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Document: 28
Do antidepressant medications relieve chronic low back pain?
Turner J A, Denny M C.
Do antidepressant medications relieve chronic low back pain?
Journal of Family Practice,
1993,
37(6),
pp.545-553
Record status
This record is a structured abstract written by CRD reviewers. The original
has met a set of quality criteria.
Author's objective
1. Whether antidepressant medications, as a group, are more effective than
placebo in decreasing pain, disability, depression, and analgesic medication
use in low back pain. 2. Whether the analgesic effects of antidepressant
medications are independent of their antidepressant effects. Type of
intervention
Treatment.
Specific interventions included in the review
Use of antidepressant medications to relieve low back pain.
Participants included in the review
People with low back pain.
Outcomes assessed in the review
Level of pain (visual analogue scale), depressive symptoms (Beck Depression
Inventory, Hamilton Depression Rating Scale), level of pain intensity and
disability, duration of pain.
Study designs of evaluations included in the review
Controlled trials and comparison studies.
What sources were searched to identify primary studies?
Medline (1966 - December 1992), PsycLIT (1967 - December 1992) were searched
on the following terms: antidepressive agents, antidepressants (using the
names of specific antidepressant medications) chronic pain, low back pain and
backache. Articles were also identified from the bibliographies of articles
and book chapters, and from inquiries to pharmaceutical companies and several
expert researchers in the field.
Criteria on which the validity (or quality) of studies was assessed
Studies were included if they reported data from placebo- controlled or drug
comparison trials evaluating antidepressant medication in samples consisting
exclusively of people with low back pain.
How were the judgements of validity (or quality) made?
Not stated.
How were decisions on the relevence of primary studies made?
Not stated.
How was the data extracted from primary studies?
A standardised coding form was developed. Each article was read independently
by two clinical psychologist clinician-researchers. Disagreements were
discussed until a consensus was reached.
Number of studies included
6 in total:
3 studies were randomised placebo-controlled trials; 1 study used a cross-over
design with randomly assigned treatment-placebo sequences; 2 studies were
uncontrolled and compared two antidepressants, the second of which was an
extension of the first and included the data of the first study.
How were the studies combined?
Narrative review - no combination was done.
How were differences between studies investigated?
Differences between subject characteristics, antidepressant medication(s)
studied, dosage, study design, and measures were identified. The quality of
the studies were also compared.
Results of the review
Effectiveness of antidepressant medication in low back pain:
Only two studies reported on the relation between blood levels of medication
and pain symptoms; one found no linear relation between imipramine blood
levels and patient symptoms, and the other found that increased trazodone
blood level was correlated with increased pain. Three studies examined the
difference between antidepressant medication and placebo in decreasing
functional disability - only one found the antidepressant medication to be
superior as measured by patients' self-report, but no significant differences
as evaluated by the clinical investigators. One study found placebo superior
to trazodone, and the third found no difference between amitriptyline and an
active placebo. Looking at the difference between antidepressant medication
and placebo in decreasing depression, three studies found no difference in
patients with varying levels of depressive symptoms (although these studies
also included some patients who were not depressed). One study of patients who
were all clinically depressed found doxepin and desipramine were associated
with significant improvement in depression. Three studies looked at the
difference between antidepressant medication and placebo in decreasing
analgesic medication use. One study found amitriptyline to be superior to
atropine placebo. Two other studies found no difference between medication
and inert placebo.
Association between analgesic and antidepressant effects:
Only two studies examined whether changes in depression correlated
significantly with changes in pain. One study reported a trend, but did not
state which pain and depression measures were used. The second study
(including data from the first) reported a significant association (measured
on the Hamilton Depression Rating Scale and a pain severity scale of 0 to 10).
In no study was outcome clearly assessed independently of the treating
clinician. No study reported the results of power calculations, and all
studies had fairly small samples, Attrition rates were high in all studies
except one. Only one study attempted to obtain and analyse outcome data for
all patients who began the study regardless of compliance.
Was any cost information reported?
No.
Author's conclusions
The literature does not demonstrate the superiority of antidepressant
medication over placebo in decreasing low back pain or associated disability
and depression. There is no convincing scientific evidence supporting the use
of antidepressant medication for low back pain relief, but the literature does
not conclusively demonstrate that antidepressants have no specific effects on
low back pain, disability and associated problems. Further randomised,
placebo-controlled, double-blind studies are clearly needed to assess the
efficacy and effectiveness of different antidepressant medications, at
different dosages, compared with one another and with placebo.
CRD commentary
A sensible and thorough review, with a good appraisal of the quality and
methodology of the studies. The review identifies the lack of quality studies
and highlights the need for further high quality research to enable
quantitative synthesis.
What are the implications of the review?
There is a lack of scientific support for the pain-relieving properties of
antidepressants.
Subject index terms
Subject Indexing from the National Library of medicine: Analgesics/tu
[Therapeutic Use]; Antidepressive-Agents/tu [Therapeutic Use];
Low-Back-Pain/dt [Drug Therapy]; Chronic-Disease; Depression/dt [Drug
Therapy]; Placebos-; Randomized-Controlled-Trials; Comparative-Study; Human;
Support,-U.S.-Gov't,-P.H.S.
Correspondence address
Judith A. Turner, PhD, Department of Psychiatry and Behavioral Sciences RP-10,
University of Washington School of Medicine, Seattle, WA 98195, USA.
Copyright
University of York, 1998
Database no.: DARE-940185
