Magazine article Clinical Psychiatry News

Psychotropics Benefit Moderate to Severe IBS

Magazine article Clinical Psychiatry News

Psychotropics Benefit Moderate to Severe IBS

Article excerpt

BOSTON -- Judicious use of antidepressants can ameliorate the psychiatric stressors that exacerbate moderate to severe irritable bowel syndrome symptoms, Dr. Douglas A. Drossman said at a meeting on neurogastroenterology and motility.

These agents can also act directly in the gut to control bowel dysfunction, said Dr. Drossman, codirector of the University of North Carolina Center for Functional GI and Motility Disorders, in Chapel Hill. "The more severe the IBS, the more likely the patient is to have comorbid psychosocial factors," Dr. Drossman said. "Any treatment that might reduce the stressor itself or the interpretation of the stressor through psychological pathways or through antidepressants is likely to have some benefit."

One of the first hurdles is to confront maladaptive negative beliefs a patient may have that can undermine good outcomes. Patients who feel that they have no control over their symptoms, who "catastrophize" and believe their condition will never get better, or who have a history of abuse have poorer outcomes--regardless of their treatment or condition, Dr. Drossman said.

He urges clinicians to establish a productive physician/patient relationship at the outset by identifying patient worries, providing reassurance, explaining the physiologic basis of symptoms, setting realistic treatment goals and time frames, and addressing cost concerns.

When choosing an antidepressant for irritable bowel syndrome (IBS), clinicians must consider the medication class and features of a particular medication within the class. Tricyclic antidepressants (TCAs) with noradrenergic activity are useful for IBS with diarrhea, especially for those patients with comorbid pain and depression. Dr. Drossman does not favor TCAs such as amitriptyline, which may cause side effects that limit tolerability through anticholinergic and antihista-minergic effects. Instead, he recommends desipramine or nortriptyline.

Selective serotonin reuptake inhibitors (SSRIs) are a good choice for patients with IBS with constipation who may also have depression, panic or anxiety symptoms, or obsessive-compulsive disorders. This makes SSRIs appropriate for housebound patients who fear having an IBS episode while away from home. …

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