Antidepressants are effective against most fibromyalgia symptoms, a meta-analysis of clinical trials reports.

Researchers at the Klinikum Saarbrücken in Germany reviewed 18 randomized, controlled trials published between 1966 and 2008. Ranging in duration from four to 28 weeks, they involved a total of 1,427 patients for a median of eight weeks (JAMA. 2009;301:198-209).

Results revealed strong evidence associating antidepressants with reduction of pain, fatigue, depressed mood, and sleep disturbances, as well as with an improved health-related quality of life.

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But the magnitude of effect varied with the class of drug. For example, pain reductions were large for tricyclic and tetracyclic antidepressants (TCAs), medium for monoamine oxidase inhibitors, and small for both selective serotonin reuptake inhibitors and serotonin and norepinephrine reuptake inhibitors (SNRIs).

Only two drugs in the analysis, duloxetine (Cymbalta) and milnacipran (Savella) have FDA approval for fibromyalgia treatment. Both are SNRIs, but the researchers also see a role for the generic TCA amitriptyline. “Short-term use of amitriptyline and duloxetine can be considered for the treatment of pain and sleep disturbances,” they write. “This recommendation is based on the number of patients studied (duloxetine) and on the effect sizes (amitriptyline).”

However, “since evidence for a long-term effect of antidepressants in fibromyalgia is still lacking, their effects should be re-evaluated at regular intervals to determine whether benefits outweigh adverse effects,” the researchers warn.