ASD/ADHD & anxiety - Lamictal or Lithium

[Anonymous]

Anonymous wrote:Psychiatrist here with some late night meandering thoughts. Both of these medications are mood stabilizers. I don’t have much of a comment on whether or not your daughter should be on that kind of medication at all, but that is what they are for. Lithium, used as an adjunct, has been shown to decrease aggressive and hyperactive behaviors in young adults with ADHD and in kids with conduct disorders, but I can’t think of any reason I would just use low dose Lithium on its own in a child.

As far as side effects and tolerability, Lamictal is the less dangerous and better tolerated medication by far. The risk of Steven Johnson’s syndrome is more or less zero if you follow the titration schedule and discontinue at the sign of a rash. The only real risk is when people stop taking it for a few weeks and then just start back at a high dose.
Lithium, on the other hand, has a lot of potential side effects. First of all, it can be fatal in an intentional overdose. It doesn’t sound like your daughter is suicidal, but it’s being used to treat emotional dysregulation and impulsivity in an adolescent, so it would be on my radar. Secondly, it causes a known birth defect. This probably isn’t a concern at 13, but would be something I would be thinking about if she was going to be on it long term. Third, it generally has a low therapeutic window before you get to Lithium toxicity. If you are using a low dose, that’s less of a concern, but it’s always something I talk to my patients about before we start it. It sits right below sodium on the periodic table, and your body will retain it like sodium if you get dehydrated. When people are on a therapeutic dose, it’s a risk. Fourth, Lithium can be hard on your kidneys. That’s part of the reason for the lab draws. She shouldn’t take ibuprofen while she’s on it. Labs should be monitored, and she should stop it if there are any kidney problems. Fifth, Lithium has the potential for a lot of other, less serious, side effects like fatigue, dizziness, GI upset, difficulty with concentration.

All that being said, I use a lot more Lithium than lamictal. For the people it works for, it really works. At a therapeutic dose it decreases suicidal thoughts, prevents manic episodes, and decreases aggression.

I would be really hesitant to start it in a 13 year old girl though for all of the reasons I outlined above, and it makes me nervous that your NP said there wasn’t a potential for side effects.

Thank you! Lamictal has been suggested a few times over the years but I have never been willing to go the mood stabilizer route, in part because although her dysregulation episodes are pretty extreme she can go months without one. However, she is now almost 18 (not 13) and they haven’t stopped and have greater consequences. The Lithium suggestion was an “integrative” approach and the suggestion was a very low non-therapeutic dose - based on new research he said. Nevertheless I talked to a psychiatrist friend and he suggested trying the Lamictal first and we could always add the very low Lithium later if we wanted to try it. Or, if it’s not that effective (like PP above), try something else. The rash is what scares me the most, and like you he assured me it’s pretty rare and starting slow will likely avoid it - which is the NP’s plan.

[Anonymous]

Anonymous wrote:

Anonymous wrote:Psychiatrist here with some late night meandering thoughts. Both of these medications are mood stabilizers. I don’t have much of a comment on whether or not your daughter should be on that kind of medication at all, but that is what they are for. Lithium, used as an adjunct, has been shown to decrease aggressive and hyperactive behaviors in young adults with ADHD and in kids with conduct disorders, but I can’t think of any reason I would just use low dose Lithium on its own in a child.

As far as side effects and tolerability, Lamictal is the less dangerous and better tolerated medication by far. The risk of Steven Johnson’s syndrome is more or less zero if you follow the titration schedule and discontinue at the sign of a rash. The only real risk is when people stop taking it for a few weeks and then just start back at a high dose.
Lithium, on the other hand, has a lot of potential side effects. First of all, it can be fatal in an intentional overdose. It doesn’t sound like your daughter is suicidal, but it’s being used to treat emotional dysregulation and impulsivity in an adolescent, so it would be on my radar. Secondly, it causes a known birth defect. This probably isn’t a concern at 13, but would be something I would be thinking about if she was going to be on it long term. Third, it generally has a low therapeutic window before you get to Lithium toxicity. If you are using a low dose, that’s less of a concern, but it’s always something I talk to my patients about before we start it. It sits right below sodium on the periodic table, and your body will retain it like sodium if you get dehydrated. When people are on a therapeutic dose, it’s a risk. Fourth, Lithium can be hard on your kidneys. That’s part of the reason for the lab draws. She shouldn’t take ibuprofen while she’s on it. Labs should be monitored, and she should stop it if there are any kidney problems. Fifth, Lithium has the potential for a lot of other, less serious, side effects like fatigue, dizziness, GI upset, difficulty with concentration.

All that being said, I use a lot more Lithium than lamictal. For the people it works for, it really works. At a therapeutic dose it decreases suicidal thoughts, prevents manic episodes, and decreases aggression.

I would be really hesitant to start it in a 13 year old girl though for all of the reasons I outlined above, and it makes me nervous that your NP said there wasn’t a potential for side effects.

Thank you! Lamictal has been suggested a few times over the years but I have never been willing to go the mood stabilizer route, in part because although her dysregulation episodes are pretty extreme she can go months without one. However, she is now almost 18 (not 13) and they haven’t stopped and have greater consequences. The Lithium suggestion was an “integrative” approach and the suggestion was a very low non-therapeutic dose - based on new research he said. Nevertheless I talked to a psychiatrist friend and he suggested trying the Lamictal first and we could always add the very low Lithium later if we wanted to try it. Or, if it’s not that effective (like PP above), try something else. The rash is what scares me the most, and like you he assured me it’s pretty rare and starting slow will likely avoid it - which is the NP’s plan.

Sorry! I don’t know where I got it in my head that she was 13!

I agree with your psychiatrist friend.

