Therapeutic effects of saffron (Crocus sativus) versus fluoxetine on Irritable Bowel Syndrome: A double-blind randomized clinical trial

Effects of a traditional herbal formula containing Melissa officinalis, Pimpinella anisum, and Rosa damascena on anxiety and depression in patients with constipation-predominant irritable bowel syndrome (IBS-C): A double-blind randomized clinical trial

INTRODUCTION

Irritable bowel syndrome (IBS) is associated with a high prevalence of anxiety and depression. This study aimed to evaluate the effects of a traditional Persian herbal formula containing Melissa officinalis, Pimpinella anisum, and Rosa damascena (MPR) on anxiety and depression in IBS patients with symptoms of constipation-predominant IBS (IBS-C).

METHODS

This double-blind randomized clinical trial was conducted in Afzalipour Hospital via block randomization method. A total of 96 IBS-C patients (based on Rome IV criteria), aged 18-60 years, were included in this study. Participants received capsules containing either 500 mg of herbal formula or placebo (cornstarch) twice a day for four weeks Anxiety and depression were assessed using the Hospital Anxiety and Depression Scale.

RESULTS

Forty-three patients in the intervention group and 45 patients in the control group completed this study. Except for the education level, there were no significant differences in the demographic characteristics between the two groups (P > 0.05). The mean levels of anxiety and depression, and total IBS symptom severity score showed no significant differences between the two groups at baseline (P > 0.05). After four weeks of treatment, the anxiety score considerably improvement in the treatment group (Cohen's d = -1.19, 95 % confidence intervals [CIs] -4.49 to 2.13), as did the depression score (Cohen's d = -1.93, 95 % CIs -4.32 to 2.79).

CONCLUSION

MPR considerably improved anxiety and depression in patients with IBS-C compared to the placebo without serious side effects.

Medicinal plants and plant-based traditional medicine: Alternative treatments for depression and their potential mechanisms of action

Background

Clinical depression is a serious public health issue that affects 4.7 % of the world's population and can lead to suicide tendencies. Although drug medications are available, only 60 % of the depressed patients respond positively to the treatments, while the rest experience side effects that resulted in the discontinuation of their medication. Thus, there is an urgent need for developing a new anti-depressant with a distinct mode of action and manageable side effects. One of the options is using medicinal plants or plant-based traditional medicine as alternative therapies for psychiatric disorders.

Objectives

Therefore, the objective of this review was twofold; to identify and critically evaluate anti-depressant properties of medicinal plants or those incorporated in traditional medicine; and to discuss their possible mechanism of action as well as challenges and way forward for this alternative treatment approach.

Methods

Relevant research articles were retrieved from various databases, including Scopus, PubMed, and Web of Science, for the period from 2018 to 2020, and the search was updated in September 2024. The inclusion criterion was relevance to antidepressants, while the exclusion criteria included duplicates, lack of full-text availability, and non-English publications.

Results

Through an extensive literature review, more than 40 medicinal plant species with antidepressant effects were identified, some of which are part of traditional medicine. The list of the said plant species included Albizia zygia (DC.) J.F.Macbr., Calculus bovis Sativus, Celastrus paniculatus Willd., Cinnamomum sp., Erythrina velutina Willd., Ficus platyphylla Delile, Garcinia mangostana Linn., Hyptis martiusii Benth, and Polygonum multiflorum Thunb. Anti-depressant mechanisms associated with those plants were further characterised based on their modes of action such as anti-oxidation system, anti-inflammation action, modulation of various neurotransmitters, neuroprotective effect, the regulation of hypothalamic-pituitary-adrenal (HPA) axis and anti-depressant mechanism. The challenges and future outlook of this alternative and complementary medicine are also explored and discussed.

Conclusion

This pool of identified plant species is hoped to offer health care professionals the best possible alternatives of anti-depressants from natural phytocompounds that are efficacious, safe and affordable for applications in future clinical settings.

Effect of Saffron Versus Selective Serotonin Reuptake Inhibitors (SSRIs) in Treatment of Depression and Anxiety: A Meta-analysis of Randomized Controlled Trials

CONTEXT

Saffron, a natural remedy with potential antidepressant and anxiolytic properties, has gained attention as a potential therapeutic option.

OBJECTIVE

This systematic review and meta-analysis aimed to evaluate the comparative effectiveness of saffron versus selective serotonin reuptake inhibitors (SSRIs) in treating depression and anxiety.

