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SUBSCRIBE: eNewsletter

Identifying and Treating Common Psychiatric Conditions Comorbid with Myalgic Encephalomyelitis and/or Fibromyalgia: Page 3 of 4

  • Eleanor Stein, MD
Jan 19, 2013
Volume: 
30
Issue: 
1
  • Comorbidity In Psychiatry

Low doses of sedating antidepressants are commonly used off-label in both ME and FM to improve sleep initiation and duration.23,24 It should be noted that the effect sizes of antidepressant effects in FM are small and “a remarkable number of patients drop out of therapy because of intolerable adverse effects or experience only a small relief of symptoms, which does not outweigh the adverse effects.”21 Symptomatic management remains the mainstay of treatment.25,26

In patients with ME or FM, psychotropic medication is indicated if the psychiatric symptoms are severe enough to interfere with hope, sleep, and/or self-management. For example, a person may be so hopeless that he or she does not have the motivation to make the lifestyle changes that would improve pain and other symptoms. Psychiatric medications work best in patients with comorbid psychiatric conditions and less well when anxiety or depressive symptoms, which are reactions to adverse life events, are coincident with the ME or FM. For the comorbid group, one treats the same as for any other psychiatric patient, using current treatment guidelines. All classes of drugs, including antipsychotics, antidepressants, and mood stabilizers, are appropriate, depending on the diagnosis.

Anticonvulsants such as lamotrigine and topiramate can be helpful as mood stabilizers and because of their antinociceptive effects. Although pregabalin is effective for FM pain, gabapentin is less so. Neither has significant psychotropic properties but can be useful as a sleep aid. Buspirone is an option as an anxiolytic, but effectiveness is modest.

Because of adverse effects (eg, tolerance, withdrawal symptoms), I avoid use of benzodiazepines except in cases of severe anxiety or muscle spasm that has failed to respond to other treatment approaches. Benzodiazepines are a last choice for treatment of ME and FM.

It is accepted (though not proved) that in patients with ME and FM, psychotropic medications usually need to be started at lower doses than those tolerated by physically healthy patients. In some patients, usual therapeutic doses can be reached; in other patients, full dose is not possible because of the severity of adverse effects. Some patients are unable to tolerate any antidepressant. For these patients, there are a couple of nonpharmacological approaches that may, with care, be used alone or to augment antidepressant effects.

Eicosopentanoic acid (EPA). EPA is an omega-3 fatty acid found in fish oil. A recent meta-analysis shows that EPA is an effective treatment for MDD at dosages of 200 to 2000 mg/d.27 A recent study reported that EPA is equally as effective as fluoxetine.28 In my experience, relatively high dosages of EPA, at least 4000 mg/d, are necessary for robust antidepressant effect. EPA is not effective for anxiety. Checking the Web site of the International Fish Oil Standards Program is advised to ensure that a fish oil product meets purity standards.29

St John’s wort. This herbal remedy has strong SSRI properties and has been found to be equally as effective as SSRI drugs in treating MDD.30,31 St John’s wort is taken as a standardized 0.3% extract of hypericin 300 mg by mouth 3 times daily. It should be noted, however, that St John’s wort has many adverse effects and a long list of drugs and other herbal supplements with which it can interact adversely. In combination with other antidepressants or neurotransmitter precursors, serotonin syndrome can occur.

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References: 

