BACKGROUND: Somatoform disorders are characterised by chronic, medically unexplained physical symptoms (MUPS). Although different medications are part of treatment routines for people with somatoform disorders in clinics and private practices, there exists no systematic review or meta-analysis on the efficacy and tolerability of these medications. We aimed to synthesise to improve optimal treatment decisions.OBJECTIVES: To assess the effects of pharmacological interventions for somatoform disorders (specifically somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, and pain disorder) in adults.SEARCH METHODS: We searched the Cochrane Depression, Anxiety and Neurosis Review Group's Specialised Register (CCDANCTR) (to 17 January 2014). This register includes relevant randomised controlled trials (RCTs) from The Cochrane Library (all years), MEDLINE (1950 to date), EMBASE (1974 to date), and PsycINFO (1967 to date). To identify ongoing trials, we searched ClinicalTrials.gov, Current Controlled Trials metaRegister, the World Health Organization International Clinical Trials Registry Platform, and the Chinese Clinical Trials Registry. For grey literature, we searched ProQuest Dissertation {\&} Theses Database, OpenGrey, and BIOSIS Previews. We handsearched conference proceedings and reference lists of potentially relevant papers and systematic reviews and contacted experts in the field.SELECTION CRITERIA: We selected RCTs or cluster RCTs of pharmacological interventions versus placebo, treatment as usual, another medication, or a combination of different medications for somatoform disorders in adults. We included people fulfilling standardised diagnostic criteria for somatisation disorder, undifferentiated somatoform disorder, somatoform autonomic dysfunction, or somatoform pain disorder.DATA COLLECTION AND ANALYSIS: One review author and one research assistant independently extracted data and assessed risk of bias. Primary outcomes included the severity of MUPS on a continuous measure, and acceptability of treatment.MAIN RESULTS: We included 26 RCTs (33 reports), with 2159 participants, in the review. They examined the efficacy of different types of antidepressants, the combination of an antidepressant and an antipsychotic, antipsychotics alone, or natural products (NPs). The duration of the studies ranged between two and 12 weeks.One meta-analysis of placebo-controlled studies showed no clear evidence of a significant difference between tricyclic antidepressants (TCAs) and placebo for the outcome severity of MUPS (SMD -0.13; 95{\%} CI -0.39 to 0.13; 2 studies, 239 participants; I(2) = 2{\%}; low-quality evidence). For new-generation antidepressants (NGAs), there was very low-quality evidence showing they were effective in reducing the severity of MUPS (SMD -0.91; 95{\%} CI -1.36 to -0.46; 3 studies, 243 participants; I(2) = 63{\%}). For NPs there was low-quality evidence that they were effective in reducing the severity of MUPS (SMD -0.74; 95{\%} CI -0.97 to -0.51; 2 studies, 322 participants; I(2) = 0{\%}).One meta-analysis showed no clear evidence of a difference between TCAs and NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.55 to 0.23; 3 studies, 177 participants; I(2) = 42{\%}; low-quality evidence). There was also no difference between NGAs and other NGAs for severity of MUPS (SMD -0.16; 95{\%} CI -0.45 to 0.14; 4 studies, 182 participants; I(2) = 0{\%}).Finally, one meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed low-quality evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95{\%} CI 0.32 to 1.22; 2 studies, 107 participants; I(2) = 23{\%}).Differences regarding the acceptability of the treatment (rate of all-cause drop-outs) were neither found between NGAs and placebo (RR 1.01, 95{\%} CI 0.64 to 1.61; 2 studies, 163 participants; I(2) = 0{\%}; low-quality evidence) or NPs and placebo (RR 0.85, 95{\%} CI 0.40 to 1.78; 3 studies, 506 participants; I(2) = 0{\%}; low-quality evidence); nor between TCAs and other medication (RR 1.48, 95{\%} CI 0.59 to 3.72; 8 studies, 556 participants; I(2) =14{\%}; low-quality evidence); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95{\%} CI 0.25 to 2.52; 2 studies, 118 participants; I(2) = 0{\%}; low-quality evidence). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0{\%} to 32{\%}), but low for NPs (0{\%} to 1.7{\%}).The risk of bias was high in many domains across studies. Seventeen trials (65.4{\%}) gave no information about random sequence generation and only two (7.7{\%}) provided information about allocation concealment. Eighteen studies (69.2{\%}) revealed a high or unclear risk in blinding participants and study personnel; 23 studies had high risk of bias relating to blinding assessors. For the comparison NGA versus placebo, there was relatively high imprecision and heterogeneity due to one outlier study. Although we identified 26 studies, each comparison only contained a few studies and small numbers of participants so the results were imprecise.AUTHORS' CONCLUSIONS: The current review found very low-quality evidence for NGAs and low-quality evidence for NPs being effective in treating somatoform symptoms in adults when compared with placebo. There was some evidence that different classes of antidepressants did not differ in efficacy; however, this was limited and of low to very low quality. These results had serious shortcomings such as the high risk of bias, strong heterogeneity in the data, and small sample sizes. Furthermore, the significant effects of antidepressant treatment have to be balanced against the relatively high rates of adverse effects. Adverse effects produced by medication can have amplifying effects on symptom perceptions, particularly in people focusing on somatic symptoms without medical causes. We can only draw conclusions about short-term efficacy of the pharmacological interventions because no trial included follow-up assessments. For each of the comparisons where there were available data on acceptability rates (NGAs versus placebo, NPs versus placebo, TCAs versus other medication, and antidepressants versus a combination of an antidepressant and an antipsychotic), no clear differences between the intervention and comparator were found.Future high-quality research should be carried out to determine the effectiveness of medications other than antidepressants, to compare antidepressants more thoroughly, and to follow-up participants over longer periods (the longest follow up was just 12 weeks). Another idea for future research would be to include other outcomes such as functional impairment or dysfunctional behaviours and cognitions as well as the classical outcomes such as symptom severity, depression, or anxiety.

