Based on my experience, Tegretol (carbamazepine) is a sensational medication for BPD dysphoria (anxiety, rage, depression and despair), mania, hypomania, and some causes of neuropathic pain such as shingles. Once a BPD patient has been on Prozac for a week, Tegretol works miraculously in all but the most severe stressors in 3 hours or less. In combination with 3mg of Risperdal it always works to stop a dysphoric spell.

When other physicians have tried this approach they have found the same results. I’ve never encountered a patient who preferred Depakote to Tegretol, and most prefer Tegretol. Neither Neurontin, Lamictil, nor Dilantin have had much effect. I’ve just started to prescribe Topamax.

For a reason I can’t understand I’m repeatedly told by psychiatrists that they won’t prescribe Tegretol because it’s "out of favor." I have never been able to get an explanation for this belief system. I’ve been unable to find out why this is the case, and welcome any information about this subject.

Some medical literature backing the safety and effectiveness of Tegretol, particularly in comparison to Depakote:

"Positive effects of carbamazepine on behavioral dyscontrol in borderline personality disorder"

Gardner DL, Cowdry RW, National Institute of Mental health, American Journal of Psychiatry April 1986.

"In a double-blind crossover trial, carbamazepine, an anticonvulsant with primary effects on subcortical limbic structures, decreased the severity of behavioral dyscontrol in 11 women with borderline personality disorder significantly more than placebo."

"Pharmacotherapy of borderline personality disorder. Alprazolam, carbamazepine, trifluoperazine, and tranylcypromine" Cowdry RW, Gardner DL, National Institute of Mental Health, Arch Gen Psychiatry 1988 Feb

"...those receiving carbamazepine demonstrated a marked decrease in the severity of behavioral dyscontrol."

"A comparison of valproate (Depakote) with carbamazepine (Tegretol) for the treatment of complex partial seizures and secondarily generalized tonic-clonic seizures in adults." Mattson RH, VA Epilepsy Cooperative Study No. 264, New England Journal of Medicine, Sept 10, 1992

"Valproate is as effective as carbamazepine for the treatment of generalized tonic-clonic seizures, but carbamazepine provides better control of complex partial seizures and has fewer long-term adverse effects."

"Open randomized comparative trial of sodium valproate and carbamazepine in adult onset epilepsy" Czapinski P, Klinika Neurologii Collegium Medicum UJ w Karkowie, Neurol Neurochir Pol May-Jun 1996

"There was no difference in effectiveness between patients with partial complex seizures with and without secondary generalization. The number of patients with adverse effects in both groups was comparable."

What about Tegretol induced melancholia?

Dr. Rex Cowdry at NIMH showed that over time some borderlines developed melancholia during carbamazepine (Tegretol) therapy. In my experience this is due to two things:

1. The development of acute dysphoria (anxiety, rage, depression and despair). Tegretol markedly reduces dysphoric spells, but doesn’t prevent them completely. Sometimes an as needed dose of Haldol, an extra dose of Tegretol, or a dose of Risperdal (usually 3mg) is needed. Please refer to the dysphoria instruction sheet I use for my patients.

2. The development of Tegretol induced low thyroid function (non-primary hypothyroidism).

Can Tegretol be used as needed for patients already taking Depakote?

Absolutely, and it works very well for a dysphoric spell. This was shown in a study published in February 1994 in the Journal of Clinical Psychopharmacology, by Drs. Tohen and Castillo at the Bipolar & Psychotic Disorders Program, McLean Hospital in Belmont MA. The article was entitled: "Concomitant use of valproate and carbamazepine in bipolar and schizoaffective disorders."

The abstract states: "...the combination of valproate and carbamazepine is usually well tolerated and that it can be effective in bipolar patients who have previously failed to respond to anticonvulsant monotherapy."

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