DATA SOURCE

Electronic databases, including PubMed, Embase, Scopus, Web of Science, and the Cochrane database, were searched from inception to April 31, 2023.

DATA EXTRACTION

Randomized controlled trials (RCTs) comparing saffron intervention with SSRIs in adults with depression or anxiety were included.

DATA ANALYSIS

Random-effects meta-analysis using standardized mean differences (SMDs) and risk ratio (RRs) with their 95% CIs calculated continuous and binary outcomes, respectively. Meta-analysis of 8 studies assessing depression outcomes revealed a nonsignificant difference between saffron and SSRIs in reducing depressive symptoms (SMD = 0.10l 95% CI: -0.09 to 0.29). Four studies reporting anxiety outcomes showed a nonsignificant difference between saffron and SSRIs in reducing anxiety symptoms (SMD = 0.04; 95% CI: -0.22 to 0.29). With regard to safety, participants receiving saffron had fewer adverse events than the SSRI group (risk difference: -0.06; 95% CI: -0.09, -0.04; I2: 0%).

CONCLUSION

Saffron could be a potential SSRI alternative to reduce depressive and anxiety symptoms with fewer adverse events. Further research with larger sample sizes and in diverse populations is warranted to validate these findings and explore potential moderators of treatment response.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO registration no. CRD42023443236.

Antidepressants for pain management in adults with chronic pain: a network meta-analysis

BACKGROUND

Chronic pain is common in adults, and often has a detrimental impact upon physical ability, well-being, and quality of life. Previous reviews have shown that certain antidepressants may be effective in reducing pain with some benefit in improving patients' global impression of change for certain chronic pain conditions. However, there has not been a network meta-analysis (NMA) examining all antidepressants across all chronic pain conditions.

OBJECTIVES

To assess the comparative efficacy and safety of antidepressants for adults with chronic pain (except headache).

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, CINAHL, LILACS, AMED and PsycINFO databases, and clinical trials registries, for randomised controlled trials (RCTs) of antidepressants for chronic pain conditions in January 2022.

SELECTION CRITERIA

We included RCTs that examined antidepressants for chronic pain against any comparator. If the comparator was placebo, another medication, another antidepressant, or the same antidepressant at different doses, then we required the study to be double-blind. We included RCTs with active comparators that were unable to be double-blinded (e.g. psychotherapy) but rated them as high risk of bias. We excluded RCTs where the follow-up was less than two weeks and those with fewer than 10 participants in each arm.  DATA COLLECTION AND ANALYSIS: Two review authors separately screened, data extracted, and judged risk of bias. We synthesised the data using Bayesian NMA and pairwise meta-analyses for each outcome and ranked the antidepressants in terms of their effectiveness using the surface under the cumulative ranking curve (SUCRA). We primarily used Confidence in Meta-Analysis (CINeMA) and Risk of Bias due to Missing Evidence in Network meta-analysis (ROB-MEN) to assess the certainty of the evidence. Where it was not possible to use CINeMA and ROB-MEN due to the complexity of the networks, we used GRADE to assess the certainty of the evidence. Our primary outcomes were substantial (50%) pain relief, pain intensity, mood, and adverse events. Our secondary outcomes were moderate pain relief (30%), physical function, sleep, quality of life, Patient Global Impression of Change (PGIC), serious adverse events, and withdrawal.

