Does Lamictal (Lamotrigine) Work For OCD?
Lamictal, the brand name for lamotrigine, is an anticonvulsant medication used to control and prevent seizures. It’s also used as a mood stabilizer for those with bipolar disorder. It may be useful in treating migraine with aura as well, which could prevent aura-triggering headaches and reduce migraine frequency. But what about OCD? Is this medication effective in banning the obsessive compulsive beast?
In recent years, the question of this effectiveness has garnered attention and shown promising results. So, let’s explore what this medication is all about.
How Lamictal Works
Much of Lamictal’s underlying psychological mechanisms are understood in relation to bipolar disorder: The medication works by decreasing the intensity of irregular activity in the brain, thus decreasing abrupt and extreme mood changes and moderating the high mania and deep depression bipolar disorder is known for.
It doesn’t work as an in-the-moment solution; studies show it has no effect when someone is experiencing an active episode of mania. Rather, it’s intended to be used as a preventative medication. It offers benefits similar to Lithium, a drug commonly prescribed for bipolar disorder, but it’s easier for most people to tolerate.
Even with the above, some doctors believe that modulating brain activity is only part of the story; they argue that the antidepressant properties of Lamictal are what make it effective, particularly against the depressive effects of bipolar disorder. That may be why this drug shows promise when used for OCD, as antidepressants, specifically SSRIs, are regarded as front-line treatments.
Another reason Lamictal may be effective against OCD is because of its ability to modulate glutamate. Glutamate is an abundant excitatory neurotransmitter that plays a major role in brain function. In order for the brain to operate at optimal levels, glutamate must be at the right concentration. In OCD, glutamate levels are often higher than in the general population, which can help explain why the OCD brain does not operate at optimal levels and, instead, causes OCD sufferers to believe intrusive thoughts that others disregard as meaningless.
This doesn’t prove that high levels of glutamate contribute to OCD symptoms, as it’s always possible that there is a reverse relationship and OCD symptoms cause higher levels of glutamate. Nonetheless, studies point to the former being the most likely: In mice, changing glutamate levels in the brain resulted in OCD-like behavior where the mice anxiously groomed themselves in a compulsive manner when those levels increased. There are also reports of low-glutamate diets resulting in remission of long-standing OCD symptoms, even when modern medications failed.
Lamictal and OCD Studies
Okay, so we know the mechanisms that may help Lamictal prove effective against OCD symptoms (antidepressive and glutamate-modulating properties). But what do the studies say?
Some studies have not shown the statistical effectiveness necessary for scientists to hypothesize that Lamictal can work against OCD. Still, many of these studies involved low doses. The studies with higher doses tell another story.
When used in conjunction with SSRIs, as opposed to stand-alone treatment, one study found that Lamictal improved symptoms of OCD in sufferers who were previously resistant to the effects of SSRIs. A mean reduction of 67.23% was observed when using the Yale-Brown Obsessive Compulsive Scale, a measurement tool that measures OCD severity. This reduction was observed after 16 weeks and nearly 91% of study participants experienced improvement. More participants responded to Lamictal than in previous studies, which, as mentioned above, was attributed to the higher doses used.
In a peer-review study that looked at various glutamate-modulating drugs, including ketamine, glycine, NAC, and memantine, researchers discussed one case where a previously treatment-resistant OCD sufferer experienced significant relief when up to 150 mg/day of lamotrigine were combined with 225 mg/day of clomipramine. They also reviewed a study where 33 SSRI-resistant patients experienced substantial improvement in obsessions and compulsions once lamotrigine was added to supplement the SSRIs.
Lamictal Side Effects
Like all medications, Lamictal comes with side effects, although their severity differs in people (with some people experiencing no side effects at all). Some of the most common side effects experienced include:
- Drowsiness or dizziness
- Feeling agitated, irritable, or more aggressive than usual
- Shakiness or tremors
- Trouble sleeping
- Nausea or vomiting
- Mild skin rash
While most rashes caused by Lamictal are minor-to-mild, it can cause serious, even deadly, rashes. The rashes are concerning enough to warrant an FDA Black Box Warning. Some of these rashes are associated with Stevens-Johnson syndrome, a medical emergency that often requires hospitalization and comes with a high fatality rate.
Stevens-Johnson syndrome causes flu-like symptoms and a spreading rash that eventually blisters. The most serious form, toxic epidermal necrolysis (TEN), involves more than 30% of the surface of the skin and drastically damages the body’s mucus membranes. TEN can have a death rate as high as 25%; it’s higher in older adults and lower in children.
Fortunately, Stevens-Johnson syndrome is very rare and usually not a reason to avoid taking the medication; it affects roughly 2-7 people per million. It’s much higher in those with HIV and other immunocompromising conditions, affecting around one in one thousand people.
Life-threatening rashes from Lamictal are more common when you start or suddenly stop your dose; in people who are allergic to trimethoprim (an antibiotic); in those who’ve developed rashes from other medications; in women; in the elderly; in those taking contraindicated medications (more on that below); and in those with inferior immune systems.
There are some medications you should not take when taking Lamictal, particularly without first speaking to your doctor or pharmacist. In general, some of the most common contraindicated medications include the following:
- Other anticonvulsants and drugs used to treat epilepsy
- Other drugs used for bipolar disorder (such as lithium)
- Medications used to treat HIV
- Rifampicin, an antibiotic used to treat tuberculosis
- Hormonal replacement therapy
Importantly, anyone using the combined birth control pill, the patch, or the vaginal ring may be at increased risk of pregnancy, as Lamictal can make these contraceptives less effective. Backup or different birth control methods may be recommended.
