Treating depression, chronic pain

We read with interest Dr. Nelson’s and Dr. Krahn’s article on treating chronic pain and comorbid major depression (Current Psychiatry, May 2004).

We treat many patients who present with depression and chronic pain—often as a partial cause of their depression. The article’s recommendations will be most useful.

We have found that two agents—lamotrigine and mirtazapine—have been particularly helpful. The authors, however, did not mention these agents or only briefly referred to them.

Lamotrigine, although not FDA-approved for these uses, has demonstrated efficacy in unipolar depression¹ and chronic pain.² Although the medication has not been studied for treating comorbid depression and chronic pain, we can attest to its usefulness for such patients.

Mirtazapine is FDA-approved for depression and has been compared favorably with selective serotonin reuptake inhibitors^3-4 or venlafaxine.⁵ Fewer data support using mirtazapine for chronic pain, but its sedating effects make it an option for treating any syndrome associated with sleep disturbance—ie, major depression and chronic pain.

Vida Robertson, MD
Michael S. Wilson, II, MD
Department of psychiatry
Louisiana State University Health Sciences Center
New Orleans

References

1. Barbosa L, Berk M, Vorster M. A double-blind, randomized, placebo-controlled trial of augmentation with lamotrigine or placebo in patients concomitantly treated with fluoxetine for resistant major depressive episodes. J Clin Psychiatry 2003;64(4):403–7.
2. Eisenberg E, Lurie Y, Braker C, et al. Lamotrigine reduces painful diabetic neuropathy: a randomized, controlled study. Neurology 2001;57(3):505–9.
3. Winokur A. DeMartinis NA 3rd, McNally DP, et al. Comparative effects of mirtazapine and fluoxetine on sleep physiology measures in patients with major depression and insomnia. J Clin Psychiatry 2003;64(10):1224–9.
4. Wade A, Crawford GM, Angus M, et al. A randomized, double-blind, 24-week study comparing the efficacy and tolerability of mirtazapine and paroxetine in depressed patients in primary care. Int Clin Psychopharmacol 2003;18(3):133–41.
5. Guelfi JD, Ansseau M, Timmerman L, Korsgaard S; Mirtazapine-Venlafaxine Study Group. Mirtazapine versus venlafaxine in hospitalized severely depressed patients with melancholic features. J Clin Psychopharmacol 2001;21(4):425–31.