Successful treatment of erythromelalgia with intrathecal hydromorphone and clonidine.

OBJECTIVE: The objective of this study was to determine if intractable pain from erythromelalgia could be successfully treated with intrathecal hydromorphone and clonidine. DESIGN: A single case of pain from erythromelalgia refractory to multiple treatment modalities was examined and treated. SETTING: The setting is an outpatient pain clinic at a major university teaching hospital. PATIENT: Our patient is an 82-year-old woman with hypertension and peripheral vascular disease. INTERVENTION: Intrathecal opioid and an alpha2-agonist were administered. OUTCOME MEASURES: Outcome was determined by means of patient self-report during office follow-up visits. RESULTS AND CONCLUSIONS: Administration of intrathecal opioid and an alpha2-agonist can be effective in the treatment of the pain of erythromelalgia and offers an alternative pain treatment modality for patients with unremitting pain refractory to more conservative therapy.

Utilization patterns of tricyclic antidepressants in a multidisciplinary pain clinic: a survey.

OBJECTIVES: Tricyclic antidepressants (TCA) have been shown to provide analgesia for a variety of neuropathic and headache pain syndromes regardless of the presence of depression. There is a high incidence of depression in patients with chronic pain, thereby making tricyclic antidepressants particularly suitable for chronic pain patients. We wanted to study patterns of use of tricyclic antidepressants in our Pain Management Center (Beth Israel Hospital, Boston, MA, U.S.A.) primarily to answer four questions: (1) What percentage of all patients were treated with tricyclic antidepressants? (2) How many patients were treated with each antidepressant, and what was the dose range used for individual antidepressants? (3) Were tricyclic antidepressants beneficial for chronic pain, and was that response dependent on a particular dose? (4) Did patients receive an adequate TCA trial, and what factors led to the discontinuation of a TCA trial? METHODS: A total of 1,145 pain clinic patient charts were reviewed in alphabetical sequence. A total of 282 patients were identified as being treated with tricyclic antidepressants. Data were obtained from these 282 charts regarding the patient's age, diagnosis, tricyclic antidepressant use and dose, other pain treatments, response to treatment, and side effects. The existing diagnosis of depression was documented if possible. Tricyclic antidepressant doses were defined as low doses when the equivalent of 50 mg or less of amitriptyline was used, and as full doses when the equivalent of at least 150 mg of amitriptyline was used. Response to treatment was noted as mild, moderate, or marked improvement. Patients reporting mild improvement were considered nonresponders. RESULTS: Of 1,145 patients, 282 were treated with tricyclic antidepressants. A total of 205 (73%) of the patients were treated with low doses and only 34 (12%) with full doses. The remaining 43 (15%) received intermediate doses. Amitriptyline was the most commonly used drug (58%). Amitriptyline and doxepin appeared to be more effective than other tricyclic antidepressants. The rate of response to our treatment among the 31 patients with a coexisting diagnosis of depression was similar to the patients without documented depression. In patients with tricyclic antidepressants as the only treatment, there was only a trend toward greater response with full dose. In terms of side effects causing dose limitation or discontinuation of the drug, clomipramine, amitriptyline, and doxepin appeared to be worse than imipramine, desipramine, and nortriptyline. CONCLUSION: Tricyclic antidepressants were used in 25% of patients referred to a multidisciplinary pain center and were commonly used in low to intermediate doses, even in situations in which there were neither side effects nor optimal clinical response.

Lymphocyte function in major depression.

Immunologic function as measured by lymphocyte response to phytohemagglutinin (PHA) mitogen was evaluated in 8 psychiatric inpatients. All were less than 45 years of age and had a DSM-III diagnosis of major depression. When patient's immunologic responses were compared with healthy age- and sex-matched controls, a significant increase in PHA mitogen stimulation was observed in the depressed group. Further, a significantly greater variance in PHA response was observed in the patients compared with controls. The literature on depression and immunity is reviewed and the clinical implications of our findings are discussed.

Poor interrater reliability of MECTA EEG recordings of ECT seizure duration.

The electroencephalogram (EEG) tracings of seizure durations recorded by the MECTA SR-1 for 24 patients undergoing right unilateral electroconvulsive therapy (ECT) were estimated independently by four psychiatrists and a neurologist. Differences among raters were often large and, overall, were statistically significant. The literature on interrater reliability for the MECTA EEG remains contradictory, and caution in MECTA EEG use appears warranted.

Prolongation of the antidepressant response to partial sleep deprivation by lithium.

Depressed patients given a loading dose of lithium on the first of 2 successive days of partial sleep deprivation (PSD), and kept at maintenance levels thereafter, showed significantly greater prolongation of the antidepressant effects of PSD than patients treated with PSD and placebo, even though the acute elevation in mood derived from PSD was as great on placebo as on lithium. Depression was assessed 3 days after PSD with an augmented version of the Hamilton Rating Scale for Depression. Patients on lithium alone, without PSD, did not have the acute elevation in mood seen in the two PSD groups and had significantly less improvement in depression than those who received PSD with lithium.