Does cymbalta cause insomnia

How To Sleep While Taking Cymbalta: What To Know

Cymbalta is a prescription medication that can help alleviate symptoms of depression, anxiety, and chronic pain.

But it can also have side effects, most commonly nausea, fatigue, and dry mouth.

Many people starting Cymbalta also have insomnia, or difficulty sleeping.

Poor sleep can have adverse effects on your physical health, and it can also make it difficult to find joy in daily life activities, a common goal for many people seeking treatment for mental health conditions.

In this article, I’ll describe how Cymbalta works, how it may affect your sleep, and some strategies that may help to improve your sleep while taking Cymbalta.

I’ll also tell you some signs that you should talk to your doctor.

What is Cymbalta?

Cymbalta is a type of medication called a serotonin and norepinephrine reuptake inhibitor, or SNRI.

SNRIs work by affecting chemicals in the brain known as neurotransmitters.

These neurotransmitters (serotonin and norepinephrine) can help regulate mood, stress, and even pain perception.

Because Cymbalta works by affecting two specific neurotransmitters, it can also be referred to as a dual reuptake inhibitor or dual-acting antidepressant.

Feeling Down?

Take our free assessment and learn about your options.

Get Started

What does it treat?

Cymbalta is often prescribed to treat major depressive disorder, or MDD.

It can also be prescribed to treat:

Generalized anxiety disorder (GAD)
Chronic pain, including fibromyalgia, arthritis, and diabetic neuropathy

It can take between 2-8 weeks for Cymbalta to start taking effect.

Some mild side effects can occur during that period, including nausea, dizziness, fatigue, dry mouth, and insomnia.

Many of these side effects will resolve on their own, but not always.

To ensure you’re reducing the risk for side effects as much as possible, take Cymbalta exactly as directed by your provider.

Don’t take Cymbalta more or less frequently than recommended by your provider, and don’t double up on doses.

If you feel that you need to adjust your Cymbalta dose, don’t do so on your own.

Talk to your prescriber before making any changes.

Cymbalta and Insomnia

Unfortunately, insomnia is a common side effect experienced by some people who take Cymbalta.

Roughly 10% or more of patients taking Cymbalta report insomnia.

Insomnia can mean difficulty falling asleep, difficulty staying asleep, waking up earlier than desired, or waking up and still feeling tired.

There are many possible causes of insomnia, but if you’re experiencing signs for the first time after starting medication, it’s possible that you have Cymbalta-induced insomnia.

Insomnia can also be a side effect of Cymbalta withdrawal and discontinuation.

If you’re experiencing signs of insomnia or any other bothersome side effects while taking Cymbalta, reach out to your provider for guidance and help.

How to Sleep While Taking Cymbalta

During the first few weeks on a new antidepressant like Cymbalta, it’s helpful to let your provider know if new symptoms or side effects emerge, including insomnia.

In some cases, your provider may recommend waiting to see if your insomnia resolves on its own as you continue the medication.

If not, they may recommend one of the following alternatives.

Slowly increase dosage

When starting a new antidepressant, it’s common for your provider to start you at a lower dose and gradually increase the dosage until you reach the recommended therapeutic amount (usually 60 mg per day).

However, if you start to experience new side effects like insomnia as the dosage increases, your provider may recommend slowing the dose increase to minimize side effects and give your body time to adjust to the medication.

Reduce dosage if needed

Your provider may recommend reducing your dosage or discontinuing the medication altogether.

Higher doses of Cymbalta can exacerbate insomnia and other sleep disturbances, which is why your provider may recommend lowering the dosage if you’re still able to reap the therapeutic benefits of the medication.

Otherwise, stopping the medication may be the best option for you.

In that case, do not stop taking Cymbalta abruptly or suddenly.

It’s crucial that you work with your provider to gradually taper off of Cymbalta to avoid experiencing withdrawal symptoms.

Establish a routine

One way to support getting adequate, quality sleep is to establish a regular sleeping routine.

