Prescription primer: fibromyalgia and antidepressants.
Subject: Antidepressants (Dosage and administration)
Continuing medical education (Tests, problems and exercises)
Fibromyalgia (Diagnosis)
Fibromyalgia (Drug therapy)
Author: Bhagar, Harpriya A. "Sonya"
Pub Date: 12/22/2008
Publication: Name: Annals of the American Psychotherapy Association Publisher: American Psychotherapy Association Audience: Academic; Professional Format: Magazine/Journal Subject: Psychology and mental health Copyright: COPYRIGHT 2008 American Psychotherapy Association ISSN: 1535-4075
Issue: Date: Winter, 2008 Source Volume: 11 Source Issue: 4
Product: Product Code: 2834251 Antidepressant Preparations NAICS Code: 325412 Pharmaceutical Preparation Manufacturing SIC Code: 2834 Pharmaceutical preparations
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 192800782
Full Text: The American College of Rheumatology classifies fibromyalgia as presenting with generalized body pains for 3 months and pain on palpitation of 11 of the 18 paired tender spots. The incidence between those aged 20-50 years is about 6%, but the percentage rises to 8% after age 80. It is more common in women than in men, and it is estimated that at least 30% of patients with fibromyalgia can have comorbid depression or anxiety (Nampiaparampil & Shmerling, 2004).

KEY WORDS: fibromyalgia, antidepressants

TARGET AUDIENCE: physicians

PROGRAM LEVEL:

DISCLOSURE:

PREREQUISITES: none.

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Treatment of fibromyalgia involves both pharmacological and non-pharmacological methods. Certainly pain management is an important component of the treatment, and several analgesics have been used. Recently, pregabalin, an antiseizure medication, was approved by the Food and Drug Administration. Other medications may be used for muscle relaxation and sleep. Exercise, a low-stress lifestyle, acupunture, massage, and chiropractic techniques, are some of the common alternatives to medications.

The role of antidepressant medications in fibromyalgia is not well understood. Antidepressants that are selective serotonin reuptake inhibitors (SSRIs) may not improve the pain symptoms of fibromyalgia, but they may improve co-morbid depression if present (Littlejohn & Guymer, 2006). On the other hand, some antidepressants can improve the core symptoms of fibromyalgia, such as pain, sleep, and disability, independent of their effects on mood and anxiety. A randomized, controlled trial of with amitryptiline (a tricydic antidepressant) and naproxen (a non-steroidal anti-inflammatory drug) showed that amitryptiline improved pain, sleep, fatigue upon waking up, and tender point score in fibromyalgia (Goldenberg, Felson, & Dinerman, 1986). In a small 15-patient study, venlafaxine, a selective serotonin and norepinephrine reuptake inhibitor (SNRI), showed improvement in pain and disability in fibromyalgia. This effect was not influenced by its antidepressant and anti-anxiety effects (Sayar, Aksu, Ak, & Tosun, 2003). In a 6-month, multicenter, randomized, double-blind, placebo-controlled study of 520 patients with fibromyalgia, duloxetine, another SNRI antidepressant, showed improvement in the outcomes measured at 3 months and at 6 months (Russell et al., 2008). In 2008, duloxetine was approved by the Food and Drug Administration for treatment of fibromyalgia.

To summarize, antidepressants can usually improve the co-morbid depressive symptoms in fibromyalgia, but some can target the pain and disability of fibromyalgia as well.

Earn CE Credit

Take CE test for free online at www.americanpsychotherapy.com or see the questions for this article on page 25.

POST CE TEST QUESTIONS

1. The symptoms of fibromyalgia are:

a) chronic generalized pain

b) fatigue

c) several tender points

d) all of the above

2. The incidence of fibromyalgla between ages 20-50 is:

a) <1%

b) 2-6%

c) 6%

d) none of the above

3. Fibromyalgia and Major Depressive Disorder are the same illness or of the same group.

a) true

b) false

c) partially true

d) none of the above

4. The percentage of patients with fibromyalgia that can have co-morbid depressive or anxiety disorder is:

a) 100%

b) 50%

c) 30%

d) 10%

5. An antidepressant approved for fibromyalgia by the FDA is:

a) duloxetine

b) tricyclic agents

c) sertraline

d) venlafaxine

6. Treatment modalities of fibromyalgia include:

a) pain management

b) treatment of sleep and muscle spasms

c) treatment of co-morbid conditions

d) all of the above

References

Goldenberg, D. L., Felson, D. T., & Dinerman, H. (1986, Nov.). A randomized, controlled trial of amitriptyline and naproxen in the treatment of patients with fibromyalgia. Arthritis Rheum., 29(11), 1371-7.

Littlejohn, G. O., & Guymer, E. K. (2006). Fibromyalgia syndrome: Which antidepressant should we choose. Curr Pharm Des., 12(1), 3-9.

Nampiaparampil, D. E., & Shmerling, R. H. (2004, Nov.) A review of fibromyalgia. The American Journal of Managed Care, 10, 794-800.

Russell, I. J., Mease, P. J., Smith, T. R., Kajdasz, D. K., Wohlreich M. M., Detke, M. J., et al. (2008, June). Efficacy and safety of duloxetine for treatment of fibromyalgia in patients with or without major depressive disorders: results from a 6-month, randomized, double-blind, placebo-controlled, fixed-dose trial. Pain, 136(3), 432-44. Epub 2008 Apr 18.

Sayar, K, Aksu, G, Ak, 1, & Tosun, M. (2003). Venlafaxine treatment of fibromyalgia. Ann Pharmacother., 37(11), 1561-5.

Harpriya A. (Sonya) Bhagar, MBBS, is an assistant professor of clinical psychiatry at Indiana University School of Medicine and is a member of the American Psychotherapy Association. She can be reached at hbhagar@iupui.edu.
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