Evidence of Prescription of Antidepressants for Non-psychiatric Conditions in Primary Care

An Analysis of Guidelines and Systematic Reviews

Alain Mercier; Isabelle Auger-Aubin; Jean-Pierre Lebeau; Matthieu Schuers; Pascal Boulet; Jean-Loup Hermil; Paul Van Royen; Lieve Peremans

Disclosures

BMC Fam Pract. 2013;14(55) 

In This Article

Results

We collected 1,325 documents on 44 conditions. After exclusion, 141 remained. After applying our criteria for data extraction, 78 documents were retrieved, including 36 GLs, 38 reviews or systematic reviews (some followed by a meta-analysis) and 4 RCTs. The guidelines enabled us to describe the evidence for AD prescription for 27 conditions. For 14 conditions, searches in CDSR and PubMed retrieved updated information. For 3 conditions (somatoform disorders, treatment refusal, and patient compliance), no data were found. Among the 44 conditions, ADs were found to be potentially beneficial with a high level of evidence in treating 15 conditions and potentially beneficial with a lower level of evidence in treating 5 others. No proof of benefit was found for 15 conditions and proof of no benefit for 9. All results are detailed in Table 2.

Pain Conditions

All results for pain conditions are described in Table 3.

Neurological Conditions

The guidelines, reviews and RCTs found prescription of sertraline, citalopram and trazodone to be potentially beneficial in treating behavioural perturbations, mood disorders and agitation in patients with dementia, though no level of evidence was available.[40,41] Potential side effects and difficulty in managing the prescription were emphasised.[42] ADs were found to have no specific effects in treating Parkinson's disease, apart from those in treating its associated psychiatric indications.[43]

Concerning stroke, three kinds of problems were assessed: treatment of emotionalism, prevention of depression and the benefit of prescribing an AD in the acute stage to facilitate recovery of motor skills. ADs were recommended for emotional instability (Level B).[44,45] They reduced the frequency and severity of crying and laughing episodes. The effect did not seem specific to one drug or class of drugs. Early prescription prevented depression, but no improvement in its severity was found when depression was actually occurring.[46] Early prescription of fluoxetine with physiotherapy found that patients with ischemic stroke and moderate to severe motor deficit could enhance motor recovery after 3 months.[47]

Antidepressants were found to provide no benefit in treating isolated sleeping disorders and primary insomnia even though they were found to be potentially beneficial in the event of psychiatric comorbidity.[48]

Antidepressants were not recommended for use in cases of restless legs syndrome, which was in fact presented as a side effect of ADs.[49]

As well, there was no evidence of a benefit in prescribing ADs for cases of sialorrhea related to neurological conditions (Amyotrophic lateral sclerosis (ALS), Parkinson's disease), although prescription was sometimes recommended.[50] Antidepressants were found to have no proof of benefit for cases of tinnitus.[51]

Urological and Gynaecological Conditions

Duloxetine was found to have potential benefits as a second-line (Level C) treatment for patients with stress urinary incontinence. Duloxetine significantly improved quality of life but TCAs did not. Anticholinergic agents, such as TCAs, were found to have potential benefits for patients with overactive bladder syndrome.[52–54] Proof of benefit was observed for incontinence caused by other urological conditions. Antidepressants were cited as a potential source of side effects for these conditions.[55]

One Cochrane review attested that all SSRIs were highly effective in reducing symptoms related to severe premenstrual syndrome, (also called pre-menstrual dysphoric disorder or luteal phase dysphoric disorder) (SMD -0.53, 95% CI: 0.68 to -0.39; P < 0.00001) with no level of evidence available.[56] Another Cochrane review reported that SSRIs and SNRIs had a mild to moderate effect in reducing hot flashes during menopause in women with a history of breast cancer, as well as in men with a history of prostate cancer (Level B).[57]

SSRIs were not recommended for erectile dysfunction. They were, however, recommended as a first-line (Level A) treatment for premature ejaculation.[58,59]

Dependence

Nortriptyline was shown to be effective for tobacco withdrawal (OR 2.79 (95% CI: 1.70–4.59) whereas moclobemide, venlafaxine and SSRIs did not show any effectiveness (no level of evidence available).[60] All guidelines and reviews agreed that ADs were not indicated for alcohol misuse or dependence.[61] It is clearly stated that depression is a direct consequence of alcohol abuse, and that AD prescription is useless if the patient does not stop drinking.

General or Non-specific Conditions and General Symptoms

The term "fatigue" pooled together a wide variety of health problems. No data was retrieved for isolated fatigue. In the NICE guideline, ADs were not found to be beneficial in treating chronic fatigue syndrome. ADs were considered as useless for cancer-related fatigue but beneficial in treating depression related to purely physical conditions, with no effect on the physical conditions themselves.[62]

Prescribing an AD provided no benefit for musculoskeletal symptoms, except for fibromyalgia, which is assessed in the "pain conditions" section of the results (see also Table 3).[63] No data was retrieved regarding prescription for unexplained complaints, somatoform disorders, treatment refusal, chronic pruritus, helping type 2 diabetes patients to lose weight, and improving medical adherence or patient compliance.

Gastroenterological Conditions

According to the CDSR, TCAs could be used as a second-line treatment and SSRIs as a third-line treatment, for irritable bowel syndrome (IBS) (no level of evidence available).[64,65]

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