Going to bed at the same time every night (within one hour of variation) and waking up at the same time each day (also within one hour of variation) can help get your circadian rhythms into a reliable pattern.

Avoiding screens for at least an hour before bed can also help, as can sleeping in a cool room.

Relaxation techniques including deep breathing exercises, imagery, and others, can also help your mind and body relax before bed.

Use sleep aids

Over-the-counter (OTC) sleep aids have become a popular resource in recent years for people hoping to get good, consistent sleep.

Melatonin, when taken at typical doses of 1-5 mg nightly, is safe to use while taking Cymbalta.

Evidence suggests that melatonin supplements can help some people to improve total sleep time, sleep quality, and sleep latency (how long it takes to fall asleep).

Melatonin may also be particularly helpful in treating chronic insomnia in people aged 55 and older.

However, some supplements can cause adverse reactions when taken with Cymbalta and should be avoided, including St. John’s wort.

Check with your provider or pharmacist before adding any OTC sleep aid or supplement to your routine to be sure it will not have an adverse interaction with Cymbalta.

Avoid caffeine or exercise before bed

Regular exercise can support a healthy sleeping schedule, but exercising right before bedtime may impair the quality of your sleep.

Though there’s little evidence to suggest that you need to avoid exercising in the afternoon or evening (in fact, some research suggests that afternoon workouts can yield the best performance in some athletes), make sure that the end of your workout occurs at least 60-90 minutes before bedtime.

Drinking or consuming caffeine close to bedtime can interfere with circadian melatonin rhythms and block sleep-promoting chemical receptors, making it difficult to sleep.

Though the rate at which you metabolize caffeine can vary depending on the individual, one study found that consuming caffeine even six hours before bedtime can reduce sleep time by one hour.

Feeling Down?

Take our free assessment and learn about your options.

Get Started

When to See a Doctor

For most people, Cymbalta can be a safe and effective treatment option for depression, anxiety, or chronic pain.

But if you’re experiencing insomnia or any other bothersome side effects while taking the medication, reach out to your provider to discuss whether adjusting the dose or switching to another antidepressant may help.

Reach out to your provider if you experience any of these rare, but serious, symptoms:

Severe dizziness
Hives, or a red or purple rash with blistering or peeling
Itching or swelling, particularly of the mouth, face, or throat
Trouble breathing
Seizure

Additional signs that the medication may not be working appropriately can include these serious side effects:

Panic attacks
Worsening mood
Feeling agitated, impulsive, aggressive, restless, or hyperactive
Confusion
Thoughts of suicide

If you experience any of the above symptoms, talk to your provider as soon as possible.

If you’re having a mental health emergency, call 911 or go to the nearest emergency room. You can also get free 24/7 support from a suicide and crisis expert by calling or texting 988. If you’d prefer to chat online, you can chat with a suicide and crisis expert by visiting the Lifeline Chat.

How K Health Can Help

Think you might need a prescription for Cymbalta (Duloxetine)?

K Health has clinicians standing by 24/7 to evaluate your symptoms and determine if Cymbalta is right for you.

Get started with our free assessment, which will tell you in minutes if treatment could be a good fit. If yes, we’ll connect you right to a clinician who can prescribe medication and have it shipped right to your door.

Frequently Asked Questions

Can Cymbalta make it hard to sleep?

Yes. Insomnia, or difficulty sleeping, is a common side effect when taking Cymbalta. For some people, insomnia will resolve on its own as your body adjusts to taking the medication.

Can I take a sleep aid with Cymbalta?

Melatonin can be used to help you sleep while taking Cymbalta, but some drugs should be avoided when taking the antidepressant medication, including St. John’s wort. Check with your provider or pharmacist before adding any OTC sleep aid or supplement to your routine to be sure it will not have an adverse interaction with Cymbalta.

Can you take Cymbalta at night before bed?

Though many people prefer to take Cymbalta in the morning, it can cause drowsiness in some people. If you experience drowsiness as a side effect of taking Cymbalta, talk to your provider about taking the medication in the evening.

How common is insomnia with Cymbalta?

