Beyond Efficacy: The Acceptability of Antidepressant Treatment to Patients with Inflammatory Bowel Disease
The recent systematic review by Macer et al1 is timely in its consideration of antidepressant prescription for patients having inflammatory bowel disease (IBD). The study's finding that some patients derive significant benefit from antidepressant therapy is promising and may help to inform clinical practice in this patient group.
We would argue, however, that the review is limited by the authors' decision to omit adverse effect outcomes in their data extraction. Clinically, side effects (such as gastrointestinal upset) are commonly reported by patients receiving antidepressants, creating negative perceptions about antidepressants among some patients with IBD.2 Of the papers included in this review, extraction and appraisal of adverse effect frequencies would have been possible for the majority. Indeed, of the 3 prospective studies included, 2 reported data on the frequency of adverse effects.3,4 The only included randomized placebo-controlled trial demonstrated an increased rate of adverse effects in participants receiving duloxetine compared with those receiving placebo (the study was significantly underpowered, however, and only demonstrated statistical significance for nausea).3 High rates of adverse effects were seen in the included cohort study: 29.9% of participants did not complete a course of mixed antidepressant treatment and a third reported adverse effects.4 A further randomized placebo-controlled trial, published subsequent to the authors' literature search, found that 57% of fluoxetine-treated participants experienced adverse effects as compared to 25% in placebo-treated participants (25%).5 The most commonly occurring adverse effects in these studies were nausea, fatigue, and drowsiness. As such, the evidence suggests that adverse effects may be common in patients with IBD treated with antidepressants. Such adverse effects could limit treatment concordance, creating an important barrier to mental and physical recovery from anxiety, depression, and their potential sequelae.
Although fully supporting the authors' recommendation that further randomized controlled trials be conducted to test the efficacy of antidepressants in patients with IBD, we would advocate additionally that scrutiny is given to adverse effects of therapy. By weighing up both efficacy and acceptability of antidepressant therapy, both patients and clinicians will be better able to make informed decisions about treatment.