Abstract
Recently I had a single anecdotal experience in which a 25-year-old male was admitted with a severe and suicidal depressive illness. Because of chronic back pain he was prescribed intramuscular tramadol. On admission he was markedly depressed and had frequent thoughts of suicide, his affect was flattened and he was significantly dysphoric. Following administration of the tramadol, I noticed some striking changes in his mental state, his depressed mood lifted and he felt great, he was also considering his future and was now determined to get better. A few days later he was to start cipramil and because of the possible interactions, tramadol was ceased. The next morning I arrived to review the patient only to discover that his mental state had deteriorated and he had made a serious attempt at overdose in the early hours of that morning. He survived.
Although accepting the analgesic benefits of the medication, I feel that these changes may also reflect the dual action of the drug on both noradrenalin and serotonin receptors. If this is the case I feel that tramadol may have a place in the setting of the acutely depressed and suicidal patient, allowing for the patient to be stabilised pending more long-term treatment with oral antidepressants.
I feel that it would be worthwhile studying the efficacy of tramadol as a rapid onset intramuscular or intravenous, potent antidepressant. Although its mode of action is incompletely understood, from animal tests at least two complementary mechanisms appear applicable: binding to mu-receptors and inhibition of the re-uptake of serotonin and noradrenalin. It has good bioavailability and has an onset of action in terms of minutes to hours, rather than weeks, with steady state levels reached within 24–36 h. It can be administered either intramuscularly or intravenously. The full details of its effect on noradrenalin and serotonin reuptake is unclear, however, studies have shown an increase in the serum levels of both. Considering the fact that many of the antidepressants currently available take 4–6 weeks before clinical benefit and satisfactory serum levels are obtained, I feel that a quicker onset intramuscular or intravenous antidepressant would be welcomed, especially in the setting of acute suicidality where rapid control of symptoms may be critical. In this clinical setting tramadol could be used to stabilise the patient and avert suicide, and then switch to an oral preparation a few days later, once the suicidal ideation is less prominent. An oral preparation with similar mode of action would be most appropriate (i.e. a medication that inhibits the same re-uptake systems e.g. venlefaxine).
In summary, I feel that so much could potentially be gained through the development of an intramuscular or intravenous antidepressant that the study in itself may open gates to a different approach to the acutely suicidal, depressed patient. I would be interested in comments from other readers on the issue and in particular researchers who may have views on these matters.