Antidepressants effective for fibromyalgia
A meta-analysis has found that patients with fibromyalgia gain both symptomatic and functional benefit from short-term treatment with antidepressants.
A total of 18 randomised controlled trials involving 1,427 participants were identified by a screen of four electronic databases. The median trial duration was 8 weeks, range 4-28 weeks.
Overall, antidepressant treatment was associated with small but significant reductions in pain (effect size -0.43), sleep disturbance (-0.32), depressed mood (-0.26) and fatigue
(-0.13). The preferred measure of health-related quality of life (HRQOL) was the fibromyalgia impact questionnaire which incorporates measures of physical function, symptoms and mood. Overall, there was a small but significant improvement in HRQOL (effect size 0.31).
The efficacy of individual drug classes was also assessed, although the authors caution that small sample sizes may limit the validity of the results. By far the most effective drugs were the tricyclics, with large effect sizes for pain reduction, sleep improvement and fatigue reduction. There was no effect on mood, reflecting the low doses used, and the improvement in HRQOL was small. MAOIs achieved a medium effect size for pain reduction, but the effects of SSRIs and SNRIs were small.
Of the 15 studies which reported their recruitment setting, 11 came from rheumatology departments, three from research centres and one from a psychiatric department. The evidence from primary care is that functional somatic syndromes tend to overlap with one another rather than form discrete entities e.g. musculoskeletal symptoms may be linked with headache and functional neurological symptoms.1
The stepped care approach recommends biopsychosocial explanation, reassurance and graded exercise as first-line treatment for patients with uncomplicated fibromyalgia. For patients with repeated presentations or symptoms in two or more body systems, antidepressant treatment should be considered.2 Reattribution is also recommended but may not be effective in a primary care setting.3
If we are to prescribe antidepressants, providing there are no contraindications, low- dose amitriptyline would appear to be the drug of choice. As yet, however, we do not know how effective this is in a primary care setting nor whether benefits are maintained long term.
Hauser W, Bernardy K, Uceyler N et al. Treatment of fibromyalgia syndrome with antidepressants. A meta-analysis. JAMA 2009;301:198-209Reviewer
Dr Phillip Bland