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The management of treatment-resistant depression in disorders on the interface of psychiatry & medicine. Fibromyalgia (FM), Chronic Fatigue Syndrome (CFS), migraine, irritable bowel syndrome, atypical facial pain, & premenstrual dysphoric disorder

  [ 45 votes ]   [ Discuss This Article ]
www.ProHealth.com • June 10, 1996


We have reviewed studies examining the efficacy of various
psychotropic medications, primarily antidepressant agents, in
the treatment of a group of disorders that appear to exhibit
some phenomenologic and genetic relationship to major
depression. These disorders all appear to benefit (albeit to
varying degrees) from antidepressant medications of several
different chemical families. This observation has important
theoretical and clinical implications. From a theoretical
perspective, these results invite the hypothesis that these
various disorders may share some particular etiologic "step"
in common with major depression-and that the various
antidepressant classes benefit these various disorders and
major depression via a common action at this hypothetical
"step". Although there is an appealing parsimony to this
hypothesis, several reservations must be considered. First, it
must be recognized that the quality of the available studies
varies widely. As noted in the text, these studies used
numerous different designs, varying diagnostic criteria for
the disorders under study, and diverse methods of rating
outcome. Interpretation is further complicated by the fact
that many studies included other concomitant medications or
therapeutic interventions in addition to the psychotropic
drugs administered. Also, the dose of antidepressant
medications administered in many of these studies, especially
those using TCAs, was often much less than that normally
administered in the treatment of major depressive disorder
itself. Finally, many of the studies did not systematically
evaluate improvement in both the physical and psychological
symptoms of a given disorder. For all of these reasons, any
theoretic discussion of the results must be tentative.
Nevertheless, the overall tally of results strongly favors the
hypothesis that antidepressant agents, regardless of their
chemical class, are generally useful in the treatment of these
disorders. At a minimum, therefore, we can conclude that
antidepressant treatment in these disorders deserves
aggressive further investigation in studies with modern,
rigorous designs. Second, even allowing that multiple
antidepressant agents are effective in these various
disorders, it still may be premature to conclude that these
disorders are related to major depressive disorder. In
particular, many of the studies found little correlation
between improvement in psychological symptoms and physical
symptoms of a given disorder. This observation would seem to
argue against a relationship with major depressive disorder.
The alternative hypothesis, however, namely, that these
disorders do not share a common etiologic "step," seems even
less attractive. It would be a remarkable coincidence if, say,
fluoxetine possessed an antidepressant property, an
independent antimigraine property, and a third, independent,
antipremenstrual dysphoric disorder property. And it would be
even more peculiar if various other antidepressant medications
chemically unrelated to fluoxetine also, by chance alone,
benefited all of these same disorders via still other
independent mechanisms. Although we cannot, of course, rule
out the possibility of multiple mechanisms and multiple
causes, the experience of scientific research often has been
that the simpler explanation of a phenomenon has proved to be
correct. Therefore, the possibility of a link among these
various antidepressant-responsive disorders deserves
investigation. From a clinical perspective, too, these results
are important. They suggest that trials of antidepressant
medications should be strongly considered in patients with
these disorders. Furthermore, other types of psychotropic
medication appear to have a role in the treatment of
individual disorders, as discussed in the corresponding
sections. In summary, the management of patients with
fibromyalgia, chronic fatigue syndrome, migraine, irritable
bowel syndrome, atypical facial pain, and premenstrual
dysphoric disorder is often d [References: 79]

Gruber AJ, Hudson JI, Pope HG Jr




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