MAIN RESULTS

This review and NMA included 176 studies with a total of 28,664 participants. The majority of studies were placebo-controlled (83), and parallel-armed (141). The most common pain conditions examined were fibromyalgia (59 studies); neuropathic pain (49 studies) and musculoskeletal pain (40 studies). The average length of RCTs was 10 weeks. Seven studies provided no useable data and were omitted from the NMA. The majority of studies measured short-term outcomes only and excluded people with low mood and other mental health conditions. Across efficacy outcomes, duloxetine was consistently the highest-ranked antidepressant with moderate- to high-certainty evidence. In duloxetine studies, standard dose was equally efficacious as high dose for the majority of outcomes. Milnacipran was often ranked as the next most efficacious antidepressant, although the certainty of evidence was lower than that of duloxetine. There was insufficient evidence to draw robust conclusions for the efficacy and safety of any other antidepressant for chronic pain.  Primary efficacy outcomes Duloxetine standard dose (60 mg) showed a small to moderate effect for substantial pain relief (odds ratio (OR) 1.91, 95% confidence interval (CI) 1.69 to 2.17; 16 studies, 4490 participants; moderate-certainty evidence) and continuous pain intensity (standardised mean difference (SMD) -0.31, 95% CI -0.39 to -0.24; 18 studies, 4959 participants; moderate-certainty evidence). For pain intensity, milnacipran standard dose (100 mg) also showed a small effect (SMD -0.22, 95% CI -0.39 to 0.06; 4 studies, 1866 participants; moderate-certainty evidence). Mirtazapine (30 mg) had a moderate effect on mood (SMD -0.5, 95% CI -0.78 to -0.22; 1 study, 406 participants; low-certainty evidence), while duloxetine showed a small effect (SMD -0.16, 95% CI -0.22 to -0.1; 26 studies, 7952 participants; moderate-certainty evidence); however it is important to note that most studies excluded participants with mental health conditions, and so average anxiety and depression scores tended to be in the 'normal' or 'subclinical' ranges at baseline already. Secondary efficacy outcomes Across all secondary efficacy outcomes (moderate pain relief, physical function, sleep, quality of life, and PGIC), duloxetine and milnacipran were the highest-ranked antidepressants with moderate-certainty evidence, although effects were small. For both duloxetine and milnacipran, standard doses were as efficacious as high doses. Safety There was very low-certainty evidence for all safety outcomes (adverse events, serious adverse events, and withdrawal) across all antidepressants. We cannot draw any reliable conclusions from the NMAs for these outcomes.

AUTHORS' CONCLUSIONS

Our review and NMAs show that despite studies investigating 25 different antidepressants, the only antidepressant we are certain about for the treatment of chronic pain is duloxetine. Duloxetine was moderately efficacious across all outcomes at standard dose. There is also promising evidence for milnacipran, although further high-quality research is needed to be confident in these conclusions. Evidence for all other antidepressants was low certainty. As RCTs excluded people with low mood, we were unable to establish the effects of antidepressants for people with chronic pain and depression. There is currently no reliable evidence for the long-term efficacy of any antidepressant, and no reliable evidence for the safety of antidepressants for chronic pain at any time point.

Off-label Uses of Selective Serotonin Reuptake Inhibitors (SSRIs)

Psychiatric drugs have primacy for off-label prescribing. Among those, selective serotonin reuptake inhibitors (SSRIs) are highly versatile and, therefore, widely prescribed. Moreover, they are commonly considered as having a better safety profile compared to other antidepressants. Thus, when it comes to off-label prescribing, SSRIs rank among the top positions. In this review, we present the state of the art of off-label applications of selective serotonin reuptake inhibitors, ranging from migraine prophylaxis to SARS-CoV-2 antiviral properties. Research on SSRIs provided significant evidence in the treatment of premature ejaculation, both with the on-label dapoxetine 30 mg and the off-label paroxetine 20 mg. However, other than a serotoninergic syndrome, serious conditions like increased bleeding rates, hyponatremia, hepatoxicity, and post-SSRIs sexual dysfunctions, are consistently more prominent when using such compounds. These insidious side effects might be frequently underestimated during common clinical practice, especially by nonpsychiatrists. Thus, some points must be addressed when using SSRIs. Among these, a psychiatric evaluation before every administration that falls outside the regulatory agencies-approved guidelines has to be considered mandatory. For these reasons, we aim with the present article to identify the risks of inappropriate uses and to advocate the need to actively boost research encouraging future clinical trials on this topic.

Vortioxetine effects on quality of life of irritable bowel syndrome patients: A randomized, double-blind, placebo-controlled trial

WHAT IS KNOWN AND OBJECTIVE

Irritable bowel syndrome (IBS) is a functional gastrointestinal disease causing a substantial productivity loss with no definite treatment. Our study investigates the effects of vortioxetine vs placebo in enhancing the IBS patients' quality of life.

METHODS

In a double-blinded, placebo-controlled, randomized trial, adults with IBS, according to the ROME IV criteria, were randomized to placebo and vortioxetine for 6 weeks. Participants were visited every two weeks to fill IBS quality of life, hospital anxiety and depression scale, and adverse effect questionnaires.

RESULTS

Eighty patients were randomized, and seventy-two finished the trial. Baseline characteristics of groups were similar. Both placebo and vortioxetine significantly increased the quality of life during course of the study (both P-values < .001), whereas vortioxetine demonstrated a greater increase (P-value < .001). According to the analysis of covariances, this enhancement was irrespective of depression or anxiety score changes (P-value = .002). Adverse effect profile was similar between the groups and can increase IBS patients' quality of life superior to placebo. Vortioxetine effects in our study were observed irrespective of the depression and anxiety levels.