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Don't miss the depression in fibromyalgia.

KANANASKIS, ALTA. -- A significant portion of all fibromyalgia patients with depression are not receiving adequate treatment for the disorder, if the experience of a multidisciplinary Canadian tertiary-care pain clinic is any indication.

A full 80% of 137 consecutive fibromyalgia patients at the pain center of McGill University Health Centre, Montreal, suffered from important depression, according to Dr. Mary-Ann Fitzcharles, reporting on her research. Of these, only 48% were being treated with any type of antidepressant and only 3% were seeing a psychologist. Moreover, only 19% of the depressed fibromyalgia patients were taking tricyclic antidepressants. Important depression was defined as that seen in a patient scoring 4 or higher on a scale of 1-10 on the depression component of the fibromylagia impact questionnaire. In addition, depression was also assessed by the anxiety and depression scale of the AIMS, and patients were seen by a psychologist and evaluated by the DSM criteria, Dr. Fitzcharles said in an interview.

"This probably underscores why rheumatologists are not very good at managing these patients," said Dr. Fitzcharles, a rheumatologist and professor of medicine at McGill. "For if we don't address the mood disorder, we're not going to be successful in pain management."

Dr. Fitzcharles reported the group's findings at the annual meeting of the Canadian Rheumatology Association. The depressed and nondepressed patients were similar in terms of age, employment status, disability status, and pain intensity on a visual analogue scale.

However, the depressed patients were found to have longer disease duration (12 vs. 7 years; P = .03). They also scored higher on the pain catastrophizing scale (30 vs. 22; P = .002), the arthritis impact measurement scale for anxiety (6.6 vs. 5.5; P = .05), and the total fibromyalgia impact questionnaire (65 vs. 57; P = .048).

After adjusting for other covariates, duration of pain was the only factor associated with depression in multivariate analysis (adjusted odds ratio, 1.11; P = .004).

Dr. Fitzcharles noted that many fibromyalgia patients commonly receive antidepressants--particularly tricyclic antidepressants--but said this largely reflects treatment patterns for fibromyalgia pain and sleep, rather than use for mood effect. "Even though they're on antidepressants, they're still significantly depressed. So the antidepressant they're taking may be not the best one," she said in an interview.

"So rather than hammering these poor patients with pain-relieving treatments, maybe we should be addressing the multiplicity of important symptoms. Because it's more than just pain. There's also a sleep disorder, fatigue, and a mood disorder. Because if we don't address everything, we're not going to be successful in anything."

With this in mind, Dr. Fitzcharles now tries to ensure that her fibromyalgia patients receive treatment specifically tailored to their complete range of symptoms. The next step in the research chain will be to determine how these individualized treatment regimens affect depression rates.

As this type of approach ultimately becomes more popular with both rheumatologists and family physicians, there may be a curbing of rheumatology referrals, which she said are often unnecessary. "The patients are typically perceived as difficult fibromyalgia patients and are being referred to us by the [general practitioners]," she said. "But the GPs are really very good at managing this. So if you've got a fibromyalgia patient who is really not responding, think of treating the mood disorder."

Dr. Fitzcharles disclosed that she is a consultant speaker for Pfizer Inc., Eli Lilly & Co., Boehringer Ingelheim, Valeant Pharmaceuticals International, and Janssen-Ortho Inc.
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Author:Vlessides, Michael
Publication:Clinical Psychiatry News
Date:Apr 1, 2009
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