A new study suggests that most antidepressants are not effective in treating pain conditions.
In 26 systematic reviews and profiles of more than 25,000 adult participants, the researchers found that the quality of the evidence showing that antidepressants are effective for pain was not high quality and inconclusive for most comparisons with placebo. I found that there is no evidence.
The results highlight the importance of individualizing decisions about prescribing antidepressants, said lead author and Sydney Musculoskeletal Health Research Fellow at the University of Sydney, Australian Musculoskeletal Health Research. said Dr. Giovanni E. Ferreira, a researcher at the Institute. Medscape Medical News .
“Our study shows that a one-size-fits-all approach to prescribing antidepressants for pain is not appropriate,” Ferreira said.
Here are the findings: publish online February 1 British Journal of Medicine (BMJ).
42 Clear comparisons
The use of antidepressants has increased in recent years, and off-label use of these drugs fibromyalgia, headacheWhen Osteoarthritis likely contributed to this increase, investigators noted.
Antidepressants are only approved for some pain conditions. For example, the US Food and Drug Administration (FDA) has approved serotonin-norepinephrine reuptake inhibitors (SNRIs). Duloxetine (Cymbalta) Fibromyalgia and chronic musculoskeletal pain only.
The current overview included 26 systematic reviews of 156 trials investigating antidepressants compared to placebo for pain status. It reported the efficacy of 8 antidepressant classes covering 22 pain conditions in 42 different comparisons.
None of the systematic reviews reported high-certainty evidence of the effectiveness of antidepressants in all forms of pain.
There were four comparisons showing moderate certainty of duloxetine efficacy. The mean difference was -5.3 (95% CI, -7.3 to -3.3). back pain, -7.3 (95% CI, -12.9 to -1.7) for postoperative pain and -6.8 (95% CI, -8.7 to -4.8) for neuropathic pain. For fibromyalgia, the risk ratio was 1.4 (95% CI, 1.3 to 1.6).
7 comparisons (including pain with aromatase inhibitors) breast cancer; depression Comorbid chronic pain; osteoarthritis of the knee; irritable bowel syndromeselective serotonin reuptake inhibitor duloxetine Paroxetine (several brands), or tricyclic antidepressants (TCAs) Amitriptyline (Elavil).
There were five comparisons in which antidepressants were not found to be effective.In 26 comparisons the evidence was inconclusive.
“The definitive evidence for the efficacy of most classes of antidepressants, including tricyclic antidepressants such as amitriptyline, the most commonly prescribed antidepressant for pain, was surprising. says Ferreira.
Of the 14 conditions in which efficacy was estimated in the review, focusing specifically on TCAs, there was evidence for only 3 conditions: neuropathic pain, irritable bowel syndrome, and chronic pain. tension headacheBut this was less certain evidence. For 11 other conditions, TCA was ineffective or the evidence was inconclusive.
In some medical conditions, pain may not be the primary reason patients seek care. For example, patients with functional dyspepsia constipation and bloating, and fibromyalgia sufferers may also have fatigue and sleep problems, researchers note.
The findings “cannot be used to decide whether to use antidepressants to improve these symptoms,” Ferreira said.
Accessible Summary
Most safety and tolerability estimates reported in the review were not informative due to the small sample size. is not large enough,” Ferreira said.
However, the overall safety profile of antidepressants is well known, especially for drugs such as amitriptyline, which have been on the market for decades.
The authors said, “Care should be taken in interpretation. [the] This is because approximately 45% of the trials included in the review and 68% of trials containing SNRIs are ‘industry-linked’.
Dr. Giovanni Ferreira
Industry-sponsored trials provide important efficacy information, but “encourage clinicians to recognize the impact of industry sponsorship on outcomes when making decisions about prescribing antidepressants for pain.” I will,” said Ferreira.
He pointed out another “caution” that most of the TCA trials for neuropathic pain were published more than 30 years ago. , the reported effect sizes were large, “meaning we are likely overestimating the therapeutic effect,” he said.
The researchers avoided using thresholds, such as a 10-point reduction on a 0-100 scale, commonly used in musculoskeletal pain studies to determine clinically relevant effects. Such thresholds are “mostly arbitrary and defined by researchers, not patients themselves,” Dr. Ferreira said.
He sees the new review as an “accessible summary” that clinicians can use to make better decisions for their chronic pain patients.
“We hope this study will help guide clinicians as to whether and when to prescribe antidepressants for pain,” Dr. Ferreira said.
“Disappointing” treatment
so Accompanying editorialCathy Stannard and her colleague Colin Wilkinson, of the NHS Gloucestershire Integrated Care Board in the UK living with pain, say the overview “adds evidence to challenge the use of pain medications”. .
The findings “suggest that treatment with antidepressants is disappointing for most adults living with chronic pain,” they wrote.
The editors note that non-healthcare services, such as mobility support and social isolation, can help people living with pain.
Identifying what is most important to patients and “signposting” them to appropriate community support “is a promising approach,” they wrote. are “evolving and not yet definitive,” they add.
Comments on Medscape Medical NewsThe results are surprising because “we’ve known for some time that antidepressants are often blunted for pain,” said Robert Bonakdar, M.D., director of pain management at the Scripps Center for Integrative Medicine in La Jolla, Calif. said not to.
The reason for this is that “by definition we are dealing with chronic pain, which is a very complex condition, and we hope that an obscure molecule can make a dramatic difference,” said one of the researchers involved. Mr Bonakdar said there was no.
A better approach, he pointed out, is multidisciplinary rehabilitation (MDR), which links medical therapy with physical therapy, cognitive therapy, biofeedback, dietary counseling, mindfulness, and acupuncture.
But coverage issues and a healthcare system that accepts a fragmented rather than a comprehensive approach to pain management are making MDR more difficult to access, he added.
“We are basically paying the price by increasing the incidence of pain and expanding the pain epidemic in the United States,” Bonakdar said.
Ferreira reported receiving support from a National Health and Medical Research Council fellowship, but did not receive support from any organization for the submitted research. . Stannard was the Clinical Director for the UK National Institutes of Health (NICE) Guidelines for Primary and Secondary Chronic Diseases. pain assessment and management, and was a topic advisor for NICE guidelines on medications related to dependence or withdrawal symptoms. Bonakdar has not reported any related financial relationships.
BMJ. Published online on February 1, 2023. full text, editorial
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