If you are taking over-the-counter medication and herbs, speak to your doctor before starting Lamictal or check drugs.com for interactions. Being able to buy medication without a prescription doesn’t imply that medication’s safety, especially when it’s mixed with other drugs. Mixing Lamictal with alcohol can be problematic as well as it can increase the nervous system side effects and cause dizziness, drowsiness, and trouble concentrating. This can be especially problematic when driving or operating heavy machinery.
There are some people who should not take Lamictal because the risks of the medication outweigh the benefits the medicine may offer. In general, the following populations are contraindicated:
- Those with meningitis
- Those with bone marrow failure
- Those with anemia
- Those with low neutrophils, a type of white blood cell
- Those with lower-than-normal platelet levels
- Those experiencing suicidal thoughts
- Those with low oxygen levels
- Those with complete heart block or second-degree atrioventricular heart block
- Those with chronic heart failure
- Those with structural heart disorders
- Those with Brugada syndrome, which affects the way electrical signals pass through the heart and can lead to dangerous arrhythmias
- Those with liver problems, including liver impairment
- Those with stage 4 kidney disease or any kidney disease that results in reduced kidney function
Of course, the above must be considered on an individual basis by discussing your underlying medical conditions with your doctor. Some conditions might not necessarily rule out Lamictal. Anemia, for example, can be serious but it can also be an extremely common occurrence treatable with iron supplements. Suicidal thoughts, along these lines, may be a symptom of bipolar disorder or OCD, especially in people whose conditions are severe. So, depending on your individual circumstances, your doctor can help figure out what’s a true contraindication and what’s not.
The Importance of Alternative and Supplemental Medications
There is no wonder drug that cures OCD, at least not in the sense a painkiller relieves a headache or amoxicillin fights off an ear infection. Maybe someday science will discover one, but right now we rely on an arsenal rather than a single weapon.
As a result, there are many drugs that show promise but none that work for everyone. Even the most commonly prescribed SSRIs only work about 40-60% of the time. Part of this is likely due to the causes of OCD; while a low level of serotonin, which SSRIs work to regulate, is a factor in OCD, it’s not the only factor. It’s always possible that serotonin plays a larger role in certain OCD sufferers than it does in others, making SSRIs more effective in those populations.
Genetics factor in as well. A person’s genes determine how efficiently they metabolize medicine, ultimately determining how effective that medication is. Drugs are designed for normal metabolizers (sometimes referred to as “extensive metabolizers”), but not everyone falls into this category.
You may be a poor or intermediate metabolizer whose genetics make it harder for your body to clear the drug, making side effects more likely (including side effects that are so intolerable or dangerous that the drug is contraindicated).
Or you may be on the other end of the spectrum and have genes that put you firmly in the ultrarapid metabolizer category. If that’s the case, the drug may work less efficiently because your body clears it before it can go into effect. Ultrarapid metabolizers often require higher doses for this reason, something that may be infeasible from a safety standpoint, so other options are used instead.
The need for drug alternatives has steadily increased over the years. This is partly due to the increased diversity in many countries around the world, as people from different ethnic backgrounds tend to metabolize drugs differently. It’s also due to our understanding of genetics and the recognition that certain classifications aren’t as rare as once thought. For example, it was once accepted that only 1-2% of the population were ultrarapid metabolizers but studies suggest that number could be closer to 10%.
This is important to recognize from a psychiatric standpoint so patients are not given drugs that their genes work against, which will not only reduce side effects but also save doctors and patients time while avoiding frustration and, possibly, a worsening condition. From a general medicine perspective, recognizing the prevalence of ultrarapid metabolizers, in particular, is important for safety, especially when prescribing drugs like codeine and tramadol. Because of the metabolites these drugs contain, some ultrarapid metabolizers can have a dramatically enhanced reaction to them, increasing the risks of overdose, hospital visits, and death.
While knowing your genetic makeup likely won’t entirely result in side-stepping the dreaded pharmacological-resistance that’s all too common in OCD treatment, it definitely helps; knowledge is power in pharmacology and everything else. Your doctor can order genetic testing that tells you how likely (or unlikely) you are to respond to the most commonly prescribed psychiatric medications. This test can also give you insight into how likely you are to experience side effects.
Is Lamictal Right for You?
Only you and your doctor can decide if Lamictal is right for you; and, perhaps, the only way to answer that question is to give it a try. Lamictal may be a promising alternative if you’ve had bad luck finding effective medications in the past or if medications have offered some relief but not enough to make a significant difference in your life. Lamictal may also be right for you if you are already on SSRIs but feel that you could benefit from a supplemental boost.
If you do decide to take Lamictal, regard it as you do other medications in terms of time frame. In other words, it takes a while to see results so be a patient patient and don’t expect to feel different overnight. It’s typically suggested to give it several weeks, assuming side effects are well tolerated, before deciding whether or not your symptoms have improved.
Lamictal is yet another tool at our disposal in the war against OCD. It might not work for everyone but that doesn’t mean it won’t work for some. And helping some OCD sufferers is certainly better than nothing.