[Anonymous]

The combination of lamictal and Zoloft have made a big difference for me, personally, as a mid 40’s adult. I was diagnosed with ADHD as an older teen, but I’m pretty sure I was also on the spectrum. My dad was obviously on the spectrum and one of my children had a neuropsych dx of adhd/mild ASD. I’m on only 50mg lamictal/50mg Zoloft. It is honestly life changing. I am much more prickly and reactive without it. It has helped my relationships with kids, husband and extended family - basically it gives me a lot more emotional bandwidth to think about how I want to respond. I’ve been on this combination almost 1.5 years. I do get a little sleepy at around 4pm and sometimes wonder if that is related.

[Anonymous]

Are people taking Lamictal at night or in the morning? I can tell my son's demeanor relaxes after taking it at night so I.'m womdering if it would be more helpful if he took it in the morning. Or split the dose and do both? Curious what others find is working.

[Anonymous]

Anonymous wrote:Are people taking Lamictal at night or in the morning? I can tell my son's demeanor relaxes after taking it at night so I.'m womdering if it would be more helpful if he took it in the morning. Or split the dose and do both? Curious what others find is working.

NP here. My DD takes lamictal twice a day. am and pm.

[Anonymous]

For those who have tried Lamictal, has it helped with anxiety? My DD has episodes of extreme dysregulation but they are always triggered by anxiety

[Anonymous]

Anonymous wrote:For those who have tried Lamictal, has it helped with anxiety? My DD has episodes of extreme dysregulation but they are always triggered by anxiety

I thought Lamictal was more calming for emotional dysregulation for sure, but if there is ADHD involved, it doesn't help ADHD overthinking, impulsivity and that type of anxiety. At least it didn't for my DD15. But I noticed a decrease in her dysregulation and when she went off of it (she thought she was better) I noticed an increase again in anger and episode again. Still trying to find a smaller combo than 3-4 meds.

[Anonymous]

My son struggled with meds for emotional dysregulation, and latuda was a game changer. He’s diagnosed with ASD, but not ADHD so I don’t know how that would change things.

[Anonymous]

From my experience, lithium was a really effective regulator but got all the side effects listed above and they didn't go away. The kidney damage wasn't severe but still happened pretty quickly. Lamictal has few side effects and has been great for anxiety. Take it at night and it helps with sleep. Not a psychiatrist, just part of a family of ADHD/depression/anxiety, but lamictal has worked well for everyone.

[Anonymous]

Anonymous wrote:From my experience, lithium was a really effective regulator but got all the side effects listed above and they didn't go away. The kidney damage wasn't severe but still happened pretty quickly. Lamictal has few side effects and has been great for anxiety. Take it at night and it helps with sleep. Not a psychiatrist, just part of a family of ADHD/depression/anxiety, but lamictal has worked well for everyone.

Op here. That’s interesting because my DD has had insomnia off and on for 3 weeks. She took the first dose of Lamictal last night and was up for 3 hours at 1am. Insomnia is a common side effect, and now she’s flat out refusing to continue.

[Anonymous]

I would never, ever let a nurse practitioner prescribe such meds to my kid. You need a psychiatrist.

[Anonymous]

Anonymous wrote:I would never, ever let a nurse practitioner prescribe such meds to my kid. You need a psychiatrist.

We’ve been to 4 psychiatrists over the last 10 years, and I’ve actually found the nurse practitioner to be more careful and to spend more time trying to understand my kid than the doctors. I also feel like I know more than they do at this point.

[Anonymous]

Anonymous wrote:

Anonymous wrote:I would never, ever let a nurse practitioner prescribe such meds to my kid. You need a psychiatrist.

We’ve been to 4 psychiatrists over the last 10 years, and I’ve actually found the nurse practitioner to be more careful and to spend more time trying to understand my kid than the doctors. I also feel like I know more than they do at this point.

I mean you already have a psychiatrist on here saying that the advice on side effects is incorrect. It also sounds like your DD has not been properly assessed for OCD or treated with anxiety exposure methods.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:I would never, ever let a nurse practitioner prescribe such meds to my kid. You need a psychiatrist.

We’ve been to 4 psychiatrists over the last 10 years, and I’ve actually found the nurse practitioner to be more careful and to spend more time trying to understand my kid than the doctors. I also feel like I know more than they do at this point.

I mean you already have a psychiatrist on here saying that the advice on side effects is incorrect. It also sounds like your DD has not been properly assessed for OCD or treated with anxiety exposure methods.

No that was talking about a therapeutic dose of Lithium, not the integrative use of Lithium Oratate, which is a newer approach.

In any event, you may be right about OCD. Do you have a psychiatrist to suggest?

[Anonymous]

Anonymous wrote:

Anonymous wrote:From my experience, lithium was a really effective regulator but got all the side effects listed above and they didn't go away. The kidney damage wasn't severe but still happened pretty quickly. Lamictal has few side effects and has been great for anxiety. Take it at night and it helps with sleep. Not a psychiatrist, just part of a family of ADHD/depression/anxiety, but lamictal has worked well for everyone.

Op here. That’s interesting because my DD has had insomnia off and on for 3 weeks. She took the first dose of Lamictal last night and was up for 3 hours at 1am. Insomnia is a common side effect, and now she’s flat out refusing to continue.

Any new medication throws a body off a little. And she is already sleep deprived from the insomnia so it's going to be worse.

Start Lamictal at 25mg and go up 25mg each week until she feels more regulated. Do not stop it for one night of insomnia after she has had 3 weeks of insomnia. Get something for sleep. Heck even Benadryl or Melatonin. Why didn't you intervene the first 3 weeks and resolved that before starting a mood stabilizer?