Can I prescribe Lamictal (lamotrigine) and risperidone for mood swings together with propranolol for extreme social anxiety?

Treatment of Mood Swings and Social Anxiety: Lamotrigine, Risperidone, and Propranolol Combination

The combination of lamotrigine and risperidone for mood swings with propranolol for social anxiety is not recommended due to lack of evidence supporting this specific combination and potential safety concerns. Instead, SSRIs should be considered as first-line treatment for both conditions.

Medication Selection for Mood Swings

For Bipolar Disorder:

• Lamotrigine is FDA-approved for maintenance therapy in adults with bipolar disorder 1
• Risperidone is FDA-approved for acute mania in adults 1
• When treating mood swings in bipolar disorder, the choice of medication should be based on:
  1. Evidence of efficacy
  2. Phase of illness (acute mania vs maintenance)
  3. Presence of confounding presentations (e.g., rapid cycling)
  4. Side effect profile and safety
  5. Patient's history of medication response
  6. Patient/family preferences

Important Considerations for Lamotrigine:

• Lamotrigine is primarily effective for preventing depressive episodes in bipolar disorder 2
• While generally well-tolerated, lamotrigine can occasionally cause psychiatric side effects including:
  • Affective switches
  • Acute psychotic episodes
  • Hallucinations 3

Important Considerations for Risperidone:

• Risperidone is primarily indicated for acute mania rather than maintenance therapy
• When combining with lamotrigine, no significant pharmacokinetic interactions have been observed 4

Treatment for Social Anxiety

First-line Recommendations:

• SSRIs are the first-line treatment for social anxiety disorder (weak recommendation, low certainty evidence) 1
• Venlafaxine (SNRI) is also suggested as an alternative (weak recommendation, low certainty evidence) 1

Propranolol Concerns:

• Propranolol is specifically listed as NOT recommended for social anxiety disorder based on negative evidence 1
• Propranolol can cause adverse mood effects including increased "tension," "depression," "fatigue," and "confusion" 5
• There is potential for abuse with propranolol in social anxiety patients 6

Alternative for Social Anxiety:

• Cognitive behavioral therapy (CBT) is recommended for social anxiety disorder, particularly individual sessions following the Clark and Wells model or Heimberg model 1

Treatment Algorithm

1. For mood swings in bipolar disorder:

   • If primarily depressive episodes: Consider lamotrigine monotherapy
   • If primarily manic episodes: Consider risperidone or other atypical antipsychotics
   • If mixed presentation: Consider FDA-approved options like lithium or valproate before combination therapy

2. For social anxiety disorder:

   • First-line: SSRI (fluvoxamine, paroxetine, or escitalopram) which are covered by national health insurance for this indication 1
   • Second-line: Venlafaxine (SNRI)
   • Consider CBT as an alternative or adjunctive treatment

3. If both conditions are present:

   • Start with an SSRI that can address both conditions
   • If inadequate response, consider adding a mood stabilizer based on predominant mood symptoms
   • Avoid propranolol due to lack of evidence and potential for adverse effects

Pitfalls and Caveats

• Unnecessary polypharmacy should be avoided 1
• Propranolol has been associated with abuse potential in social anxiety patients 6
• Combining multiple psychotropic medications increases risk of side effects and drug interactions
• Beta blockers like propranolol can worsen mood states, particularly increasing depression and fatigue 5
• Regular monitoring for psychiatric side effects is essential when using lamotrigine 3

The most evidence-based approach would be to start with an SSRI for social anxiety, which may also help with mood symptoms, and then reassess the need for additional mood stabilization if symptoms persist.