Treating Pain in Depressive Patients with Duloxetine

Migraine or depression, what comes first? Many of us have both but, would we be able to answer this "chicken or the egg" question? It might be harder than you think.

The easy answer would be - "Yah, I've got a migraine. It's an incurable disease. Of course I am depressed about it." Thus, migraine is first.

Those who had depression before migraine hit them would object. "I have a depression, it's a disease, migraine's just a symptom." Here, depression is first.

Many won't even be able to pinpoint what came first. Curiously enough, some of the underlying physiological mechanisms are similar - low serotonin levels, magnesium/calcium deficiencies, etc.

No wonder migraines and depression oft walk hand in hand.

However, for those of us who have depression as a primary concern with the pain that follows, there's some good news.

Well, may be not so good since you'll have to take a powerful antidepressant with serious side-effects but at least the pain could be reduced.

A new study to evaluate the efficacy of duloxetine in treating painful physical symptoms that occur along with depression was reported by Juan Castaño, MD, Primary Psychiatric Unit, IAPS, Hospital del Mar, Barcelona, Spain, and colleagues.

They tested a theory that certain antidepressants reduce pain via a wide variety of actions on the neuroregulatory mechanisms associated with pain perception and transmission:

"Serotonin and norepinephrine play a key modulating role in pain mechanisms in the central nervous system. Drugs like duloxetine, which inhibit the reuptake of these 2 neurotransmitters, are thought to reduce the nociceptive afferent transmission in the ascending spinal pathways."

In other words: Serotonin and norepinephrine are neurotransmitters , chemicals that relay, amplify and modulate signals between cells in the nervous system. Duloxetine and some other antidepressants make sure that both of those neurotransmitters stay in the bloodstream because these chemicals have the capacity to scale down a "pain" response of our bodies.

All the patients who participated in the study had chronic pain. Most frequently reported pain was in the back followed by the neck and limbs.

Unfortunately, arthritis, fibromyalgia, and migraine headache patients were excluded from this experiment. It does not, however, means that people with depression who suffer from migraine or tension headaches won't benefit from similar treatment. It was done, most likely, for the reasons outlined above - it's hard to tell what came first, depression or a migraine.

The total response concerning depression, including remissions, was 67.5% with a duloxetine dosage of 60 mg QD. With duloxetine 120 mg QD, the estimated probability of remission was 65%. In terms of pain, the total response was 57% of the patients.

A drug working for more than half of people who take it is not such a bad result for medicine as we know it. It's a better than 50/50 chance that duloxetine will help in treatment of both pain and depression.

However, as Dr. Castano points out, the pain is not just in your head - when it hurts, it hurts. "Further studies will be required to understand the treatment of major depression in patients with coexisting pain symptoms to a greater extent. The depressive response alone does not explain the pain response."

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link: Duloxetine Effectively Reduces Concomitant Pain in Depressive Patients: Presented at ECNP