Question: Do Antidepressants Help Chronic Pain Patients?
It's not uncommon for patients with chronic pain, such as arthritis and fibromyalgia, to be prescribed antidepressants. When is it appropriate for an arthritis or fibromyalgia patient to take an antidepressant? How do antidepressants benefit those patients?
Patients with chronic diseases such as rheumatoid arthritis, lupus, and fibromyalgia can experience depression -- it's not uncommon. For many patients, the depression is temporary or even brief, but others with recurring symptoms may benefit from a visit to a counselor, psychologist, or psychiatrist. Medication is often prescribed to help with the symptoms of depression, too.
Some of the more common antidepressants include drugs that are called selective serotonin reuptake inhibitors (SSRIs) such as:
- Prozac (fluoxetine)
- Lexapro (escitalopram)
- Celexa (citalopram)
- Zoloft (sertraline)
- Paxil (paroxetine)
As the name suggests, SSRIs target the neurotransmitter (brain chemical) serotonin. They are effective medications for many patients and typically, side effects are moderate or tolerable.
Other antidepressants target two neurotransmitters -- for example, serotonin and norepinephrine -- and are called dual inhibitors. According to rheumatologist Scott J. Zashin MD, "Both classes of antidepressants (SSRIs and dual inhibitors) help control fatigue and pain associated with fibromyalgia or chronic pain syndromes, although the dual inhibitors may be even more effective in terms of pain relief."
Dr. Zashin further explained, "Cymbalta (duloxetine) and Effexor (venlafaxine) are considered SNRIs (selective serotonin and norepinephrine reuptake inhibitors) -- also referred to as dual inhbitors or dual reuptake inhibitors. The company which manufactures Cymbalta is presently conducting studies to determine if this drug is effective for the treatment of fibromyalgia." (Note: Cymbalta was approved by the FDA for the treatment of fibromyalgia in 2008.)
Tricyclic antidepressants were considered the standard treatment for depression before SSRIs were developed. Tricyclic antidepressants (e.g., Elavil or amitriptyline) are given in low doses to help patients fall asleep and obtain the restorative non-REM sleep.
According to Dr. Zashin, "Tricyclic antidepressants may help both fatigue and pain. Due to numerous side effects, in the dose required to treat depression, they are seldom used for this indication."
Warnings Surround the Use of Antidepressants
The use of antidepressants is not without warnings. The FDA states that adults should be observed for increased depression or suicidal thoughts or behavior during the first few months of treatment or following a change in medication dosage. Patients should immediately contact their doctor if depression symptoms worsen or if suicidal thoughts or behavior increase. Patients should be aware of all potential side effects and report changes to their doctor.
Dr. Zashin is clinical assistant professor at University of Texas Southwestern Medical School and an attending physician at Presbyterian Hospitals of Dallas and Plano. Dr. Zashin is author of Arthritis Without Pain - The Miracle Of TNF Blockers. The book is useful for anyone on one of the biologic drugs or considering the biologic drugs.