Comment: The quality of evidence is downgraded by study quality (unclear allocation concealment), imprecise results (few studies for each outcome) and indirectness (short follow-up time, 46% of the studies were conducted in China).
A Cochrane review [Abstract] 1 included 26 studies with a total of 2159 subjects. Participants aged 18 to 65 years and had to meet the requirements for diagnosis of a somatoform disorder, based on chronic, multiple, medically unexplained physical symptoms (MUPS). The studies 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 2 and 12 weeks.The most often assessed outcomes in the studies were the 'severity/intensity of MUPS' and 'depression'. 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, n=239). New-generation antidepressants (NGAs) were effective in reducing the severity of MUPS (SMD -0.91; 95% CI -1.36 to -0.46; 3 studies, n=243). NPs were effective in reducing the severity of MUPS (SMD -0.74; 95% CI -0.97 to -0.51; 2 studies, n=322).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, n=177). 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, n=182).One meta-analysis comparing selective serotonin reuptake inhibitors (SSRIs) with a combination of SSRIs and antipsychotics showed evidence in favour of combined treatment for severity of MUPS (SMD 0.77; 95% CI 0.32 to 1.22; 2 studies, n=107).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, n=163) or NPs and placebo (RR 0.85, 95% CI 0.40 to 1.78; 3 studies, n=506); nor between TCAs and other medication (RR 1.48, 95% CI 0.59 to 3.72; 8 studies, n=556); nor between antidepressants and the combination of an antidepressant and an antipsychotic (RR 0.80, 95% CI 0.25 to 2.52; 2 studies, n=118). Percental attrition rates due to adverse effects were high in all antidepressant treatments (0% to 32%), but low for NPs (0% to 1.7%).
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