LETTERS
One Patient With Bipolar Depression and Medically Unexplained Pain Symptoms Despite Treatment To the Editor: Pain is frequently linked with unipolar depression, which has been intensively investigated in a number of prior studies.1,2 Even though association is demonstrated between pain and unipolar depression, little is known about the relationship between pain and bipolar depression, or its common localizations. Here is a case in which medically unexplained pain is located in a rare area beneath gingiva. Case Report A 62-year-old woman with a diagnosis of major depressive disorder presented with mood symptoms characterized by depression, anhedonia, poor appetite, fatigue, insomnia, and suicidal ideation for about 2 weeks. About 10 years prior, she had the first episode of major depression and attempted suicide by swallowing a large amount of detergent. Total gastrectomy was performed to save her life. No specific physical illness and substance abuse were identified. She complained about severe pain beneath the gingiva from about 7 years ago without any medical findings. She was treated with venlafaxine 150 mg/day and quetiapine 200 mg/day for years but still had many recurrences of major depression, especially during severe gingiva pain attacks. Upon admission, duloxetine 60 mg/day plus estazolam 2 mg/day were prescribed. During day 14 of her hospital stay, however, there were no clinical improvements in her mood and pain symptoms. Therefore, olanzapine was added and titrated to 10 mg/day for
augmentation therapy. For treatment of refractory depression, her family was invited to clarify her prior psychiatric and medical history. Surprisingly, manic episode characterized by euphoric mood, overspending, increased psychomotor activity, and decreased sleep were present in the past. Under the impression of bipolar disorder, duloxetine was tapered and only olanzapine was kept. Her gingiva pain improved dramatically within 2 days after duloxetine withdrawal. Finally, she was discharged from our acute ward and received outpatient follow-up on day 28. Discussion Unipolar depression and pain can provoke and perpetuate one another; this has been investigated by several previous studies.1,2 However, the association between bipolar depression and pain has not yet been extensively studied. Recently, a few studies provided a better understanding between pain and bipolar depression.3,4 Bipolar depression patients are significantly more likely than normal individuals to suffer from at least moderate pain.3 In one study, roughly two-thirds of the women with bipolar depression suffered concomitant pain, whose localizations arose at multiple sites, while the most common location of pain was in the back.4 Furthermore, head, neck, limb, and joint locations had also been reported in the same study.4 Antidepressants are known to predispose bipolar depression patients to manic switches and to increase the risk of suicide in the absence of a mood stabilizer.5 On the other hand, if antidepressants could lead to a worsening of pain when mood swings still need more large-scale studies to support this point of view. The case shown above presented medically
J Neuropsychiatry Clin Neurosci 26:3, Summer 2014
unexplained pain beneath the gingiva, which was never reported in prior studies and may mislead a delayed diagnosis and treatment of bipolar disorder and even a poor prognosis. The authors report no financial relationships with commercial interests. Ching-En Lin, M.D. Dept. of Psychiatry, Taipei Tzuchi Hospital, The Buddhist Medical Foundation, Taipei, Taiwan School of Medicine, Tzu-Chi University, Hualien, Taiwan Li-Fen Chen, M.D. Dept. of Psychiatry, Tri-Service General Hospital, Taipei, Taiwan School of Medicine, National Defense Medical Center, Taipei, Taiwan Pei-Fei Shih, B.S.N. Dept. of Nursing, Taipei Tzuchi Hospital, The Buddhist Medical Foundation, Taipei, Taiwan School of Medicine, Tzu-Chi University, Hualien, Taiwan Send correspondence to Dr. Chen; e-mail: [email protected] References 1. Ohayon MM, Schatzberg AF: Chronic pain and major depressive disorder in the general population. J Psychiatr Res 2010; 44:454–461 2. Kroenke K, Wu J, Bair MJ, Krebs EE, Damush TM, Tu W: Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. J Pain 2011;12:964‒973 3. Goldstein BI, Houck PR, Karp JF: Factors associated with pain interference in an epidemiologic sample of adults with bipolar I disorder. J Affect Disord 2009; 117:151–156 4. Failde I, Dueñas M, Agüera-Ortíz L, et al: Factors associated with chronic pain in patients with bipolar depression: a crosssectional study. BMC Psychiatry 2013; 13:112 5. Goldberg JF: Antidepressant use and risk for suicide attempts in bipolar disorder. J Clin Psychiatry 2011; 72:1697, author reply 1697 [author reply]
http://neuro.psychiatryonline.org
