Last updated 11/16/2024
In the middle of the mood spectrum, treatment (with pills) can go one of two ways: an antidepressant, or a mood stabilizer with antidepressant effects (MSAE). For a big-picture view, see Treating the Middle of the Mood Spectrum. On this page, I’ll narrow down to the exact point along the mood spectrum where the best strategy switches from antidepressants to MSAEs.
Notice the overlap in options
As shown in the picture below, antidepressants should be used with increasing caution from left to right across the mood spectrum.
Coming back the other way, mood stabilizers are used in Bipolar I (depression with mania); and more specific mood stabilizers with antidepressant effects (MSAEs) are used for the yellow-orange region (Bipolar II). Because lamotrigine has no significant long-term risks, and usually no side effects, it is the most obvious MSAE to consider for the middle of the mood spectrum (after or in addition to regular sleep hours, the #1 non-medication mood stabilizer).
Notice the overlap in the middle of the spectrum: antidepressants with caution, and lamotrigine. Which one is best for mid-spectrum depression? Answer: there is no research to guide us here, because the middle of the mood spectrum does not have a DSM label. (The sound you hear is the grinding of my teeth).
Choosing between an antidepressant and lamotrigine
So, how to choose? Let’s look at how the choice is usually considered, and then I’ll show you how I think of it.
The usual approach: people think antidepressants are generally safe, and “lamotrigine”, that sounds strange. Worse, lamotrigine is associated with “bipolar” and people in the mid-spectrum don’t have that. They don’t want to have that, so lamotrigine doesn’t sound good. Thus the balance of the mid-spectrum is tilted toward antidepressants.
However, recently concerns have been raised about the potential for severe withdrawal symptoms when antidepressants are stopped. These symptoms can limit a person’s ability to function (can’t work, can’t take care of family, can’t go to school), and can make stopping the antidepressant very difficult. Exactly how often this happens is still uncertain, but even skeptics acknowledge that it happens to at least 1 person in 100 coming off an antidepressant: 1%. My guess: about 1-in-20, 5%. (The most concerned voices say the rate is more like 10% to 20%: 1 in 10, or even 1 in 5 people).
Lamotrigine has a 1-in-2,000 risk of causing a severe allergic reaction that is very painful and requires emergency hospitalization. So now compare: a 1-in-2000 risk of pain and hospitalization; versus a 1-in-20 risk of severe withdrawal limiting ability to function. This is like comparing apples and oranges, right? But one is roughly 20 times less common than the other. Doesn’t that tilt the balance? I think if people really understood the risks involved, the picture would look like this:
References
Bloom R, Amber KT. Identifying the incidence of rash, Stevens-Johnson syndrome and toxic epidermal necrolysis in patients taking lamotrigine: a systematic review of 122 randomized controlled trials. Anais brasileiros de dermatologia. 2017 Jan;92:139-41.
Phelps J. Antidepressant withdrawal — A clinician’s middle view. Mad in America, October 2023