Psychotropics, Antidepressants, and Visceral Analgesics in Functional Gastrointestinal Disorders

Abstract

Purpose of ReviewThe functional gastrointestinal disorders, or disorders of gut-brain interaction as defined by the Rome IV criteria, are the most common diagnostic entities in gastroenterology. Treatments that address the dysregulation of gut-brain interaction with these disorders are increasingly gaining interest as a better option than for example traditional analgesics, particularly opioids. Antidepressants, antianxiety and antipsychotic medications, and visceral analgesics, now termed neuromodulators, are included in this update addressing the evidence of treatment benefit in disorders of brain-gut interaction.Recent FindingsBy a careful selection based on a multidimensional clinical profile, a decreased symptom burden, particularly regarding abdominal pain, nausea, and vomiting, as well as improved social function and quality of life, can be obtained by use of neuromodulators. There is good evidence for the peripheral neuromodulators from studies in bowel disorders, and the central neuromodulators both from indirect evidence in chronic pain disorders as well as selected disorders of brain-gut interaction.SummaryBasic knowledge about the pharmacologic properties and clinical use of neuromodulators in disorders of brain-gut interaction improves the treatment outcome and avoids use of traditional analgesics.

Reduction in IBS symptom severity is not paralleled by improvement in quality of life in patients with irritable bowel syndrome

“…By following their five‐step approach, clinicians can identify if and which psychological factors contribute to the disease burden in the individual patient and consider psychological treatments. In some patients, this might include the use of pharmacological neuromodulators, but other therapy options include cognitive behavioral therapy (CBT), gut‐directed hypnotherapy, and dynamic psychotherapy . Due to the relative lack in therapist availability, clinical implementation of these therapies is still limited.…”

Marshall and Warren Lecture 2019: A paradigm shift in pathophysiological basis of irritable bowel syndrome and its implication on treatment

“… 3, 68, 69 In fact, as can be seen from Tables 2 and 3, most of these agents used in the treatment of IBS target peripheral rather than central mechanisms of the disease. The psychopharmacological agents used in the treatment of IBS such as tricyclic antidepressants, serotonin reuptake inhibitors, and serotonin nor‐epinephrine reuptake inhibitors, believed to target the central mechanisms, also work peripherally, and hence, these have been renamed as visceral neuromodulators when used in the treatment of FGIDs 9 . In fact, these agents have prominent anticholinergic and serotonin modulatory activities at the level of enteric nervous system, work at a dose much lower than that used in the psychiatric disorders, and are known to work even in absence of psychological comorbidity in patients with FGIDs 9 .…”

“…However, most started inappropriately interpret the term “functional” as idiopathic or cryptogenic; unfortunately, the patients suffering from this illness were labeled as neurotic, apprehensive, otherwise healthy individuals with an imaginary illness 3 . The psychogenic origin of the condition is largely based on the uncontrolled or case–control studies that showed that the patients with IBS, particularly those with severe symptoms often have more psychological and psychiatric comorbidities and on the fact that these patients also respond to treatment with psychotropic agents though some studies did show IBS including postinfection IBS (PI‐IBS) to develop more often among patients with anxiety and depression 7–9 . However, IBS is a multifactorial condition, and the existing evidences are not enough to incriminate psychological comorbidity to be uniformly the cause for all patients with IBS.…”

“…In fact, association does not prove causation, and patients with any chronic illness are expected to develop psychological comorbidities as compared with the healthy controls. Moreover, patients with IBS respond to much lower doses of the psychotropic drugs, and these drugs not only work in the big brain but also on the little brain present in the gut (the enteric nervous system) 9 . Hence, these evidences are far from enough to label IBS as psychogenic only.…”

“…Hence, these evidences are far from enough to label IBS as psychogenic only. In fact, currently, the psychotropic agents are also classified as visceral neuromodulators when used in patients with FGIDs 9 . A recent study showed that patients with IBS without psychological morbidities develop it during long‐term follow‐up in a frequency similar to development of FGIDs during long‐term follow‐up of patients with psychological conditions 10 .…”