Is lamotrigine (Lamictal) used to treat anxiety?

Lamotrigine for Anxiety: Evidence-Based Assessment

Lamotrigine is not indicated or recommended as a treatment for anxiety disorders, as there is insufficient high-quality evidence supporting its use for this purpose. Current clinical guidelines do not include lamotrigine among recommended pharmacotherapies for anxiety disorders.

Current Guideline Recommendations for Anxiety

According to the 2023 Japanese Society of Anxiety and Related Disorders guidelines, the recommended first-line pharmacotherapies for anxiety disorders (specifically social anxiety disorder) include:

• SSRIs (escitalopram, fluvoxamine, paroxetine, sertraline)
• SNRIs (venlafaxine)
• Pregabalin 1

The Canadian Clinical Practice Guidelines similarly recommend these medications as first-line treatments, with benzodiazepines, gabapentin, and certain MAOIs as second-line options 1.

Lamotrigine's Approved Indications

Lamotrigine is FDA-approved for:

• Epilepsy with partial seizures
• Maintenance treatment in bipolar I disorder 2

Specifically, lamotrigine has demonstrated efficacy in:

• Delaying time to intervention for mood episodes in bipolar disorder
• Particularly effective for preventing depressive episodes in bipolar disorder
• Less effective for preventing manic/hypomanic episodes compared to lithium 2

Limited Evidence for Anxiety

The available research on lamotrigine for anxiety is sparse and of limited quality:

• One small, single-blind pilot study showed some benefit when lamotrigine was added to lithium in patients with bipolar disorder who had comorbid anxiety disorders 3
• A literature review suggested possible benefits in patients with treatment-resistant depression with comorbid anxiety, but noted inconsistent results across studies 4
• Another review concluded that lamotrigine use in anxiety disorders has "little supportive evidence" 5

Clinical Considerations

When treating anxiety disorders, clinicians should:

1. Start with evidence-based first-line treatments (SSRIs, SNRIs, pregabalin)
2. Consider second-line options (benzodiazepines, gabapentin) if first-line treatments fail
3. Reserve off-label use of medications with limited evidence for treatment-resistant cases

Potential Risks

Lamotrigine carries important risks that must be considered:

• Risk of serious rash, including Stevens-Johnson syndrome (0.1% in bipolar studies) 2
• Requires slow titration over 6 weeks to minimize rash risk 6
• Potential for psychiatric side effects including psychotic episodes and hallucinations 7
• Numerous drug interactions requiring careful monitoring 6

Conclusion

While lamotrigine is an effective treatment for bipolar disorder (particularly for preventing depressive episodes) and epilepsy, it should not be considered a standard treatment option for anxiety disorders based on current evidence and guidelines. Patients with anxiety disorders should be treated with medications that have established efficacy and safety profiles for this indication.