In this original species called humans everything is somehow connected to everything else. So it’s actually a good idea to occasionally use therapies for illness and suffering that don’t get to the root of the problem, i.e. don’t fight the primary cause of the suffering, but rather approach the symptoms in a roundabout way. At first glance, it may seem absurd to treat chronic pain with antidepressants, but on second glance the connection between physical and emotional pain is quite obvious. Finally, physical pain is known to weigh heavily on mood. Conversely, a depressive tendency also changes the pain threshold and makes you more susceptible to physical complaints. In addition, the brain regions that process physical pain and those that modulate mood are neurochemically similar.
in one extensive Cochrane Review has now been analyzedhow well antidepressants help with chronic pain. Chronic pain is defined as complaints that have lasted longer than three months – at least one in five adults worldwide suffers from it. In many countries in Europe, but also in parts of Africa, chronic pain is much more common and affects one third to one half of the adult population. No other ailment leads to so many sick days, early retirement and permanent limitations in everyday life.
Cochrane Reviews – this comprises 278 pages – are considered to be extremely thorough because, after extensive literature research, only the data from the methodologically most valuable studies are considered in a meta-analysis. However, the current overview of 176 studies with more than 28,000 patients produced sobering results. As a result, there is insufficient evidence that most antidepressants are effective for chronic pain and safe to use for long periods of time. The authors not only recorded substantial pain relief as a drug effect, but also included changes in mood, sleep, quality of life and physical functions.
The long-term effects of antidepressants are also not understood
Among the drugs studied were common antidepressants and blockbusters such as amitriptyline, fluoxetine, citalopram, paroxetine, sertraline and duloxetine – but only the latter showed clinically relevant pain relief, at least in the short term. Although high quality standards were applied when selecting the studies, the authors criticized the overall mediocre quality of the studies. The average duration of the study was just ten weeks, which is very short when examining the effects of treatments for chronic pain.
“Chronic pain is a global health problem,” says the study’s lead author, Tamar Pincus of the University of Southampton. “Millions of people around the world are prescribed antidepressants, but there isn’t enough scientific evidence that they’re any good, nor is the long-term health impact really understood.” The studies are simply not good enough, and almost half of them were financed by the pharmaceutical industry, so marketing interests cannot be ruled out.
“We will be asking regulatory agencies such as NICE in the UK and the FDA in the US to update their guidelines to reflect the latest scientific evidence,” says Newcastle University statistician Gavin Stewart, who was also involved in the study. “And funders should stop funding small and skewed studies because measuring the benefit of a therapy for chronic pain is complex.”
The study authors admit that while chronic pain is “incredibly common,” there is “unfortunately very little we can do about it,” Pincus said. There is good evidence, especially for non-pharmacological measures: More exercise, targeted physical activity, less stress, a healthier lifestyle and – particularly difficult to implement in the case of chronic pain – the confidence that the symptoms will improve can be proven to help. In recent years, the pharmacological options for doctors in patients with persistent pain have also become fewer: opioids are rarely considered an option, not least because many patients become dependent. Paracetamol and ibuprofen are also not the drugs of choice in the long run. For these reasons, the use of antidepressants has increased in recent years; Amitriptyline alone (trade name “Saroten”) has been prescribed 10 million times in the past 12 months in the UK.
Nevertheless, pain patients should not immediately stop taking their medication
In practice, however, there are always positive experiences with antidepressants for chronic pain, which suggest their use after careful examination and consideration. “In patients with chronic nerve pain, the evidence is very good,” says Marcus Schiltenwolf, head of the department for conservative orthopedics and pain therapist at Heidelberg University Hospital, who, however, for other pain symptoms, is the first choice to change lifestyle, physical activity and, if necessary, psychotherapy.
The Cochrane authors do not require pain patients to stop taking antidepressants immediately. Finally, patient groups were examined for the meta-analysis. In individual cases, the medication could be helpful, but this is not reflected in the overall evaluation. In addition, the placebo effect, i.e. the belief that the medication will help, can contribute significantly to pain relief. During the next visit to the family doctor, however, it makes sense for the patients to discuss further medication with their doctor, says Pincus.
In addition, the worldwide pain problem cannot be solved medically alone. Some people – including the elderly, women, the chronically ill and the unemployed – are more likely to experience chronic pain and appear to be more susceptible to it. Socioeconomic class plays an important role – those who belong to a group with low income and little education complain more often about pain, feel it more intensely and feel more affected by the symptoms. The extent to which mental suffering and physical complaints overlap has been shown time and again in studies in recent years. For example, those who feel excluded from a group, who are alone, without prospects and depressed, become more sensitive to physical pain and simply thinner. Emotional pain also hurts physically. And sometimes it doesn’t even help when the doctor comes.