Neuropathy Treatment & Induced Cycling
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Q:  Neuropathy Treatment & Induced Cycling

Dr. Phelps--

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). 

Jim Phelps

Published November, 2004


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