Insomnia is very common when taking Cymbalta. Over 10% of patients taking the drug reported insomnia as a side effect.

K Health articles are all written and reviewed by MDs, PhDs, NPs, or PharmDs and are for informational purposes only. This information does not constitute and should not be relied on for professional medical advice. Always talk to your doctor about the risks and benefits of any treatment.

K Health has strict sourcing guidelines and relies on peer-reviewed studies, academic research institutions, and medical associations. We avoid using tertiary references.

Caffeine Effects on Sleep Taken 0, 3, or 6 Hours before Going to Bed. (2013).
https://jcsm.aasm.org/doi/10.5664/jcsm.3170
Clinical Practice Guideline for the Pharmacologic Treatment of Chronic Insomnia in Adults: An American Academy of Sleep Medicine Clinical Practice Guideline. (2017).
https://jcsm.aasm.org/doi/10.5664/jcsm.6470
Comparing Performance During Morning vs. Afternoon Training Sessions in Intercollegiate Basketball Players. (2017).
https://pubmed.ncbi.nlm.nih.gov/28538305/
Cymbalta (duloxetine hydrochloride) capsules. (2008).
https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf
Duloxetine (Cymbalta). (2020).
https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Duloxetine-(Cymbalta)
Duloxetine in the treatment of major depressive disorder. (2007).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2654630/
Effects of caffeine on the human circadian clock in vivo and in vitro. (2015).
https://www.science.org/doi/10.1126/scitranslmed.aac5125
Effects of Evening Exercise on Sleep in Healthy Participants: A Systematic Review and Meta-Analysis. (2019).
https://pubmed.ncbi.nlm.nih.gov/30374942/
Meta-Analysis: Melatonin for the Treatment of Primary Sleep Disorders. (2013).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3656905/
Normalizing sleep quality disturbed by psychiatric polypharmacy: a single patient open trial (SPOT). (2016).
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5527988/
The energy hypothesis of sleep revisited. (2008).
https://www.sciencedirect.com/science/article/pii/S0301008208000865

How to Sleep While Taking Cymbalta

Sleep is essential to keep us healthy, both physically and mentally. However, many things can affect the quality of our sleep.

If you’re struggling with a mood disorder, for example, you may be experiencing a lack of sleep as a side effect. Or if you live with debilitating chronic pain, your sleep may be affected as well.

Around 21 percent of adults in the U.S. experienced a mental illness, including depression and bipolar disorder, in 2020, respectively. Additionally, in 2019, over 20 percent of American adults experienced chronic pain.

If you struggle with major depression or chronic pain, chances are you’ve been prescribed Cymbalta®.

Cymbalta is a drug primarily used to treat the aforementioned conditions, which can include depression, anxiety and certain chronic pain issues.

But Cymbalta, as with many medications, may come with some side effects — some of which can affect your sleep.

In this guide, we’ll talk about how this drug works, its common side effects and how to sleep while taking Cymbalta.

Overview of Cymbalta

One of the more common antidepressants prescribed, Cymbalta is used to treat mental health disorders like major depressive disorder and generalized anxiety disorder.

Cymbalta has also been approved by the FDA for use in helping those with fibromyalgia, nerve pain and damage from diabetes (diabetic peripheral neuropathy) and long-term musculoskeletal pain.

The brand name for duloxetine, Cymbalta is a serotonin-norepinephrine reuptake inhibitor.

Serotonin-norepinephrine reuptake inhibitors (or SNRIs) work primarily on two chemicals in your brain: serotonin and norepinephrine. Cymbalta works to prevent your brain from reabsorbing these two neurotransmitters. This then has a positive effect on your mood and helps relieve pain.

This works differently from selective serotonin reuptake inhibitors, which only prevent the reabsorption of serotonin.

Cymbalta can also help break the vicious cycle between depression and chronic pain. Chronic pain can lead to depression, which can then make the pain worse, or vice versa, according to research.

You may be prescribed an SNRI like Cymbalta if it’s the right treatment for your diagnosis and health at the time, or if selective serotonin reuptake inhibitors (SSRIs) have not worked before.