Pharmacological interventions for somatoform disorders in adults.

Importance Primary care clinicians find managing chronic pain challenging. Evidence of long-term efficacy of opioids for chronic pain is limited. Opioid use is associated with serious risks, including opioid use disorder and overdose. Objective To provide recommendations about opioid prescribing for primary care clinicians treating adult patients with chronic pain outside of active cancer treatment, palliative care, and end-of-life care. Process The Centers for Disease Control and Prevention (CDC) updated a 2014 systematic review on effectiveness and risks of opioids and conducted a supplemental review on benefits and harms, values and preferences, and costs. CDC used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework to assess evidence type and determine the recommendation category. Evidence Synthesis Evidence consisted of observational studies or randomized clinical trials with notable limitations, characterized as low quality using GRADE methodology. Meta-analysis was not attempted due to the limited number of studies, variability in study designs and clinical heterogeneity, and methodological shortcomings of studies. No study evaluated long-term (≥1 year) benefit of opioids for chronic pain. Opioids were associated with increased risks, including opioid use disorder, overdose, and death, with dose-dependent effects. Recommendations There are 12 recommendations. Of primary importance, nonopioid therapy is preferred for treatment of chronic pain. Opioids should be used only when benefits for pain and function are expected to outweigh risks. Before starting opioids, clinicians should establish treatment goals with patients and consider how opioids will be discontinued if benefits do not outweigh risks. When opioids are used, clinicians should prescribe the lowest effective dosage, carefully reassess benefits and risks when considering increasing dosage to 50 morphine milligram equivalents or more per day, and avoid concurrent opioids and benzodiazepines whenever possible. Clinicians should evaluate benefits and harms of continued opioid therapy with patients every 3 months or more frequently and review prescription drug monitoring program data, when available, for high-risk combinations or dosages. For patients with opioid use disorder, clinicians should offer or arrange evidence-based treatment, such as medication-assisted treatment with buprenorphine or methadone. Conclusions and Relevance The guideline is intended to improve communication about benefits and risks of opioids for chronic pain, improve safety and effectiveness of pain treatment, and reduce risks associated with long-term opioid therapy.

/pdf/cdc-guideline-for-prescribing-opioids-for-chronic-pain-j4r6nt5nmj.pdf

CDC Guideline for Prescribing Opioids for Chronic Pain—United States, 2016

/pdf/cdc-guideline-for-prescribing-opioids-for-chronic-pain-48d7kdjqlr.pdf

CDC guideline for prescribing opioids for chronic pain

Summary estimates of treatment effect from random effects meta-analysis give only the average effect across all studies. Inclusion of prediction intervals, which estimate the likely effect in an individual setting, could make it easier to apply the results to clinical practice

/pdf/interpretation-of-random-effects-meta-analyses-3wqyseoko4.pdf

Interpretation of random effects meta-analyses.

Importance Many people meditate to reduce psychological stress and stress-related health problems. To counsel people appropriately, clinicians need to know what the evidence says about the health benefits of meditation. Objective To determine the efficacy of meditation programs in improving stress-related outcomes (anxiety, depression, stress/distress, positive mood, mental health–related quality of life, attention, substance use, eating habits, sleep, pain, and weight) in diverse adult clinical populations. Evidence Review We identified randomized clinical trials with active controls for placebo effects through November 2012 from MEDLINE, PsycINFO, EMBASE, PsycArticles, Scopus, CINAHL, AMED, the Cochrane Library, and hand searches. Two independent reviewers screened citations and extracted data. We graded the strength of evidence using 4 domains (risk of bias, precision, directness, and consistency) and determined the magnitude and direction of effect by calculating the relative difference between groups in change from baseline. When possible, we conducted meta-analyses using standardized mean differences to obtain aggregate estimates of effect size with 95% confidence intervals. Findings After reviewing 18 753 citations, we included 47 trials with 3515 participants. Mindfulness meditation programs had moderate evidence of improved anxiety (effect size, 0.38 [95% CI, 0.12-0.64] at 8 weeks and 0.22 [0.02-0.43] at 3-6 months), depression (0.30 [0.00-0.59] at 8 weeks and 0.23 [0.05-0.42] at 3-6 months), and pain (0.33 [0.03- 0.62]) and low evidence of improved stress/distress and mental health–related quality of life. We found low evidence of no effect or insufficient evidence of any effect of meditation programs on positive mood, attention, substance use, eating habits, sleep, and weight. We found no evidence that meditation programs were better than any active treatment (ie, drugs, exercise, and other behavioral therapies). Conclusions and Relevance Clinicians should be aware that meditation programs can result in small to moderate reductions of multiple negative dimensions of psychological stress. Thus, clinicians should be prepared to talk with their patients about the role that a meditation program could have in addressing psychological stress. Stronger study designs are needed to determine the effects of meditation programs in improving the positive dimensions of mental health and stress-related behavior.

