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Gastroenterology Ask the Expert

Use of Antidepressants in the Treatment of IBS?

Posted 04/08/2003 from Medscape Gastroenterology

Question
When is it recommended to start antidepressant therapy in patients with irritable bowel syndrome (IBS)? Which is the preferred approach: tricyclic antidepressants or selective serotonin reuptake inhibitors (SSRIs)?

Amir Belson, MD

Response
from Yehuda Ringel, MD, 04/08/2003

The treatment approach in patients with IBS is usually guided by the predominant symptoms (ie, pain, diarrhea, or constipation) as well as the severity of the disorder.

Most patients with IBS have mild and infrequent symptoms with no, or only little, associated disability. These patients do not usually need antidepressants. Reassurance, education, recommendations for dietary changes, and short-term symptomatic treatment are sufficient in most of these cases. Patients who have moderate or severe symptoms that considerably affect their daily activities and quality of life may require additional pharmacologic treatments, including psychopharmacologic (eg, antidepressants) and/or psychological and behavioral therapies.[1]

The rationale for the use of antidepressants in IBS is the coexistence of psychological disturbances, particularly in patients with more severe symptoms who seek medical care, and their effect/action on reducing gut sensation. The latter neuromodulatory analgesic effect of these agents is unrelated to their psychotropic effects. Thus, antidepressants can be used in IBS patients with or without psychiatric comorbidity (eg, depression, anxiety).

A recent meta-analysis of 12 studies concluded that antidepressants are effective in IBS patients. On average, 3.2 patients need to be treated to achieve 1 positive response in a patient's symptoms.[2] Tricyclic antidepressants have been best studied in IBS patients with pain and diarrhea. Low doses of desipramine (50-100 mg) or amitriptyline (25-75 mg) appear to be effective in controlling IBS symptoms in these patients. Although data on SSRIs are still limited, the current information suggests a beneficial effect. SSRIs may be preferred in older patients or in those with constipation because they have little or no anticholinergic effects.[1]

Long-term adverse effects are common with antidepressant treatment and relate to the anticholinergic, serotonergic, sedative antihistaminic, and alpha-adrenergic effects. These effects must be considered in choosing the treatment approach. In addition, because psychotropic agents also affect intestinal motility,[3] the patient's bowel function should also be considered when selecting an antidepressant medication.

Finally, because the disorder is multidetermined, it is important to view medication therapy as part of a more comprehensive management plan in the setting of IBS.[4]

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References
Drossman DA, Camilleri M, Mayer EA, Whitehead WE. AGA technical review on irritable bowel syndrome. Gastroenterology. 2002;123:2108-2131. Abstract
Jackson JL, O'Malley PG, Tomkins G, Balden E, Santoro J, Kroenke K. Treatment of functional gastrointestinal disorders with antidepressant medications: a meta-analysis. Am J Med. 2000;108:65-72. Abstract
Chial HJ, Camilleri M, Burton D, Thomforde G, Olden KW, Stephens D. Selective effects of serotonergic psychoactive agents on gastrointestinal functions in health. Am J Physiol Gastrointest Liver Physiol. 2003;284:G130-G137. Abstract
Ringel Y, Drossman DA. Psychosocial factors in functional gastrointestinal disorders: Toward a more comprehensive understanding and approach to treatment. Medscape Conference Coverage, Digestive Disease Week 2001; Medscape Gastroenterology, 2001. Available at: http://www.medscape.com/viewarticle/418547 Accessed April 3, 2003.
About the Panel Members
Yehuda Ringel, MD, Assistant Professor, Department of Medicine, University of North Carolina at Chapel Hill; Attending Physician, Department of Digestive Diseases and Nutrition, University of North Carolina Hospitals, Chapel Hill

Medscape Gastroenterology 5(1), 2003. � 2003 Medscape

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