Posted by Rudiger on July 10, 2001, at 11:08:04
The following are excerpts from an article published in the March 2001 issue of the Journal of Clinical Psychiatry.
Treatment of Refractory Major Depression with Tramadol MonotherapyRecent reports describe treatment of patients with refractory major depression using augmentation with the mi-opiate agonists oxycodone and oxymorphone and the partial agonist buprenorphine. (1.,2.) We report a patient with refractory major depression who responded to tramadol hydrochloride monotherapy.
Case report. Mr. A, a 64-year-old white man, was diagnosed with chronic major depressive disorder with melancholic features (DSM-IV criteria). His first episode occurred around 1984, and since being diagnosed in 1986, he has failed adequate medication trials of the following antidepressants: amitriptyline, amoxapine, bupropion, clomipramine, doxepin, fluoxetine, fluvoxamine, imipramine, maprotiline, mirtazapine, nefazodone, paroxetine, phenelzine, sertraline, tranylcypromine, and venlafaxine. Furthermore, he has failed augmentation trials with bupropion, lithium, and methylphenidate. In addition to antidepressant medications, several anxiolytic medications were tried unsuccessfully, including alprazolam, buspirone, clonazepam, lorazepam and temazepam. Neither supportive nor insight-oriented psychotherapy was helpful, and Mr. A has declined electroconvulsive therapy. He experienced mild relief with nortriptyline for approximately 2 years.
In 1998, Mr. A developed facial pain secondary to a salivary stone. At that time, he was taking no psychiatric medications and received tramadol for the pain. Tramadol improved the pain slightly, and ultimately the pain resolved. However, on tramadol treatment, Mr. A noticed immediately that his depressive symptoms improved 60% to 70%. Since 1998, he has continued taking 100mg of tramadol 3 to 4 times daily. He finds that if he awakens to take a dose at 4:00 a.m., he will wake without depressive symptoms. He describes feeling the effect of tramadol within 30 minutes, but if he misses several doses, he will feel no effect for hours.
Evaluation by the Structured Clinical Interview for DSM-IV (3.) revealed that he had had comorbid obsessive-compulsive disorder (OCD) since 1965 and panic disorder (in remission) since 1974. ...Additionally, there is no indication from Mr. A's history or collateral information that he has any covert history of opioid abuse.
[Mr. A's] preferential response to opiates...suggests dysfunction of his endogenous opioid system. Furthermore, among recovering opiate addicts, depression rates are high.(4.) Recent research (5.) has demonstrated an increase in the number of endogenous opioid receprtors in the central nervous system of depressed suicide victims. Tramadol is an atypical centrally acting analgesic with mi-receptor activity, and it also weakly inhibits norepinephrine and serotonin reuptake.(6.) Structurally, it is similar to the antidepressant venlafaxine. (7.) Tramadol has been shown to induce some antidepressant-type effects in mice, which appeared to be related to tramadol's noradrenergic activity(8.), and has been reported effective in augmenting treatment in 12 patients with major depressive disorder who had a partial response to selective serotonin reuptake inhibitors.(9.) Because Mr. A has comorbid OCD that improved on treatment with tramadol, it is interesting that tramadol has been shown to be efficacious in an open-label study of treatment-refractory OCD.(10.) Tramadol may represent an alternative to commonly used antidepressants in select treatment-refractory patients. More research is necessary to establish the antidepressant effect of opiates such as tramadol, as well as to determine if there is a distinct subset of depressed patients with endogenous opioid dysfunction.
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Nathan Andrew Shapira, M.D., Ph.D.
Marcia L. Verduin, B.A.
University of Florida Brain Institute
Gainesville, FloridaJohn D. DeGraw, M.D.
Meadowcrest Multispecialty
Crystal, Florida
poster:Rudiger
thread:69593
URL: http://www.dr-bob.org/babble/20010708/msgs/69593.html