|
Lamotrigine Use in Geriatric Patients With Bipolar Depression
Results
The study group contained 5 women. Their average age was 71.5 years (range
65 to 85). The average score on the HDRS at the beginning of the study
was 27 (range 20 to 35). Four patients had rapid-cycling BD. One patient
had mixed BD. All patients had an early age of onset, as judged by their
first contact with a psychiatrist or their first hospitalization. Table 1 displays their HDRS scores before and after lamotrigine treatment.
Of the 5 who were given lamotrigine, 3 had remission of symptoms, as judged
by clinical interview and reduction of HDRS scores by 50%. These 3 patients
had rapid-cycling BD. In the overall group, 3 of the 4 women with rapid-cycling
BD responded, and the patient with mixed-state BD did not respond. At 3-month
follow up, these 3 patients had not required rehospitalization and were
doing well. Lamotrigine was well tolerated, and none of the patients developed
a rash. One patient did develop coarse hand tremor that improved when the
dosage of lamotrigine was decreased.
Discussion
From this small case series, it is clear that the management of refractory
rapid-cycling or mixed BD in elderly patients remains a challenge. Lamotrigine
appeared to help and be well tolerated by the patients and was used in
combination with both lithium and valproate. None of these patients had
any difficulty with rashes. The nature of rapid-cycling BD (with spontaneous
switches to depression, hypomania, mania, or euthymia) makes it difficult
to ascertain whether any new agent actually helped in the acute phase of
the episode of mood disturbance or even helped in the long-term maintenance
of these patients. Prolongation of the wellness period in these patients
is probably what clinicians should strive for, rather than the therapeutic
goal of keeping patients euthymic for the rest of their lives. It is also
important to note that in this study psychosocial issues in addition to
medication were considered to be an integral contributing factor in the
improvement of depressive symptoms. Three of the 5 patients had experienced
difficulty coping in the community and were to be transferred to a nursing
home facility after discharge from the inpatient psychiatric unit. At the
nursing home, they would receive a much higher level of care than they
had received in the community prior to their admission. For example, their
medication would be supervised and they would be helped with activities
of daily living, such as meal preparation. This was a source of comfort
that would reduce worry and stress for both the patients and their families
and promote compliance with medication.
In summary, lamotrigine may have a role in the treatment of geriatric patients
with BD 1 depression. We recommend that lamotrigine be combined with lithium
or valproate in these patients, because its efficacy in preventing manic
episodes has not been proven. Lamotrigine may also be used as monotherapy
in patients with BD II depression or rapid-cycling BD II (14).
|
Table 1 Hamilton Depression Rating Scale scores before and after lamontrigine
|
|
Patient
|
BD subtype
|
HDRS scale befor LAM
|
HDRS score after LAM
|
|
1
|
Rapid-cycling
|
26
|
6
|
|
2
|
Mixed-state
|
28
|
27
|
|
3
|
Rapid-cycling
|
29
|
7
|
|
4
|
Rapid-cycling
|
34
|
30
|
|
5
|
Rapid-cycling
|
35
|
17
|
|
BD = bipolar disorder; HDRS = Hamilton Depression Rating Scale; LAM = lamotrigine
|
Skepticism and caution are warranted when interpreting the results of an
open, small, uncontrolled case series, because potential unintentional
bias, placebo response, and random variability can lead to false-positive
results. Thus, the methodological limitations of this study highlight the
need for randomized controlled trials. In clinical work, lamotrigine is
a part of our armamentarium, and it seems to have a role as an adjuvant
medication with lithium and valproate, or with both together.
References
1. Salzman C. Psychiatric medications for older adults. New York: The Guilford
Press; 2001. p 78–9.
2. Calabrese JR, Bowden CL, Sachs GS, Ascher JA, Monaghan E, Rudd GD. A
double-blind placebo controlled study of lamotrigine monotherapy in outpatients
with bipolar 1 depression. Lamictal 602 study group. J Clin Psychiatry
1999:60;79–88.
3. Fogelson DL, Sternbach H. Treatment refractory bipolar disorder treated
with lamotrigine. J Clin Psychiatry 1997;58:271–3.
4. Calabrese JR, Fatemi SH, Woyshville MJ. Antidepressant effects of lamotrigine
in rapid cycling disorder [letter]. Am J Psychiatry 1996;153:1236.
5. Maltese T. Adjunctive lamotrigine treatment for major depression. Am
J Psychiatry 1999;156:1833.
6. Anderson GD, Yau MK, Gidal BE, Harris SJ, Levy RH, Lai AA, and others.
Bidirectional interaction of valproate and lamotrigine in healthy subjects.
Clin Pharmacol Ther 1996;60:145–56.
7. Walden J, Hesslinger B, van Calker D, Berger M. Additon of lamotrigine
to valproate may enhance efficacy in the treatment of bipolar affective
disorder. Pharmacopsychiatry 1996;17:59–60.
8. Sporn J, Sachs G. The anticonvulsant lamotrigine in treatment-resistant
manic-depressive illness. J Clin Psychopharmacol 1997;17:185–9.
9. Fatemi SH, Rappoport DJ, Calabrese JR, Thuras P. Lamotrigine in rapid
cycling bipolar disorder. J Clin Psychiatry 1997;58:522–7.
10. Kusumaker V, Yatham LN. Lamotrigine treatment of rapidly cycling bipolar
disorder. Am J Psychiatry 1997;154:1171–2.
11. Calabrese JR, Bowden CL, McElroy SL, Cookson J, Andersen J, Keck PE
Jr, and others. Spectrum of activity of lamotrigine in treatment-refractory
bipolar depression. Am J Psychiatry 1999;156:1019–23.
12. Calabrese JR, Bowden CL, Sachs GS, Yatham LN and others. A placebo-controlled
18 month trial of lamotrigine and lithium maintenance treatment in recently
depressed with bipolar 1 disorder. Arch General Psychiatry 2003. Forthcoming.
13. Bowden CL, Calabrese JR, Sachs GS, Yathan LN, Asghar SA, Hompland M,
and others. A placebo- controlled 18 month trial of lamotrigine and lithium
maintenance treatment in recently manic or hypomanic patients with bipolar
1 disorder. Arch Gen Psychiatry 2003. Forthcoming.
14. Calabrese JR, Suppes T, Bowden CL, and others. A double blind placebo
controlled prophylaxis study of lamotrigine in rapidly cycling bipolar
disorder. Lamictal 614 study group. J Clin Psychiatry 2000;61:841–50.
--------------------------------------------------------------------------------
Manuscript received January 2002, revised, and accepted June 2002.
1 Staff psychiatrist, Department of Psychiatry, Baycrest Centre for Geriatric
Care, Toronto, Ontario.
2 Head, Department of Psychiatry, Baycrest Centre for Geriatric Care, Toronto
Ontario.
Address for correspondence: Dr M Robillard, Baycrest Centre for Geriatric
Care, Department of Psychiatry, 3560 Bathurst Street, Toronto, ON M6A 2E1
e-mail: mrobillard@baycrest.org
1 | 2
| 3
|