Cymbalta is sometimes used to treat depression from bipolar disorder. However, as with other SNRIs, it can cause several negative side effects. If you struggle with or have been diagnosed with bipolar disorder, talk to a healthcare professional before taking Cymbalta.

It’s possible to see improvements in energy, sleep or appetite within the first week or two of taking Cymbalta, indicating that the medication is working.

A depressed mood may take longer to see signs of improvement though, taking anywhere from six to eight weeks.

online mental health assessment

your mental health journey starts here

Side Effects of Cymbalta

Many medications often have side effects, and Cymbalta is no exception.

Here are some of Cymbalta’s more common side effects:

Typically, these side effects go away or improve within a week or two.

As with any medication, there is a possibility of more adverse effects. These can include liver failure, severe dizziness, abnormal bleeding, abdominal pain, seizures or serotonin syndrome. Reach out to your healthcare provider if you experience any of these rare, but serious, symptoms.

Going off Cymbalta can also cause withdrawal symptoms, so be sure to speak with your healthcare provider before you stop taking the medication.

Our complete Guide to Duloxetine Side Effects goes over all the common side effects and risks of using Cymbalta for mood disorders.

Does Cymbalta Affect Sleep?

Yes, Cymbalta does affect sleep — but in different ways. Two common side effects of Cymbalta are feeling tired and sleepy or having trouble sleeping.

How is it possible that one medication can produce opposite side effects? Well, different medications can have different side effects on different people.

In most cases, the more common side effects of Cymbalta are temporary.

Fatigue can be described as a constant feeling of tiredness or weakness and can be mental, physical or both. If you’re having trouble starting or maintaining activities, difficulty concentrating or a combination of the two, you may be experiencing fatigue as a side effect of Cymbalta.

However, a large number of people who take Cymbalta experience difficulty sleeping or insomnia. Insomnia, or trouble falling or staying asleep, has been reported in nine percent of those taking Cymbalta.

Some people also reported waking up earlier as a mild side effect.

How Does Cymbalta Affect Sleep?

Cymbalta and other serotonin-norepinephrine reuptake inhibitors work primarily to prevent your brain from reabsorbing serotonin and norepinephrine — chemicals that keep our brains active when we’re awake.

Norepinephrine and serotonin also play a part in suppressing rapid eye movement (REM) sleep, or the sleep that happens about 90 minutes after you fall asleep. This is when your brain has a mix of activity and most of your dreaming occurs.

Since Cymbalta helps keep more serotonin and norepinephrine in your system, you may feel more energized and have trouble falling asleep.

There are many reasons why you may be experiencing insomnia. But if you’re having trouble sleeping after starting medication, you may have Cymbalta-induced insomnia.

Trouble sleeping or insomnia can also be an adverse effect of Cymbalta withdrawal.

Poor sleep can also worsen depression in addition to your physical health, leading to a cycle of deteriorating emotional health and overall wellbeing.

How to Sleep While Taking Cymbalta

If your sleep has been affected while taking Cymbalta, don’t worry. We have tips and strategies to help you manage any sleep-related issues.

Pay Attention to Your Side Effects

Whenever you start a new treatment for depression or generalized anxiety disorder, it’s always good to keep track of side effects. It’s also a good idea to let your healthcare provider know if any new ones emerge.

For the first few weeks on Cymbalta, pay attention to your sleep and if you’re having trouble falling or staying asleep.

Your healthcare provider may recommend waiting to see if the side effect resolves itself on its own. If your insomnia doesn’t go away, they may try a different medication or treatment for your depression.

Increase or Reduce Dosage

When starting a new antidepressant, you’ll typically be prescribed a lower dosage and your healthcare provider may gradually increase it until reaching the recommended amount (up to 60mg a day).

You should take the same dose for at least 14 days before increasing the dosage. If you start experiencing insomnia after increasing your dosage, your provider may wait for the side effects to subside and your body to adjust before increasing the amount of medication again.