https://jamanetwork.com/journals/jamainternalmedicine/articlepdf/1809754/ioi130131.pdf

Meditation Programs for Psychological Stress and Well-being: A Systematic Review and Meta-analysis

The Association Psychosomatics in Gastroenterology of the DGVS aims to sharpen the profile of psychosomatic proportions in diagnostics, differential diagnostics and therapy of gastroenterological diseases, increasingly establish psychosomatic aspects in further education and clinical practice guidelines, deepen the cooperation with psychosomatic societies and strengthen the job satisfaction and mental health of gastroenterologists in Germany.

[Psychosomatics in gastroenterology - statement of the Work Group for Psychosomatics in Gastroenterology of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS)]

Opioids provide some modest pain relief for patients with rheumatoid arthritis, but prescription of these drugs is influenced by their association with risks for the individual and for society. Is denial of a treatment, even if that treatment is imperfect, justified when patients experience considerable pain and other treatment options are limited?

Pain management: Opioids for RA: a clinical dilemma.

Die gesetzlichen Rahmenbedingungen und die formalen Moglichkeiten der Respektierung der eigenen Wunsche am Ende des Lebens in Form einer Patientenverfugung werden dargestellt. Mediziner und Psychotherapeuten sollten wahrend ihrer Ausbildung ihre Einstellungen zu Tod und Sterben reflektieren. Sie sollten Fahigkeiten erwerben, mit ihren Patienten/Klienten uber die Durchfuhrung bzw. das Unterlassen von medizinischen Behandlungen bei Erkrankungen mit infauster Prognose bzw. im Endstadium zu sprechen und die Entscheidungen schriftlich festzuhalten. Anhand von Fallbeispielen werden medizinisch-ethische Konflikte und Gesprachstechniken der systemischen Familienmedizin in der medizinischen Behandlung am Lebensende dargestellt. Gesprache von Arzten mit Patienten uber medizinische Masnahmen sind ein Kostenfaktor im medizinischen System. Wir diskutieren, ob dieser Faktor in der aktuellen und zukunftigen medizinischen Versorgung in Deutschland berucksichtigt wird.

Gespräche über das Lebensende

The valid messages and recommendations from the S3 guideline on chronic pancreatitis require some additions, and some verification, in the section entitled “The treatment of pain.”

Before initiating symptomatic medication or endoscopic or surgical pain treatment, a detailed analysis of the pain should be conducted in order to identify possible non-visceral (partial) causes of chronic upper abdominal pain, such as psychological disorders or musculoskeletal pain syndromes (1). In a proportion of patients with chronic pancreatitis, central pain is present that responds unsatisfactorily to surgical or endoscopic procedures (1).

The intensity of pain in chronic alcohol toxic pancreatitis correlates with the presence of affective disorders and further chronic pain syndromes but not with the CT results of chronic pancreatitis. Within a stepwise pain management approach, the first step should be to wean patients with chronic pancreatitis and substance dependency (alcohol, tobacco) off the substance they are misusing (2). The problem of misuse of prescribed opioids in substance-dependent persons deserves mentioning.

In a three-week randomized controlled study, pregabalin was superior to placebo regarding effective pain reduction (36% versus 24%) (3). Pregabalin was not listed among the options for drug therapy in the article.

Regarding Table 4 of the article: because of the half-lives of paracetamol (acetaminophen) and metamizole, the recommendation is for a minimum of 4 doses per day in patients with chronic pain. Levopromazine is a neuroleptic of low potency, not a tricyclic antidepressant. The use of neuroleptics in the treatment of chronic pain should be regarded critically because of limited data and because of the drugs’ side effects.

/pdf/correspondence-letter-to-the-editor-additions-required-4oi49dkydy.pdf

Correspondence (letter to the editor): Additions Required

Mit der S3-Leitlinie „Umgang mit Patienten mit nicht-spezifischen, funktionellen und somatoformen Korperbeschwerden (NFS)“ (AWMF Registernr. 051–001) gibt es erstmals einen breiten, evidenzbasierten Konsens uber psychosoziale und somatische Disziplinen hinweg zu Terminologie und Versorgung dieser grosen, gerade in der Schmerzmedizin hochrelevanten Patientengruppe.

Winfried Häuser

Papers

[Psychosomatics in gastroenterology - statement of the Work Group for Psychosomatics in Gastroenterology of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS)]

Pain management: Opioids for RA: a clinical dilemma.

Gespräche über das Lebensende

Correspondence (letter to the editor): Additions Required

Nicht-spezifische, funktionelle und somatoforme Körperbeschwerden – Relevanz für die Schmerzmedizin