Acute Lower Back Problems in Adults - Antidepressants

Panel findings and recommendations:

• Antidepressant medications are not recommended for the treatment of acute low back problems. (Strength of Evidence = C.)

Antidepressant medications have been widely used for both depressed and nondepressed patients with chronic low back problems. The extent to which these medications are used in treating patients with acute low back problems is unknown. Some researchers have hypothesized that the medications may possibly have a pain–relieving effect in addition to antidepressant properties. If so, the medications could help some patients who have chronic pain whether or not the patients are also depressed. The therapeutic objective of using antidepressant medications for low back problems is to reduce pain.

Literature Reviewed.

Of 18 articles screened, 3 RCTs met review criteria. [125] <http://text.nlm.nih.gov>– [127] <http://text.nlm.nih.gov> Other articles also contained information used by the panel. [128] <http://text.nlm.nih.gov>, [129] <http://text.nlm.nih.gov>

Evidence on Efficacy.

No studies were found evaluating the efficacy of antidepressant medications for treatment of acute low back problems. The three studies reviewed all compared an antidepressant medication to a placebo in a double–blind fashion in patients with chronic, not acute, low back pain. These studies all randomized patients to receive either a pharmacologically inert placebo or an antidepressant medication. Alcoff, Jones, Rust, et al. [125] <http://text.nlm.nih.gov> used imipramine, as did Jenkins, Ebbutt, and Evans. [127] <http://text.nlm.nih.gov> Goodkin, Gullion, and Agras [126] <http://text.nlm.nih.gov> used trazodone. The studies found no significant differences between groups receiving antidepressant and placebo in terms of pain reduction, functional limitations, depression, or the use of opioids. All three studies had methodological flaws, including small sample sizes, lack of power calculations, and incomplete description of followup.

Potential Harms and Costs.

Antidepressant medications can produce a variety of side effects including dry mouth, drowsiness, constipation, urinary retention, orthostatic hypotension, and mania. [128] <http://text.nlm.nih.gov>, [129] <http://text.nlm.nih.gov>
The cost of treatment with antidepressant medications can vary from low to high depending on the medication used, dose, and length of treatment.

Summary of Findings.

No studies were found that evaluated the efficacy of antidepressant medications for treatment of acute low back problems. The studies reviewed all evaluated patients with chronic low back problems. They found no significant differences between antidepressants and placebo on any outcome measured. Numerous reported side effects are associated with antidepressant medications, but the potential for serious side effects is small in otherwise healthy adults.

Bigos S, Bowyer O, Braen G, et al. Acute Low Back Problems in Adults.
Clinical Practice Guideline No. 14. AHCPR Publication No. 95–0642.
Rockville, MD: Agency for Health Care Policy and Research, Public Health
Service, U.S. Department of Health and Human Services. December 1994.