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 Table of Contents  
LETTER TO EDITOR
Year : 2018  |  Volume : 23  |  Issue : 2  |  Page : 137-138

Role of tramadol as an augmenting agent in treatment-resistant depression


Department of Psychiatry, Maharishi Markandeshwar Institute of Medical Sciences and Research, Mullana, Ambala, Haryana, India

Date of Web Publication14-Nov-2019

Correspondence Address:
Leezu Bhusri
C/O Dr. Neeraj Loona, House No. 212, Sector-15, Panchkula, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmhhb.jmhhb_6_19

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How to cite this article:
Bhusri L, Bathla M, Gupta P, Singh AH. Role of tramadol as an augmenting agent in treatment-resistant depression. J Mental Health Hum Behav 2018;23:137-8

How to cite this URL:
Bhusri L, Bathla M, Gupta P, Singh AH. Role of tramadol as an augmenting agent in treatment-resistant depression. J Mental Health Hum Behav [serial online] 2018 [cited 2019 Dec 10];23:137-8. Available from: http://www.jmhhb.org/text.asp?2018/23/2/137/271007



Sir,

Major depression is one of the most common psychiatric illnesses worldwide and leading cause of disability. Treatment-resistant depression is defined as inadequate response to at least one antidepressant trial of adequate dose and duration.[1] As depression is a heterogenous disorder no single reason for treatment-resistant depression can be identified. However, some of the factors could be variable nonresponse rates, genetic disposition; medical comorbidities, breakthrough episodes, and misdiagnosis of depression.[2]

Augmentation therapy is started when patient doesn't respond or improve despite an adequate trial of two antidepressants of different classes prescribed in clinically effective dose and a minimum duration of 6-weeks period. There have been only few case studies mentioning the role of tramadol in treatment-resistant depression.[3]


  Case Report Top


A 24-year-old male, graduate, unmarried, Hindu by religion, working as a salesman, hailing from rural area, with an introvert, anxious, not sociable/adjustable, worrisome premorbid personality with poor ability to handle stress. No history of psychiatric complaints in the past/substance abuse, no medical comorbidities and insignifi cant family history, presented to psychiatry outpatient department with the complaints of low mood, decreased energy, increased fatiguability, decreased interest in work, decreased sleep, decreased appetite, decreased confi dence, worrying about future, and suicidal ideas for 2 months. There was no history of any elated mood, self-muttering, self-laughing, suspiciousness, auditory or visual hallucinations, obsessions or compulsions, roadside accident, or seizure episode.

Mental state examination

Speech was decreased in rate/flow/volume, mood, and affect were depressed with restricted range; thought: Suicidal ideations were present. There was no cognitive decline.

Diagnosis

The patient was diagnosed with severe depression without psychotic symptoms. (F32.2) as per ICD-10 criteria.

The patient was assessed on Hamilton depression rating scale for (HDRS). The score on day 1 was 27. Patient was started on tablet escitalopram 10 mg OD for a period of 10 days, but patient reported with the complaints of premature ejaculation and was then started on venlafaxine 37.5 mg BD gradually increased to 150 mg over 3 weeks along low-dose benzodiazepines and titrated to 225 mg over a period of 6 weeks; continued for 12 weeks. HAM-D: 13 (at 6 weeks); but continued to have the residual symptom of disturbed sleep; Patient was also tried mirtazapine up to 30 mg, nitrazepam up to 10 mg, quetiapine up to 200 mg for the adequate duration as an adjunctive therapy for sleep disturbance, but there was no improvement in symptoms. Polysomnography was planned in view of residual disturbed sleep to rule out any sleep disorders which showed poor sleep efficiency of 36%; anoxia-hypoxia index 1.9 and SpO2 (nadir) 92%.

Patient was started on tramadol 50 mg OD. The patient showed improvement in HAM-D: 8. (at 14 weeks) and continued thereafter.


  Discussion Top


Tramadol is a centrally acting synthetic opioid analgesic with effective affinity for the mu-opioid receptor (μ). It also shares monoaminergic action that resulted in the research of tramadol as a potential treatment for augmentation in depression. A significant response has been seen with tramadol in improving depressive symptoms.

In our case, tramadol showed improvement in depressive symptoms, although in some studies it is known to lower the seizure threshold, and therefore should be used with caution in patients with a history of epilepsy.[3] There are few reports showing its beneficial effects in clinical settings, such as the treatment of refractory major depression, and severe suicidal ideation.[4] Few other studies, along with some experimental and clinical data, show that tramadol has the inherent property of improving mood.[5] Thus, tramadol can be used as an augmenting agent in treatment-resistant depression.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Acknowledgment

None.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
MacGill M. What is depression and what can I do about it? Medical News Today; November, 2017. Available from: https://www.medicalnewstoday.com/kc/depression-causes-symptoms-treatments-8933. [last accessed on 2019 Jan 20].  Back to cited text no. 1
    
2.
Thase ME, Rush AJ. Treatment resistant depression. In: Bloom FE, Kupfer DJ, editors. Psychopharmacology: The Fourth Generation of Progress. New York: Raven Press Ltd.; 1995. p. 1081-97.  Back to cited text no. 2
    
3.
Barber J. Examining the use of tramadol hydrochloride as an antidepressant. Exp Clin Psychopharmacol 2011;19:123-30.  Back to cited text no. 3
    
4.
Shapira NA, Verduin ML, DeGraw JD. Treatment of refractory major depression with tramadol monotherapy. J Clin Psychiatry 2001;62:205-6.  Back to cited text no. 4
    
5.
Spencer C. The efficacy of intramuscular tramadol as a rapid-onset antidepressant. Aust N Z J Psychiatry 2000;34:1032-3.  Back to cited text no. 5
    




 

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