Apologies for not writing in awhile. I’ve been busy.
I ran into a bit of literature recently that I wanted to discuss. It was brought to my attention by a dear lady in my life, my mom.
According to the Archives of General Psychiatry, approximately 27 million Americans were on antidepressants in 2005. (1) That’s roughly 10% of the US population. That up from 13.3 million in 1996. That basically means 1 in 10 people you pass by on the street is on medication for depression. Now there is a meta-analysis discussing how antidepressants seem to fare no better than placebo, meaning that you’re just as good taking a sugar pill as the actual medication, but today I’m going to focus on a different aspect of treatment. One that involves pain.
Pain and depression usually accompany one another. A report from WebMD quote stats that 65% of depressed people also complain of pain.(2) The article explains how some of the neurotransmitters for mood are also used in pain perception and those pathways are probably linked. Many people who have arthritis or back pain are depressed. One very common medication class to treat pain associated with things like arthritis or back pain are the NSAIDS or non-steroidal anti-inflammatory medications. These are better known as Motrin and Advil (ibuprofen), Aleve (naproxen), Celebrex (celecoxib), aspirin and diclofenac. This is not a comprehensive list. I myself take the occasional ibuprofen for headache or bad muscle pain when I overdo it at the gym.
Some of the more common antidepressants used today are Prozac (fluoxetine), Zoloft (sertraline), Celexa (citalopram), and Paxil (paroxetine). These are known as SSRIs or selective serotonin reuptake inhibitors. They work, at least we think they do, by stopping neurons from taking back serotonin in the brain, allowing them more time to work on receptors. Other drugs that have similar effects are amitriptyline, imipramine and desipramine. Cymbalta (duloxetine) and Effexor (venlafaxine) stop serotonin reuptake as well as norepinephrine reuptake. They are known as SNRIs or serotonin-norepinephrine reuptake inhibitors. Makes sense. All of these can be used for depression.
It has been known for some time that the combo of antidepressants such as those listed above while taken with NSAIDS can increase the risk for bleeding in the GI tract. Ulcers have been reported while concomitant use of the medicines is in play. A study that came out earlier last year sheds some light on a new problem that may or may not exist. Apparently according to the results, NSAIDs may decrease the efficacy of depression medication.
A murine study has shown that certain known cytokines (chemicals released from cells to “message” other cells) play a part in depression, or specifically, making you feel normal, whatever that may be. Antidepressant medications apparently need these cytokines for the full effect of combating depression. These cytokines are TNFα, IFNγ, and p11. SSRIs like citalopram increase these cytokines. Ibuprofen decreases these cytokines which the researchers believe lead to inadequate depression treatment. The mice in the study who took both types of drugs continued to have problems with depression, while those that had no NSAIDs seemed to exhibit non-depressed behavior. (3)
This could be a serious complication if a person is taking depression medication and pain medication such as ibuprofen. Pain medication, while helping physical pain, may be diminishing the treatment of mental anguish or depression. I don’t recommend someone stop taking ibuprofen all at once if it is needed. Talking to a competent doctor would be a good start. In some cases, exercise can benefit the pain, especially low impact movement like swimming in a warm pool. And I’m definitely all about movement. Sometimes the movement causes people great pain. Again look to a competent doctor to help with options for managing.
If you or someone you know is taking NSAIDs and antidepressants and are considering halting the use, take careful note to how you react. It is possible that it might take time for any improvement to come. SSRIs usually take up to 6 weeks to show any benefit. If you started an SSRI while already taking an NSAID, you may as well have not been taking it.
I think it’s important to note that these aren’t major placebo controlled trials in humans that we’re dealing with. So I don’t think anyone can say with certainty that this is the case, that NSAIDs stop SSRIs from working. I think what we can say is that more studies are needed and that there is some anecdotal evidence to support the hypothesis. But lets be clear, although the science is backing it up for now, it’s still very much a hypothesis that needs further testing. However, I’m always game for getting rid of meds.
1.Mark Olfson; Steven C. Marcus. National Patterns in Antidepressant Medication Treatment
Arch Gen Psychiatry, Aug 2009; 66: 848 – 856
3. JL Warner-Schmidt et. al. Antidepressant effects of selective serotonin reuptake inhibitors (SSRIs) are attenuated by iantiinflammatory drugs in mice and humans PNAS May 31, 2011 vol. 108 no. 22 9262-9267
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