Dr. Goldsmith and Colleagues Reply

We thank Victor I. Reus, M.D., and Lee Rawitscher, M.D., for pointing out the risk of seizures due to drug-drug interactions when tramadol hydrochloride is used. Although it was not specifically stated in our original letter, our patient was appropriately informed of the risk of seizures as well as serotonergic syndrome when fluoxetine was added to her tramadol treatment, which had rapidly alleviated her OCD symptoms.

The risk of seizures associated with tramadol has been reported. As noted by Drs. Reus and Rawitscher, seizures have been reported when SSRIs (as well as tricyclic antidepressants and other tricyclic compounds, monoamine oxidase inhibitors, opioids, neuroleptics, and other drugs that lower the seizure threshold) are combined with tramadol (1). A nested case-control study by Jick et al. (2) investigated the risk of idiopathic seizures in patients taking tramadol and found that patients receiving tramadol alone did not have an increased risk of seizures. Seizures are also increased in those at otherwise greater risk of convulsive activity (e.g., those with epilepsy, head trauma, or metabolic disorders and those taking other substances that lower the seizure threshold) (1).

The importance of treating postpartum psychiatric illnesses cannot be understated, given that mothers are at a greater risk of not bonding with their babies or having normal relationships with their infants while suffering from such illnesses (3). Patients with OCD taking SSRIs often have to wait 8–10 weeks for symptomatic relief and many have an inadequate or partial response (4, 5). In a case series from Sichel et al. (6), OCD symptoms began an average of 2.2 weeks postpartum. Since early diagnosis and rapid treatment of OCD during the postpartum period are imperative for appropriate mother-child bonding, the use of tramadol for the rapid remission of symptoms may be appropriate for some patients during SSRI titration.