites is to look for anything that might be accelerating or inducing cycling. You're not on one, but I always look for an antidepressant in the mix of medications, as those can cause cycling. The other common cause of cycling is an erratic sleep schedule or overall daily rhythm (worst case would be rotating shift work, from days to swing to night shifts, for example).  Oh, and of course (this is such a obvious one, it should be a given) minimal alcohol, which usually means about a drink or two a week for most of my patients. As I've mentioned to several other folks who wrote this week, that sleep and regular rhythm thing may have a remarkable non-medication solution.  No good research on it yet, but it is almost sure to be harmless if it doesn't work and it's cheap and boy if it worked it would be a really cool solution to the problem of being exposed to too much light at night. Here's the whole story, which ends with a link to the outfit that makes the $40 tool (to which I have no financial links): Bipolar Disorder -- Light and Darkness. 

Dr. Phelps