Dear Editor

Dr Friedman correctly draws our attention to the long-term developmental effects of selective serotonin reuptake inhibitors (SSRIs) on breast-fed infants (1). As Dr Misri observes at the end of her article, these effects “remain unknown” (2). Dr Misri, however, reviews the relative safety of these compounds on fetal and early infant development. As she notes, the dangers of no treatment for mothers with depression include maternal suicide, impairments in the mother–child relationship (as illustrated in my letter [3]) and breakdown of the spousal relationship. Long-term risks to the fetus, including delayed motor development, reduced growth, and a lower IQ, compared with infants whose mothers were successfully treated for depression, are also well reviewed by Dr Misri. Up-to-date information to help patients evaluate risks versus benefits are now available through such resources as Mother Risk at the Hospital for Sick Children in Toronto (416-813-6780; www.motherisk. org).

While Dr Friedman’s animal data are interesting, they are not convincing as scientific evidence of proven risk in humans.

References

1. Friedman EH. Neurobiology of the use of selective serotonin reuptake inhibitors during pregnancy [letter]. Can J Psychiatry 2001;46:371.
2. Misri, S, Kostares D, Kostares X. The use of selective serotonin reuptake inhibitors during pregnancy and lactation:current knowledge. Can J Psychiatry 2000;45:2857.
3. Jerome L. The use of selective serotonin reuptake inhibitors during pregnancy and lactation:current knowledge [letter].  Can J Psychiatry 2000;45:940.

Laurence Jerome, MD
London, Ontario

Dear Editor:

The term “rapid-cycling” was initially used to denote a variant of bipolar illness with 4 or more episodes yearly and a poor response to lithium (1). In some patients, rapid cycling is associated with the use of antidepressant drugs(2). Antidepressant use, however, may be unavoidable for patients who experience persistent depression despite treatment with mood stabilizers. The treatment of rapid cycling can thus be challenging in patients who have a concurrent physical disorder, such as fibromyalgia, in which antidepressants are the mainstay of pharmacological treatment(3). We describe such a case, wherein the use of tryptophan in a low dose notably improved symptoms of fibromyalgia and also resulted in a sustained mood stabilization.

Case Report

Ms A is a 40-year-old lady who has presented with a history of recurrent episodes of depression since her mid-teens. The depressive episodes have varied in duration between 2 days and 3 months, and have been characterized by symptoms of sad mood, anhedonia, poor concentration, lack of energy, and amotivation. She has a history of hypomanic spells, which she has described as “binges,” characterized by expansive mood, including overactivity, decreased requirement for sleep, excessive spending of money, consumption of large quantities of alcohol, and the use of street drugs. She also has a history of polysubstance abuse from adolescence until her early twenties. Physically, she has suffered from fibromyalgia, with symptoms of diffuse myalgia, fatigue, decreased pain threshold, localized areas of tenderness, and nonrestorative sleep. Family history revealed that her father suffered from depression, her mother from fibromyalgia and depression, and that a brother had bipolar disorder. The mood disorder was severe enough to interfere with her level of functioning;

she had been unable to run her daycare centre for several years.

Ms A had tried various antidepressant drugs, including sertraline 250 mg, fluoxetine 20 mg, amitriptyline 150 mg, and clomipramine 200 mg daily. Antidepressants were either ineffective or resulted in accelerated cycle frequency and induced hypomania. Similarly, mood stabilizers such as lithium 1200 mg, divalproex sodium 1250 mg, and carbamazepine 600 mg daily, used alone or in combination, were ineffective. The mood stabilizers combined with antidepressants led to increased cycle frequency. She questioned the effectiveness of various treatment interventions and became increasingly frustrated with her ongoing mood instability, chronic pain condition, and poor psychosocial functioning. At this time, it was decided to prescribe a trial of tryptophan. The dosage was gradually increased over a couple of weeks to 4 g daily. She remained on lorazepam 1 mg and oxazepam 25 mg daily, which she had taken for several years. Within 2 weeks of reaching the 4 g dosage, she developed a mixed state characterized by symptoms of feeling “revved up,” irritable, agitated, with racing thoughts, preoccupation with thoughts of suicide, and dysphoria. The tryptophan dosage was gradually lowered to 2 g, and her mood has been quite stable for at least 18 months. She continues to experience symptoms of fibromyalgia, but these are not as intense or disabling as before. She has been gainfully employed for more than 1 year and remains on the drug regimen of tryptophan 2 g, lorazepam 1 mg, and oxazepam 25 mg daily.