Q: Neuropathy Treatment & Induced Cycling
I'm a physician who's enjoyed life one or two notches below hyperthymia, and
so have many relatives---no onewith BPAD and no one with recurrent MDD. Could
always get half a day's work in by 9a.m. excelled without being boastful, play
several instruments, yadda-yadda.
A couple years ago I was nailed with a fish toxin and put on nortriptyline 10
and Effexor xr75mg for peripheral neuropathy. This has kept me from going nuts
due to pain in the hands and feet. If I miss a dose or accidently take an extra
one, I'm a sitting duck for 3-4 WEEKS of rapid cycling every 48-72 hours.
QUESTION: Are people with neuropathy and hyperthymia being "kindled" toward
BPAD II by antidepressants, or do you think the meds. are neuroprotective, as
others would suggest? The neuropathy meds. are keeping me off narcotics, but
are they harmful? Neurontin led to galactorrhea and increased PRL on 2 trials.
I could use lower doses of nortriptyline/effexor but be awake some nightly due
to pain. Thanks,
child psychiatrist in Iowa
Dear Doc' --
You are already aware of the hypothesis that antidepressants could "kindle" an
underlying bipolar predilection. I'm one of those who strongly fears this risk,
though it remains a hypothesis, and there is some evidence to the contrary
(though much weaker, in my view, than the evidence going the other way).
Unfortunately, I would agree with your guess, though
you framed it as a question, that this possible kindling process could happen
even if the target for the antidepressants was neuropathic pain, not
depression. From what I've seen on this subject, it really wouldn't make much
difference; but again, this is still a working hypothesis, not fully established
as a risk. Plenty of psychiatrists don't worry about this so much, including
now Bob Post of the NIMH, who was one of the original writers about this
possible risk, though this "new" perspective of his comes to me anecdotally,
only indirectly in his writing.
For a well-referenced discussion of the pro's and con's
of antidepressants in bipolar disorder, see if you can find the August issue of
Psychiatric Times (not online yet), wherein Drs. Altshuler and Ghaemi present
these respective points of view (pgs 88-93). Dr. Ghaemi's essay I find most
convincing; leaving a small niche of people whose cycling is well controlled but
whose depression (or pain?) remains as candidates for antidepressants, used
probably long-term, as advocated by Dr. Altshuler.
You may have heard (took me a while to bump into it)
that lamotrigine is being used in pain clinics for neuropathic pain. Might be
worth considering; or carbamazepine, plus one or both antidepressants
(accounting for the enzyme induction phase might be a bit tricky re: dosing, but
that is over after a while; watch out for any pregnancy risk, of course).
Published November, 2004