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The Pharmaceutical Journal Vol 272 No 7290 p311 13 March 2004	This article Reprint Photocopy
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POEM (Patient-Oriented Evidence that Matters)

Tricyclics, not SSRIs, effective for chronic back pain
POEM series

Clinical question Are antidepressants effective in the management of chronic low back pain?

Bottom line Tricyclic and tetracyclic antidepressants that inhibit noradrenaline reuptake appear to produce moderate symptom reductions for patients with chronic low back pain. Selective serotonin reuptake inhibitors do not appear to benefit patients with chronic low back pain. None of the antidepressants seems to have much effect on functional status.

Synopsis The authors systematically reviewed several databases looking for randomised placebo-controlled trials of oral antidepressants in managing chronic low back pain. They included studies designed to assess the treatment of multiple medical conditions if there were sufficient data to assess treatment effect on the subset with back pain. They included non-English publications. Two reviewers extracted the data, but they do not report on how discrepancies were resolved or on the degree of agreement between the reviewers. Additionally, they developed a 22-point methodological quality-rating scale based on criteria from the Cochrane Collaboration Back Review Group and the old Agency for Health Care Policy and Research guidelines. Disagreements on the assignment of quality were resolved through consensus. The authors identified 22 trials, but excluded 15: nine lacked a placebo, three used parenteral antidepressants, two included neck and back pain without sufficient detail to extract the back pain data, and one was so poorly reported that no baseline pain data and no denominator data were available. The seven finalists included only patients with chronic low back pain. One was a placebo-controlled study of two antidepressants. The methodological quality scores ranged from 11 to 19. Five trials evaluated noradrenaline reuptake inhibitors (amitriptyline, nortryptiline, maprotiline, imipramine). Using different assessment techniques, four reported decreases in pain, although the decreases may not have been clinically important. Only one of these studies found any effect on function. The studies using antidepressants that do not inhibit noradrenaline reuptake (paroxetine, trazodone) had negligible effects on pain or function.

Level of evidence 1a (systematic review, with homogeneity, of randomised controlled trials).

Reference Staiger TO, Gaster B, Sullivan MD, Deyo RA. Systematic review of antidepressants in the treatment of chronic low back pain. Spine 2003;28:2540–45