Antidepressants for non-specific low back pain.
BACKGROUND
Antidepressants are commonly used in the management of low-back pain. However, their use is controversial.


OBJECTIVE
The aim of this review was to determine whether antidepressants are more effective than placebo for the treatment of non-specific low-back pain.


METHODS
Randomised controlled trials were identified from MEDLINE and EMBASE (to September 2007), PsycINFO to June 2006, the Cochrane Central Register of Controlled Trials 2006, issue 2, and previous systematic reviews.


METHODS
We included randomised controlled trials that compared antidepressant medication and placebo for patients with non-specific low-back pain, and used at least one clinically relevant outcome measure.


METHODS
Two blinded review authors independently extracted data and assessed the methodological quality of the trials. Meta-analyses were used to examine the effect of antidepressants on pain, depression and function, and the effect of antidepressant type on pain. To account for studies that could not be pooled, additional qualitative analyses were performed using the levels of evidence recommended by the Cochrane Back Review Group.


RESULTS
Ten trials that compared antidepressants with placebo were included in this review. The pooled analyses showed no difference in pain relief (six trials; standardized mean difference (SMD) -0.06 (95% confidence interval (CI) -0.28 to 0.16)) or depression (two trials; SMD 0.06 (95% CI -0.29 to 0.40)) between antidepressant and placebo treatments. The qualitative analyses found conflicting evidence on the effect of antidepressants on pain intensity in chronic low-back pain, and no clear evidence that antidepressants reduce depression in chronic low-back pain patients. Two pooled analyses showed no difference in pain relief between different types of antidepressants and placebo. Our findings were not altered by the sensitivity analyses which varied the level of methodological quality required for inclusion in the meta-analyses to allow data from additional trials to be examined. Two additional trials were identified in September 2007 and await assessment.


CONCLUSIONS
There is no clear evidence that antidepressants are more effective than placebo in the management of patients with chronic low-back pain. These findings do not imply that severely depressed patients with back pain should not be treated with antidepressants; furthermore, there is evidence for their use in other forms of chronic pain.
Urquhart
D M
DM
Monash University - Central and Eastern Clinical School Alfred, Department of Epidemiology and Preventive Medicine, Hospital Commercial Rd Melbourne 3004, Melbourne, Victoria, Australia, 3004. Donna.Urquhart@med.monash.edu.au
Hoving
J L
JL
Assendelft
W W J J
WW
Roland
M
M
van Tulder
M W
MW
D000928:Antidepressive Agents / Q000627:therapeutic use*; D002908:Chronic Disease; D003863:Depression / Q000188:drug therapy; D006801:Humans; D017116:Low Back Pain / Q000188:drug therapy* / Q000523:psychology; D015990:Placebo Effect; D016032:Randomized Controlled Trials as Topic
D000928:Antidepressive Agents