Heart-focused anxiety as a mediating variable in the treatment of non-cardiac chest pain by cognitive-behavioural and psychopharmacological treatment by paroxetine

Untangling Nonerosive Reflux Disease From Functional Heartburn

Heartburn is a common symptom in clinical practice, but as many as 70% of patients have normal findings from upper endoscopy. Most of these patients have nonerosive reflux disease (NERD) or functional esophageal disorders. NERD is the most common phenotype of gastroesophageal reflux disease, and functional heartburn is the most common cause for refractory heartburn. In patients with NERD, symptoms arise from gastroesophageal reflux and esophageal hypersensitivity, whereas in patients with functional heartburn, symptoms result from esophageal hypersensitivity. A diagnosis of NERD requires endoscopy and reflux testing, whereas a diagnosis of functional heartburn also requires esophageal manometry. NERD is treated most commonly with medical, endoscopic, and surgical antireflux approaches, whereas functional heartburn as well as NERD can be treated with neuromodulators, psychological intervention, and complementary medicine options.

The potential role of behavioral therapies in the management of centrally mediated abdominal pain

BACKGROUND

Chronic abdominal pain carries a substantial health care burden but little is known about best practices for it management across ambulatory, hospital, and emergency room settings. This is especially true when abdominal pain presents in the absence of peripheral triggers like tissue injury (e.g. appendicitis) or altered bowel movements (e.g. IBS). Unfortunately, once central sensitization has occurred, pain can present without any stimulation or with minimal peripheral stimulation (feeling of clothing on the area) to the abdominal region. Several studies have proven the superior efficacy of behavioral interventions on many centrally mediated pain conditions including headaches and musculoskeletal problems. However, behavioral treatment of centrally mediated abdominal pain is less investigated due to the complexity of the patients involved and the poor understanding of the factors which either initiate or maintain persistent GI pain.

PURPOSE

We examine the evidence for a range of psychological and behavioral interventions in the context of centrally mediated abdominal pain. In addition to a strong rationale for a behavioral approach tied to the fear avoidance model of pain, we describe the structure, therapeutic targets, current evidence and relevance for each class of behavioral interventions.

Systematic review: the treatment of noncardiac chest pain with antidepressants

BACKGROUND

Noncardiac chest pain (NCCP) is a common condition, affecting approximately 25% of the general population. The cause of NCCP can be classified as gastro-oesophageal reflux disease (GERD)-related NCCP, where antireflux therapy is the main treatment modality or alternatively as non-GERD-related NCCP, where pain modulators, including antidepressants, are utilised.

AIM

To provide a systematic review evaluating the evidence for the use of antidepressants in the treatment of non-GERD-related NCCP.

METHODS

A computerised literature and manual search was conducted to identify relevant randomised, placebo-controlled studies, published in any language for the evaluation of the effectiveness of antidepressant as a therapeutic intervention for NCCP.

RESULTS

Six randomised placebo-controlled trials of antidepressant treatment for NCCP were identified. The medications included were selective serotonin reuptake inhibitors [paroxetine (n = 2), sertraline (n = 1)], tricyclic antidepressant [impramine (n = 1)], serotonin-norepinephrine reuptake inhibitor [venlafaxine (n = 1)] and a triazolopyridine [trazodone (n = 1)]. The percentage reduction in chest pain was statistically significant with venlafaxine (50% vs. 10%; P < 0.001), sertraline (63% vs. 15%; P = 0.02) and imipramine (52% vs. 1%; P = 0.03). The improvement in chest pain symptoms was independent of improvement in depression scores. Clinical global improvement also significantly improved in patients on venlafaxine, sertraline, paroxetine and trazodone. The percentage of patients in treatment groups reporting adverse effects were relatively high compared with those in placebo groups, although majority were statistically insignificant or significance was not reported. Nonetheless, adverse events were the reported reason for discontinuation of trials in 53% of patients from the antidepressant groups compared with 29% from the placebo group.

CONCLUSIONS

There is modest evidence for the benefit of antidepressants in reducing NCCP and improving patients' general health. However, there is significant heterogeneity amongst the studies with several study limitations to warrant more rigorous trials and to assess the usefulness of low-dose antidepressants in non-GERD NCCP.