From the Guidelines
I strongly recommend continuing your current regimen of bupropion XL 150mg and lamotrigine (increasing as planned to 50mg) for at least 4-6 more weeks before considering adding Trintellix, as this allows sufficient time to assess the efficacy and tolerability of your current medications, given that bupropion takes 6-8 weeks for full effect and lamotrigine requires slow titration 1. Mal de Debarquement Syndrome (MDDS) episodes appear seasonal for you, and your current medication approach targeting both depression/anxiety and neurological symptoms is reasonable.
Since bupropion is associated with a lower rate of sexual adverse events than fluoxetine or sertraline 1, and you have already experienced sexual side effects with fluoxetine, it is prudent to continue with bupropion and monitor its effectiveness. Additionally, lamotrigine's slow titration is crucial to minimize the risk of adverse effects, and increasing the dose as planned to 50mg is a reasonable approach.
If you must travel in June, it is essential to maintain your current medications without changes during travel to minimize disruption. Consider vestibular rehabilitation therapy as a non-pharmacological approach for MDDS symptoms, which may help alleviate some of your neurological symptoms. The combination of bupropion (which affects dopamine and norepinephrine) with lamotrigine (which modulates glutamate and stabilizes neural activity) may help both mood symptoms and the neurological dysregulation in MDDS.
Some key points to consider:
- Bupropion's efficacy and potential for lower sexual adverse events compared to other antidepressants 1
- Lamotrigine's need for slow titration to minimize adverse effects
- The importance of monitoring therapeutic response and adverse effects regularly, beginning within 1 to 2 weeks of initiation of therapy 1
- The potential benefits of vestibular rehabilitation therapy for MDDS symptoms
If this combination proves insufficient after adequate trial, Trintellix could be considered as an alternative to bupropion rather than an addition, as polypharmacy increases side effect risks. However, prioritizing the current regimen and allowing sufficient time for its evaluation is crucial before making any changes to your medication regimen.
From the Research
Mal de Debarquement Syndrome (MdDS) Symptoms and Treatment
- The symptoms experienced, including constant bobbing and swaying sensations, visual disturbances, fatigue, brain fog, cognitive impairment, derealization, depression, and anxiety, are consistent with MdDS 2, 3, 4, 5.
- MdDS is often characterized by a prolonged rocking sensation that begins immediately following a lengthy exposure to motion, usually a sea voyage 3.
- The condition can be triggered by passive motion, typically by exposure to water, air, or land transportation, and affects middle-aged individuals, predominantly women 3, 5.
- Treatment of MdDS with common vestibular suppressants is nearly always ineffective, and benzodiazepines can be helpful but have limited usefulness due to the potential for addiction 3.
Treatment Options and Considerations
- Repetitive transcranial magnetic stimulation over the dorsolateral prefrontal cortex has been shown to decrease the rocking dizziness of MdDS, with successful responses associated with decreases in the coherence between brain networks with nodes in the parietal and occipital lobes 2.
- Noninvasive brain stimulation and readaptation of the vestibulo-ocular reflex are also being explored as treatment options for MdDS 5.
- The use of medications such as fluoxetine, bupropion, and lamotrigine may be considered, but their effectiveness and potential side effects should be carefully evaluated 2, 4.
- The consideration of adding trintellix to the current medication regimen should be based on the individual's response to the current treatment and the potential benefits and risks of the additional medication.
Psychological Components and Comorbidities
- MdDS is often associated with stress, anxiety, and depression, which should be considered when treating patients 4.
- The condition can have a significant impact on daily life, and patients may experience fatigue, cognitive slowing, and visual motion intolerance 5.
- A comprehensive diagnostic approach should include evaluation of the patient's psychological components and comorbidities, in addition to the apparent self-motion symptoms 4.