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Antidepressants are often used for chronic pain. Some expert guidelines recommend them for managing low back pain and/or osteoarthritis (OA). In fact, about 1 in 4 people seeking treatment for low back pain are prescribed an antidepressant within 3 months of diagnosis.

Recently, a systematic review of 33 antidepressant trials (with a total of 5,318 participants) evaluated the safety and efficacy of antidepressant use for low back pain (with and without radiculopathy/ sciatica), hip or knee OA, or a combination of both. Many were evaluations of the serotonin-norepinephrine reuptake inhibitor (SNRI) duloxetine (15 trials); and the tricyclic antidepressants (TCAs) amitriptyline, nortriptyline, doxepin, desipramine and imipramine (14 trials).

The main findings were as follows: There was limited evidence of an SNRI benefit (moderate certainty) for reducing pain linked with back pain or knee OA at about 2 weeks through 13 weeks. The authors noted, though, that the effect was actually too small to be considered clinically relevant. SNRIs (with a low to very low level of certainty) were effective short-term (= 2 weeks) for sciatica but did not reduce pain beyond 2 weeks. TCAs (with a low to very low level of certainty) were effective long-term (3- 12 months) for sciatica. The authors added that most of the individual trials that showed a benefit were sponsored by pharmaceutical companies, probably with considerable bias.

SNRIs had a higher risk of any side effect (nausea was most commonly reported); however, the number of studies evaluating the side effects of other antidepressants was too small to detect harm.

Antidepressants are widely used for low back pain including sciatica, and OA; however, this review provided scant evidence to support their use for these indications.


• Ferreira G, et al. BMJ 2021;372:m4825 http://dx.doi.org/10.1136/bmj.m4825


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