Your healthcare provider may also reduce your Cymbalta dosage or have you fully stop taking the medication if insomnia persists. A higher dosage can make insomnia worse, as found in a single patient trial.

If your healthcare provider believes you’ll still benefit from Cymbalta for a depressive disorder or generalized anxiety disorder, they may reduce your dosage over time.

If stopping the use of Cymbalta is the best option for you, talk to your healthcare provider before you stop taking it. You’ll need to gradually taper off use so you don’t experience withdrawal effects.

Use Sleep Aids

If you’re having insomnia since starting Cymbalta, certain sleep aids can help.

Melatonin has been shown in some research to ease falling asleep and help establish better-sleeping patterns.

Melatonin is safe to use with the typical dosage of 1mg to 5mg nightly. However, using melatonin while taking Cymbalta can increase side effects of dizziness, drowsiness, confusion and difficulty concentrating.

You should speak with your healthcare provider if you are currently taking Cymbalta before taking melatonin as well.

Other sleep supplements and medications can have adverse effects when taken with Cymbalta. Some drugs that don’t interact well with Cymbalta include St. John’s wort, other antidepressants like monoamine oxidase inhibitors, non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, blood thinners, some migraine medications, high blood pressure medications and more.

Make sure to let your healthcare provider know about any other medications you are taking before starting a Cymbalta prescription to treat anxiety or depression.

Change Your Cymbalta Schedule

If you notice that you’re feeling fatigued or more alert and energized after taking your Cymbalta dose, you may want to change up your dosage schedule.

Cymbalta can be taken any time of day so long as it is taken at the same time every day for the most effective results.

If you currently take Cymbalta at night but are having trouble sleeping, switch to taking it first thing in the morning. Be sure to pay attention to your energy levels and talk to your healthcare provider if you’re still struggling with insomnia.

Avoid Caffeine

While many of us turn to coffee to beat the afternoon slump, caffeine comes back with a vengeance when you’re trying to sleep.

Caffeine counteracts sleepiness by blocking the brain chemical adenosine, which signals our body to become drowsy and sleep to rebuild energy levels.

Try to eliminate that post-lunch cup of coffee or switch to a drink with lower levels of caffeine, such as green tea. You can also try some stretching or go for a quick walk around the block for an energy boost that won’t mess with your sleep.

Practice Good Sleep Hygiene

A good way to make sure you get a good night’s rest is to make sure you have good sleep hygiene.

Keep a set bedtime and wake-up time, avoid large meals too close to bedtime, limit or stop screen time at least 30 minutes before bed and take time to unwind from the day. Establishing a routine before your head hits the pillows will help you sleep better at night.

psych meds online

psychiatrist-backed care, all from your couch

More Information on Treating Depression

Cymbalta is a common treatment option for depression, anxiety, bipolar disorder, nerve pain, fibromyalgia and more. As with many medications, there can be mild side effects or more serious adverse effects.

Having trouble sleeping or insomnia is a common side effect of Cymbalta. There are techniques though to improve your sleep.

Some effective ways to sleep while taking Cymbalta are to ensure you’re taking the correct dosage, using sleep aids and establishing good sleep hygiene to start.

These tips alone may not help your insomnia so talk to your healthcare provider about your side effects.

There isn’t a universal medication or treatment option for depression. You can seek medical advice online from our psychiatry service for an evaluation to learn about all your options and figure out which is the best fit for you.

18 Sources

Hims & Hers has strict sourcing guidelines to ensure our content is accurate and current. We rely on peer-reviewed studies, academic research institutions, and medical associations. We strive to use primary sources and refrain from using tertiary references.