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One Patient With Bipolar Depression and Medically Unexplained Pain Symptoms Despite Treatment To the Editor: Pain is frequently linked with unipolar depression, which has been intensively investigated in a number of prior studies.1,2 Even though association is demonstrated between pain and unipolar depression, little is known about the relationship between pain and bipolar depression, or its common localizations. Here is a case in which medically unexplained pain is located in a rare area beneath gingiva. Case Report A 62-year-old woman with a diagnosis of major depressive disorder presented with mood symptoms characterized by depression, anhedonia, poor appetite, fatigue, insomnia, and suicidal ideation for about 2 weeks. About 10 years prior, she had the first episode of major depression and attempted suicide by swallowing a large amount of detergent. Total gastrectomy was performed to save her life. No specific physical illness and substance abuse were identified. She complained about severe pain beneath the gingiva from about 7 years ago without any medical findings. She was treated with venlafaxine 150 mg/day and quetiapine 200 mg/day for years but still had many recurrences of major depression, especially during severe gingiva pain attacks. Upon admission, duloxetine 60 mg/day plus estazolam 2 mg/day were prescribed. During day 14 of her hospital stay, however, there were no clinical improvements in her mood and pain symptoms. Therefore, olanzapine was added and titrated to 10 mg/day for
augmentation therapy. For treatment of refractory depression, her family was invited to clarify her prior psychiatric and medical history. Surprisingly, manic episode characterized by euphoric mood, overspending, increased psychomotor activity, and decreased sleep were present in the past. Under the impression of bipolar disorder, duloxetine was tapered and only olanzapine was kept. Her gingiva pain improved dramatically within 2 days after duloxetine withdrawal. Finally, she was discharged from our acute ward and received outpatient follow-up on day 28. Discussion Unipolar depression and pain can provoke and perpetuate one another; this has been investigated by several previous studies.1,2 However, the association between bipolar depression and pain has not yet been extensively studied. Recently, a few studies provided a better understanding between pain and bipolar depression.3,4 Bipolar depression patients are significantly more likely than normal individuals to suffer from at least moderate pain.3 In one study, roughly two-thirds of the women with bipolar depression suffered concomitant pain, whose localizations arose at multiple sites, while the most common location of pain was in the back.4 Furthermore, head, neck, limb, and joint locations had also been reported in the same study.4 Antidepressants are known to predispose bipolar depression patients to manic switches and to increase the risk of suicide in the absence of a mood stabilizer.5 On the other hand, if antidepressants could lead to a worsening of pain when mood swings still need more large-scale studies to support this point of view. The case shown above presented medically
J Neuropsychiatry Clin Neurosci 26:3, Summer 2014
unexplained pain beneath the gingiva, which was never reported in prior studies and may mislead a delayed diagnosis and treatment of bipolar disorder and even a poor prognosis. The authors report no financial relationships with commercial interests. Ching-En Lin, M.D. Dept. of Psychiatry, Taipei Tzuchi Hospital, The Buddhist Medical Foundation, Taipei, Taiwan School of Medicine, Tzu-Chi University, Hualien, Taiwan Li-Fen Chen, M.D. Dept. of Psychiatry, Tri-Service General Hospital, Taipei, Taiwan School of Medicine, National Defense Medical Center, Taipei, Taiwan Pei-Fei Shih, B.S.N. Dept. of Nursing, Taipei Tzuchi Hospital, The Buddhist Medical Foundation, Taipei, Taiwan School of Medicine, Tzu-Chi University, Hualien, Taiwan Send correspondence to Dr. Chen; e-mail: [email protected] References 1. Ohayon MM, Schatzberg AF: Chronic pain and major depressive disorder in the general population. J Psychiatr Res 2010; 44:454–461 2. Kroenke K, Wu J, Bair MJ, Krebs EE, Damush TM, Tu W: Reciprocal relationship between pain and depression: a 12-month longitudinal analysis in primary care. J Pain 2011;12:964‒973 3. Goldstein BI, Houck PR, Karp JF: Factors associated with pain interference in an epidemiologic sample of adults with bipolar I disorder. J Affect Disord 2009; 117:151–156 4. Failde I, Dueñas M, Agüera-Ortíz L, et al: Factors associated with chronic pain in patients with bipolar depression: a crosssectional study. BMC Psychiatry 2013; 13:112 5. Goldberg JF: Antidepressant use and risk for suicide attempts in bipolar disorder. J Clin Psychiatry 2011; 72:1697, author reply 1697 [author reply]
http://neuro.psychiatryonline.org
E29
