Antidepressant Pharmacotherapy: Considerations for the Pain Clinician

Abstract

Antidepressant pharmacotherapy presents many challenges to clinicians dealing with patients suffering from chronic pain. Co-existent depression and pain continues to present clinicians with a plethora of difficult treatment selections. Treated in isolation, each of these disease states can prove difficult to treat. Collectively, depression and pain often present significantly more difficult challenges to the clinician. Antidepressants may be used as a primary treatment modality for depression in a patient dealing with chronic pain. At other times these agents may be used to treat certain specific chronic pain syndromes, possibly in the face of concomitant depression. Clinicians should be aware of the many peculiarities associated with this broad class of medications. Included in this review are considerations for drug selection, dose escalation, and common drug related problems (eg, adverse drug reactions). In addition, attention is paid to the appropriate selection of an agent for use in either the primary management of pain or depression.

Mirtazapine improves sleep and lowers anxiety and depression in cancer patients: superiority over imipramine

“…In the present study, the mirtazapine group did not report any significant difference in analgesic effect when compared with the imipramine and control groups. Depression and pain have a reciprocal relationship, which means that decreased depressive symptom severity also causes a decreased degree of pain [8,19]. Although the significant decrease in severity of depression and anxiety was found, the non-significant decrease in pain degree in our study may have been due to the small sample size or analgesic use.…”

“…Among the 145 patients, 19 were not included in the study. Of the 126 that remained, 53 (42%) diagnosed with major depressive disorder, adjustment disorder, and/or anxiety disorders such as generalized anxiety disorder and panic disorder were included in the study.…”

Neuropathic Pain in Multiple Sclerosis–Current Therapeutic Intervention and Future Treatment Perspectives

“…TCAs are the most studied and clinically used antidepressants for the treatment of neuropathic pain (65). They can be divided into two major groups: tertiary amines, for example, doxepin, imipramine, and amitriptyline, and secondary amines, for example, nortriptyline and desipramine (66).…”

“…However, the use of SSRIs for the treatment of neuropathic pain seems to be less effective than other antidepressants and the number of clinical studies is limited (67). Paroxetine and citalopram, for example, showed just a modest activity for pain management, whereas fluoxetine had no therapeutic activity on pain at all (65). This leads to the assumption that noradrenaline reuptake inhibition is the major underlying mechanism of the analgesic efficacy of TCAs.…”

“…Interestingly, low doses mainly impact serotonin and high doses mainly affect norepinephrine (32). Case reports and empirical studies indicate that venlafaxine can be clinically used to treat neuropathic pain, and its efficacy is comparable to TCAs (65). In general, venlafaxine use may lead to increased blood pressure and has a discontinuation syndrome with abrupt cessation.…”