Mental Health By the Numbers. (n.d.). NAMI. Retrieved from https://www.nami.org/mhstats
Zelaya, C. E. , Dahlhamer, J. M., Lucas, J. W., & Connor, E. M. (2020, November). Products - Data Briefs - Number 390 - November 2020. Centers for Disease Control and Prevention. Retrieved from https://www.cdc.gov/nchs/products/databriefs/db390.htm
Dhaliwal, J. S., Spurling, B. C., & Molla, M. (2021, June 11). Duloxetine - StatPearls. NCBI. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK549806/
Cymbalta (duloxetine hydrochloride) capsules. (n.d.). Accessdata.fda.gov. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2010/022516lbl.pdf
Marks, D. M., Shah, M. J., Patkar, A. A., Masand, P. S., Park, G. Y., & Pae, C. U. (2009). Serotonin-norepinephrine reuptake inhibitors for pain control: premise and promise. Current neuropharmacology, 7(4), 331–336. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2811866/
Sheng, J., Liu, S., Wang, Y., Cui, R., & Zhang, X. (2017). The Link between Depression and Chronic Pain: Neural Mechanisms in the Brain. Neural plasticity, 2017, 9724371. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5494581/
Duloxetine (Cymbalta). (n.d.). NAMI. Retrieved from https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Duloxetine-(Cymbalta)
Volpi-Abadie, J., Kaye, A. M., & Kaye, A. D. (2013). Serotonin syndrome. The Ochsner journal, 13(4), 533–540. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3865832/
Brain Basics: Understanding Sleep National Institute of Neurological Disorders and Stroke. (2022, April 1). National Institute of Neurological Disorders and Stroke. Retrieved from https://www.ninds.nih.gov/health-information/patient-caregiver-education/brain-basics-understanding-sleep
Sleep Basics: REM & NREM, Sleep Stages, Good Sleep Habits & More. (2020, December 7). Cleveland Clinic. Retrieved from https://my.clevelandclinic.org/health/articles/12148-sleep-basics
Label for CYMBALTA (Duloxetine Delayed-Release Capsules). (n.d.). Accessdata.fda.gov. Retrieved from https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/021427s049lbl.pdf
DULOXETINE (CYMBALTA). (n.d.). Johns Hopkins Medicine. Retrieved from https://www.hopkinsmedicine.org/neurology_neurosurgery/centers_clinics/peripheral_nerve/patient_info/duloxetine_2007.pdf
Magnuson, V., Wang, Y., & Schork, N. (2016). Normalizing sleep quality disturbed by psychiatric polypharmacy: a single patient open trial (SPOT). F1000Research, 5, 132. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5527988/
Duloxetine (Cymbalta). (n.d.). NAMI. Retrieved from https://www.nami.org/About-Mental-Illness/Treatments/Mental-Health-Medications/Types-of-Medication/Duloxetine-(Cymbalta)
Xie, Z. , Chen, F., Li, W. A., Geng, X., Li, C., Meng, X., Feng, Y., Lu, W., & Yu, F. (2017, May 01). A review of sleep disorders and melatonin. Taylor & Francis. Retrieved from https://www.tandfonline.com/doi/full/10.1080/01616412.2017.1315864
Melatonin Dosage by Age and Weight. (2022, April 5). Sleep Foundation. Retrieved from https://www.sleepfoundation.org/melatonin/melatonin-dosage-how-much-should-you-take
Cymbalta and melatonin Interactions. (n.d.). Drugs.com. Retrieved from https://www.drugs.com/drug-interactions/cymbalta-with-melatonin-949-2273-1548-0.html
Fatigue. (2021, April 24). MedlinePlus. https://medlineplus.gov/ency/article/003088.htm

This article is for informational purposes only and does not constitute medical advice. The information contained herein is not a substitute for and should never be relied upon for professional medical advice. Always talk to your doctor about the risks and benefits of any treatment. Learn more about our editorial standards here.

Duloxetine for the treatment of painful neuropathy, chronic pain or fibromyalgia

Review question

Does duloxetine work to treat pain generated by nerves when damaged by disease or pain caused by fibromyalgia?

