Summary: Doctors are using more and more antidepressants for chronic pain like low back pain and osteoarthritis. The rise is alarming. Even many medical guidelines recommend them. But researchers say most of the proof for these drugs comes from trials paid for by drug makers. Some open, honest studies from recent years found little benefit from antidepressants for back pain and osteoarthritis.
In the 1960s, antidepressants were seen as orphan drugs, meaning drugs for a few rare conditions. Over the decades, that changed a lot. Now doctors seem to use antidepressants for many conditions, not just mood disorders.
Doctors widely prescribe antidepressants for pain, nerve problems, headaches, arthritis, low back pain and more. But researchers warn that there is not enough proof these drugs work for many of these conditions. And these are highly toxic drugs with many side effects.
CDC data shows that in the last 30 days, 13-14% of adults used antidepressants, rising to almost 25% for women older than 60. Remember, those numbers cover just the last 30 days, not a whole year. Yes, the numbers are worrying. They show how often doctors prescribe these drugs.
So most adults will be prescribed antidepressants for some reason during their life. What is worrying is that doctors often prescribe them for conditions where they do not seem to work.
Sadly, many medical guidelines also say to use antidepressants for pain when other common painkillers fail.
Do antidepressants help back pain and osteoarthritis?
One new and very large study found no benefit from antidepressants for back pain and osteoarthritis. These two are the top causes of chronic pain in middle-aged and older adults. So they are one reason so many people get antidepressants.
This study was published in the journal BMJ. It looked at every clinical study on antidepressants for low back or neck pain, sciatica, and knee or hip osteoarthritis.
This systematic review included 33 randomized clinical trials with a total of 5318 people. It found weak proof that some antidepressants, like SNRIs (serotonin-noradrenaline reuptake inhibitors), eased back pain. The proof for antidepressants in osteoarthritis was even weaker. And antidepressants do not seem to help sciatica.
The study concluded that antidepressants seem to do very little for low back pain or osteoarthritis. And given how toxic these drugs are, it is hard to justify using them for these conditions.
And how well a drug works is not the only thing to weigh. These drugs cause nausea, fatigue, mood problems, weight gain and many other side effects. The long-term harm could be even greater.
Why do guidelines still recommend antidepressants for pain?
Studies show mild proof that antidepressants help these common painful conditions, so many guidelines recommend them. That is why other factors matter, such as the fact that drug makers paid for many of these trials.
Trials paid for by drug makers carry bias, no matter how well they are run. Even a little bias can significantly change a study’s results.
Also, very few studies have checked the safety of using antidepressants for these pains over the long term. Yet low back pain and osteoarthritis need long treatment, sometimes with drugs for life.
So experts say we urgently need open trials free of drug-maker influence. Those trials would show whether antidepressants have any role in these chronic painful conditions. Until then, trials paid for by drug makers should count for less.
Even more worrying is the rising use of antidepressants in children and young adults. The US FDA approved duloxetine for fibromyalgia in kids and teens. But the drug can cause serious side effects like hallucinations, suicidal thoughts and more. The drug maker has intentionally downplayed the risk of these side effects.
In short, antidepressants may do little for back pain and osteoarthritis. And they carry a risk of severe side effects. Right now, most proof for these drugs comes from trials paid for by drug makers, which tend to be biased. We urgently need open studies to learn what antidepressants can and cannot do for different health conditions.
Frequently asked questions
What antidepressant helps with back pain?
No antidepressant has strong proof behind it for back pain. A review in the BMJ pooled 33 randomized trials with 5,318 people. It found only weak proof that SNRIs, the serotonin-noradrenaline reuptake inhibitors, eased back pain. It concluded the benefit was very small. Given the side effects, using these drugs for low back pain is hard to justify.
Which antidepressant is best for arthritis pain?
None stands out. The same BMJ review looked at knee and hip osteoarthritis. It found even weaker proof for antidepressants there than for back pain. Its conclusion was that these drugs do very little for osteoarthritis. Osteoarthritis needs long-term treatment, and there are very few long-term safety studies. So the case for taking them for arthritis pain is thin.
Do antidepressants help sciatica?
They do not seem to. The BMJ review of 33 randomized trials included sciatica, along with low back pain, neck pain and osteoarthritis. Antidepressants did not seem to help sciatica. That matters, because many people with nerve pain running down the leg are offered an antidepressant when common painkillers fail. The trial proof does not back it up.
Why are people hesitant to take antidepressants for pain?
Because the trade-off is poor. These drugs cause nausea, fatigue, mood problems and weight gain, and long-term harm may be greater still. Duloxetine, approved in the US for fibromyalgia in kids and teens, can cause hallucinations and suicidal thoughts. Much of the proof for antidepressants in pain comes from trials paid for by drug makers. And very few studies have checked safety over years of use.
Dr. Gurpreet Singh Padda, MD, MBA, MHP
