Is there a legitimate psychiatric indication for using topiramate (Topamax)?

From the Guidelines

Topiramate is not recommended as a first-line treatment for psychiatric indications due to limited evidence of its efficacy in bipolar disorder and potential side effects. According to the practice parameter for the assessment and treatment of children and adolescents with bipolar disorder 1, controlled studies in adults have not found topiramate to be helpful, and the one study of topiramate in children and adolescents was equivocal. Some key points to consider when evaluating the use of topiramate for psychiatric indications include:

• The lack of FDA approval for bipolar disorder in adults or youths
• Limited evidence of efficacy in adult studies, with controlled studies finding no benefit for topiramate in bipolar disorder 1
• Potential side effects, such as cognitive slowing, paresthesias, kidney stones, and metabolic acidosis, which require careful monitoring
• The availability of alternative treatments with more established efficacy and safety profiles, such as lithium, valproate, and antipsychotic agents, which are approved for bipolar disorder in adults and have some evidence of efficacy in youths 1 In clinical practice, topiramate may be considered as an adjunctive treatment for patients who have not responded to other treatments, but its use should be carefully weighed against the potential risks and benefits. It is essential to prioritize treatments with more robust evidence of efficacy and safety, such as lithium, valproate, and antipsychotic agents, which are approved for bipolar disorder in adults and have some evidence of efficacy in youths 1.

From the Research

Psychiatric Indications for Topiramate

• Topiramate has been evaluated for various psychiatric conditions, including bipolar disorder, bulimia, post-traumatic stress disorder, and schizoaffective disorder 2.
• Studies suggest that topiramate may have mood-stabilizing properties in bipolar disorder, with open clinical trials showing a 50-65% response rate for refractory bipolar mania and a 40-56% response rate for refractory bipolar depression 2.
• Topiramate has also been used in the management of nonepileptic neurologic and psychiatric conditions, including migraine prophylaxis, obesity, substance dependence, and neuropathic pain 3.

Efficacy in Bipolar Disorder

• A study found that topiramate was effective in treating a patient with bipolar I disorder, with the patient showing significant improvement and remaining mostly asymptomatic for over 17 months 4.
• However, a review of the use of topiramate for treatment of psychiatric disorders found that topiramate lacks efficacy in the treatment of acute mania, but may be effective in binge eating disorders, bulimia nervosa, alcohol dependence, and possibly in bipolar disorders in depressive phase 5.
• A Cochrane review found that topiramate was no more or less efficacious than placebo as monotherapy or add-on therapy in the treatment of manic and mixed episodes in bipolar disorder, but lithium was more efficacious than topiramate as monotherapy 6.

Side Effects and Tolerability

• Common side effects of topiramate include attention, concentration, and memory problems, fatigue, sedation, transient paresthesias, nausea, and anorexia 2.
• Topiramate was generally well tolerated, with serious adverse events being rare 5.
• The Cochrane review found no difference between topiramate and placebo or alternative drugs in terms of troublesome side effects or side effects of any nature 6.