References

1. Carruthers BM, Jain AK, De Meirleir K, et al. Myalgic encephalomyelitis/chronic fatigue syndrome: clinical working case definition diagnostic and treatment protocols: a consensus document. J Chronic Fatigue Syndr. 2003;11:7-115.
2. Arnow BA, Hunkeler EM, Blasey CM, et al. Comorbid depression, chronic pain, and disability in primary care. Psychosom Med. 2006;68:262-268.
3. Wolfe F, Clauw DJ, Fitzcharles MA, et al. The American College of Rheumatology preliminary diagnostic criteria for fibromyalgia and measurement of symptom severity. Arthritis Care Res (Hoboken). 2010;62:600-610.
4. Fuller-Thomson E, Nimigon J. Factors associated with depression among individuals with chronic fatigue syndrome: findings from a nationally representative survey. Fam Pract. 2008;25:414-422.
5. Nater UM, Lin JM, Maloney EM, et al. Psychiatric comorbidity in persons with chronic fatigue syndrome identified from the Georgia population. Psychosom Med. 2009;71:557-565.
6. Hickie I, Lloyd A, Wakefield D, Parker G. The psychiatric status of patients with the chronic fatigue syndrome. Br J Psychiatry.1990;156:534-540.
7. Jason LA, Evans M, Brown A, et al. Sensitivity and specificity of the CDC empirical chronic fatigue syndrome case definition. Psychology.2010;1:9-16.
8. Courjaret J, Schotte CK, Wijnants H, et al. Chronic fatigue syndrome and DSM-IV personality disorders. J Psychosom Res.2009;66:13-20.
9. Nater UM, Jones JF, Lin JM, et al. Personality features and personality disorders in chronic fatigue syndrome: a population-based study. Psychother Psychosom.2010;79:312-318.
10. Fietta P, Fietta P, Manganelli P. Fibromyalgia and psychiatric disorders. Acta Biomed.2007;78:88-95.
11. Thieme K, Turk DC, Flor H. Comorbid depression and anxiety in fibromyalgia syndrome: relationship to somatic and psychosocial variables. Psychosom Med.2004;66:837-844.
12. Arnold LM, Hudson JI, Hess EV, et al. Family study of fibromyalgia. Arthritis Rheum.2004;50:944-952.
13. Raphael KG, Janal MN, Nayak S, et al. Psychiatric comorbidities in a community sample of women with fibromyalgia. Pain.2006;124:117-125.
14. Gracely RH, Ceko M, Bushnell MC. Fibromyalgia and depression. Pain Res Treat.2012;2012:486590. Epub 2011 Nov 19.
15. Pae CU, Luyten P, Marks DM, et al. The relationship between fibromyalgia and major depressive disorder: a comprehensive review. Curr Med Res Opin. 2008;24:2359-2371.
16. Stein E. Let Your Light Shine Through. http://eleanorsteinmd.ca. Accessed December 5, 2012.
17. White PD, Goldsmith KA, Johnson AL, et al; PACE Trial Management Group. Comparison of adaptive pacing therapy, cognitive behaviour therapy, graded exercise therapy, and specialist medical care for chronic fatigue syndrome (PACE): a randomised trial. Lancet. 2011;377:823-836.
18. Lorig KR, Sobel DS, Ritter PL, et al. Effect of a self-management program on patients with chronic disease. Eff Clin Pract. 2001;4:256-262.
19. Vercoulen JH, Swanink CM, Zitman FG, et al. Randomised, double-blind, placebo-controlled study of fluoxetine in chronic fatigue syndrome. Lancet. 1996;347:858-861.
20. Wearden AJ, Morriss RK, Mullis R, et al. Randomised, double-blind, placebo-controlled treatment trial of fluoxetine and graded exercise for chronic fatigue syndrome [published correction appears in Br J Psychiatry. 1998;173:89]. Br J Psychiatry. 1998;172:485-490.
21. Häuser W, Wolfe F, Tölle T, et al. The role of antidepressants in the management of fibromyalgia syndrome: a systematic review and meta-analysis. CNS Drugs. 2012;26:297-307.
22. Arnold LM, Rosen A, Pritchett YL, et al. A randomized, double-blind, placebo-controlled trial of duloxetine in the treatment of women with fibromyalgia with or without major depressive disorder. Pain. 2005;119:5-15.
23. Nishishinya B, Urrútia G, Walitt B, et al. Amitriptyline in the treatment of fibromyalgia: a systematic review of its efficacy. Rheumatology (Oxford).2008;47:1741-1746.
24. Fisher MM, Rose M. Anaesthesia for patients with idiopathic environmental intolerance and chronic fatigue syndrome. Br J Anaesth. 2008;101:486-491.
25. Fitzcharles MA, Ste-Marie PA, Goldenberg D, et al. 2012 Canadian Guidelines for the Diagnosis and Management of Fibromyalgia Syndrome. Oshawa, Ontario: Canadian Pain Society; 2012:1-44.
26. Sublette ME, Ellis SP, Geant AL, Mann JJ. Meta-analysis of the effects of eicosapentaenoic acid (EPA) in clinical trials in depression. J Clin Psychiatry. 2011;72:1577-1584.
27. Jazayeri S, Tehrani-Doost M, Keshavarz SA, et al. Comparison of therapeutic effects of omega-3 fatty acid eicosapentaenoic acid and fluoxetine, separately and in combination, in major depressive disorder. Aust N Z J Psychiatry. 2008;42:192-198.
28. The International Fish Oil Standard Program. http://www.ifosprogram.com/industry-home. Accessed December 5, 2012.
29. Linde K, Berner MM, Kriston L. St John’s wort for major depression. Cochrane Database Syst Rev. 2008;(4):CD000448.
30. Rahimi R, Nikfar S, Abdollahi M. Efficacy and tolerability of Hypericum perforatum in major depressive disorder in comparison with selective serotonin reuptake inhibitors: a meta-analysis. Prog Neuropsychopharmacol Biol Psychiatry. 2009;33:118-127.
31. Arnold LM, Clauw DJ, Dunegan LJ, Turk DC; FibroCollaborative. A framework for fibromyalgia management for primary care providers. Mayo Clin Proc. 2012;87:488-496.

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