Summary: Doctors often use antidepressants for low back pain, especially when non-steroidal anti-inflammatory drugs (NSAIDs) fail. But experts think the evidence for antidepressants in back pain is weak, in both men and women. And most studies showing a benefit were paid for by drug makers. A new systematic review pooled data from 33 clinical studies. It found no solid evidence for using antidepressants for chronic back pain.
Low back pain is one of the top causes of chronic pain and disability. People with low back pain may live with it for a long time. And even when treatment works, the pain often comes back.
The main treatments for low back pain in men and women are NSAIDs and physical therapy. But these do not work for many people. Then doctors have to look at other options.
Studies show that people with low back pain often have many other health problems too. For example, mood and emotional disorders are common in people with low back pain. So it is no surprise that many people with back pain take antidepressants.
Also, most treatment guidelines list antidepressants as one of the treatment options for chronic back pain and even other joint pain. But even with that advice, there is little proof these drugs work.
A new systematic review of 33 clinical trials found little proof that antidepressants help low back pain. Yet doctors still use these drugs widely. That is worrying, because antidepressants have many side effects. So the harm from this approach may well be greater than the benefit.
In the latest systematic review, researchers looked at whether antidepressants help low back pain and osteoarthritis in people whom painkillers did not help. A systematic review is a special study that pools the data from many clinical trials. So its conclusions carry a lot of weight.
The researchers say they did find some benefit from antidepressants. But the odds of benefit were slim, and any benefit was small. For example, antidepressants may help with osteoarthritis. But only one in ten patients can expect to benefit, and only after three or more months of steady use.
Note that many of the studies showing some benefit were paid for by drug makers. So researchers say we need bigger clinical trials that are not funded by industry.
Experts also noted that many of the guidelines on antidepressants rest on old data and studies. And many of those studies have flaws in how they were done.
In this systematic review, researchers included 33 clinical trials with a total of 5000 adults with low back pain, neck pain, sciatica pain, and hip or knee osteoarthritis.
The researchers used a 0–100-point scale to measure how much antidepressants helped back pain. Zero means no pain at all. Researchers say about a 10-point gain on this scale may count as clinically significant (meaningful). But antidepressants beat placebo by only 5.3 points. That gain is just too small to justify regular use of antidepressants for chronic back pain. Even for osteoarthritis, the gain was 9.7, which is barely acceptable.
So the researchers concluded there is not enough proof to justify antidepressants for low back pain.
These are not the first findings like this. Many earlier studies said the same thing: doctors should look at other treatments for chronic low back pain, including options without drugs.
Experts go further. They say most drugs play only a small role in treating chronic back pain, and doctors must understand that. Opioids, cannabis, gabapentinoids and antidepressants are especially disputed, because their harm outweighs their possible benefits.
Frequently asked questions
Do antidepressants help with lower back pain?
Very little. A BMJ systematic review of 33 clinical trials, covering about 5,000 adults, measured pain on a 0 to 100 scale. About a 10-point change counts as meaningful. Antidepressants beat placebo by only 5.3 points for back pain. The researchers concluded there is not enough proof to justify antidepressants for low back pain.
Why do doctors prescribe antidepressants for back pain?
Three reasons. First, the first-line treatments, anti-inflammatory drugs (NSAIDs) and physical therapy, do not work for everyone. So doctors reach for another option. Second, mood and emotional disorders are common in people with low back pain. Third, most treatment guidelines list antidepressants as an option for chronic back pain. But much of that advice rests on old studies. And many of the trials that showed a benefit were paid for by drug makers.
Do antidepressants help with osteoarthritis pain?
A little more than for back pain, but not by much. In the same review, antidepressants eased hip and knee osteoarthritis pain by 9.7 points on the 100-point scale. That is just under the roughly 10 points that counts as meaningful. Only about one patient in ten could expect a benefit, and only after three or more months of steady use.
Dr. Gurpreet Singh Padda, MD, MBA, MHP
