Mood Stabilizer Combinations for Bipolar Disorder

To the Editor: The article by Marlene P. Freeman, M.D., and Andrew L. Stoll, M.D., on combinations of mood stabilizers for treatment of bipolar disorder (1) noted the potentially dangerous interaction of lamotrigine with valproate. Unfortunately, the authors failed to mention that the risk of severe and at times fatal rashes associated with lamotrigine is much higher in the pediatric population. Readers should have been reminded of the one in 50 to one in 100 chance of life-threatening rashes associated with the use of lamotrigine in children and adolescents under 16 years. The product information monograph bears a boxed warning emphasizing that lamotrigine is not approved for use in patients below the age of 16 years.