Did you know that antidepressant medications are often prescribed to people? without depression?

Is true. Antidepressants are often prescribed for chronic pain, especially pain related to nerve disease (called neuropathic pain), low back or chronic neck pain, and certain types of arthritis.

In fact, some guidelines for the treatment of chronic low back pain and osteoarthritis (the most common type of arthritis) include antidepressants. One specific antidepressant, duloxetine (Cymbalta), is FDA approved for these conditions.

Simply how antidepressants reduce pain is not well understood. One possibility is that they affect the chemicals in the brain involved in the perception of pain, a mechanism that differs from how they combat depression.

It is not usually the first choice to relieve pain

For people with chronic back or neck pain or osteoarthritis of the hip or knee, an antidepressant medication is not usually the first recommended treatment. Typically, other approaches are first attempted, such as physiotherapy, exercise, excess weight loss, nonsteroidal anti-inflammatory drugs (NSAIDs), or cortisone injections. But if they are not helpful, antidepressants like duloxetine or amitriptyline may be a reasonable step.

When pain is prescribed, the initial dose is usually low (often lower than the initial dose for depression). If necessary, gradually increase. Ideally, people should notice a benefit within a few weeks of starting the medication and the lowest effective dose can be continued. It may be recommended to switch to a different antidepressant if the pain is not well controlled, side effects occur, or there is an interaction with another medication.

A new study suggests that antidepressants do not work well for common types of pain

Previous research on antidepressants for chronic pain, such as duloxetine for osteoarthritis of the knee, amitriptyline or duloxetine for chronic low back pain i amitriptyline for chronic neck pain, demonstrated a modest short-term profit. But studies were limited: most trials were small and lasted only a few months or less. It should be noted that medication side effects, such as nausea, constipation, and erectile dysfunction, were common in these trials.

Now one 2021 study has combined data from previous research to better understand the safety and efficacy of antidepressants in these conditions. The news is not good:

  • On average, antidepressant treatment minimally reduced pain and disability compared with placebo. The improvement in pain – about 4 points on a scale of 0 to 100 – was considered too small to be noticed.
  • People treated with certain antidepressants for chronic pain often stopped taking the medication because it did not work, causing unacceptable side effects, or both.
  • People with chronic pain and depression experienced no better improvement than people with chronic pain alone.

Sciatica can be an exception: antidepressants can reduce pain for up to a year. However, the quality of the previous research was poor, so the study authors did not trust these findings.

These findings call into question the usefulness of antidepressant treatment for these common causes of chronic pain. However, they do not rule out the possibility that some people may get more relief from these medications than others.

The conclusion

The available evidence suggests that, on average, the benefit of antidepressants for osteoarthritis or chronic low back pain and neck pain is, at best, modest and usually temporary. This is disappointing because, for many who suffer from pain, there are no reliably effective treatments (in the absence of joint replacement for osteoarthritis).

Therefore, if you are using an antidepressant for pain and you are not sure if it works, talk to your doctor if you need to consider stopping it. But don’t stop it alone. There may be other reasons why your doctor recommends this medicine and many antidepressants should be reduced, not left at the same time, to avoid discontinuation symptoms.

If you are taking an antidepressant for pain, it is worth checking if it is really doing something for you and if it may be time to shorten the list of medications. Not only can you simplify your medical regimen, but you can also reduce the cost of your medications and the risk of medication-related side effects.

Follow me on Twitter @RobShmerling


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