Relevance

Duloxetine is a medicine used to treat depression and urinary incontinence (urinary leakage), and may also be useful for certain types of pain. Pain can occur spontaneously when there is damage to the nerves that carry pain information to the brain (neuropathic pain). When nerve damage occurs outside of the spinal cord, it is called peripheral neuropathy. Another type of pain, nociceptive pain, occurs when nerves sense damage to another tissue (such as a prick in the skin). Some types of pain of unknown origin occur without visible nerve or tissue damage. This type of pain occurs, for example, with fibromyalgia. The purpose of this review was to evaluate the benefits and harms of duloxetine for the treatment of neuropathic pain and chronic pain of all types.

Study profile

We reviewed all published scientific literature and found 18 trials with a total of 6407 participants that were of sufficient quality to include in this review. Eight clinical trials examined the effect of duloxetine in painful diabetic neuropathy and six in pain associated with fibromyalgia. Three trials looked at painful physical symptoms associated with depression, and one small study looked at duloxetine for stroke pain or spinal cord disease (central pain).

Main findings and quality of evidence

The usual dose of duloxetine is 60 mg. There was moderate-quality evidence that duloxetine at this dose reduced pain in painful diabetic peripheral neuropathy and fibromyalgia. In diabetic peripheral neuropathic pain, 50% or slightly more had an improvement on duloxetine 60 mg per day more than one and a half times more often than in the placebo group. In other words, five people with diabetic peripheral neuropathy must receive duloxetine in order for one of them to achieve an effect of 50% or more. The effect on fibromyalgia was similar, but the number of patients needed to be treated for improvement of 50% or more was eight. Based on only one study, it is not possible to determine whether the 20 mg dose is effective, and the 120 mg dose was no more effective than 60 mg.

We calculated that there were sufficient trials for diabetic neuropathy to draw these conclusions and no further trials are required. For fibromyalgia and the painful symptoms associated with depression, more trials are needed to make strong claims about the effectiveness of duloxetine.

Most people who take duloxetine will have at least one side effect. They are mostly minor and the most common are feeling unwell, insomnia or drowsiness, headache, dry mouth, constipation or dizziness. About one in six people will stop taking duloxetine due to side effects. Serious problems associated with duloxetine are very rare.

Although duloxetine is useful in the treatment of neuropathic pain and fibromyalgia, there is little evidence from clinical trials comparing duloxetine with other antidepressants as to which is better.

We conclude that duloxetine can be used to treat pain associated with diabetic neuropathy and possibly fibromyalgia.

The information contained in this review is current up to November 2013, when the most recent literature search was made.

Translation notes:

Translation notes: Translation: Alexandrova Elvira Grigorievna. Editing: Gamirova Rimma Gabdulbarovna, Ziganshina Lilia Evgenievna. Russian translation project coordination: Kazan Federal University. For questions related to this transfer, please contact us at: [email protected]

Depression

Russian Academy of Medical Sciences
SCIENTIFIC CENTER FOR MENTAL HEALTH

DEPRESSION (from hope to certainty).
(INFORMATION FOR PATIENTS AND THEIR FAMILIES)

MOSCOW
2008

Oleichik I. V. - Candidate of Medical Sciences, Leading Researcher of the Department for the Study of Endogenous Mental Disorders and Affective States

© 2008, Oleichik I.V.
© 2008, NTsPZ RAMS

The vast experience accumulated by mankind and reflected in many literary works convincingly shows that sadness (sadness, spleen) has always gone side by side with people, being one of the natural human emotions. None of us is immune from failures, illness, breakups, loss of loved ones, financial collapse. Each person can face something inevitable and inevitable, when it seems that life loses its meaning, and despair becomes boundless. However, normally, sadness, sadness and melancholy, as natural reactions to traumatic events, weaken over time and the person's condition returns to normal without special treatment. The situation is different with depressions, which are mental disorders that differ from natural physiological reactions in greater intensity, special severity of experiences and persistence of manifestations. True depression rarely goes away on its own, requiring persistent, sometimes long-term treatment.
A depressive state (from the Latin word depressio - suppression, oppression) is a disease that concerns not only an individual specific sick person, but is also a significant burden of modern society, since it is spreading more and more widely in the world, causing enormous damage to the health of the population and the state. economy. And this applies to all countries, regardless of their level of social development. Every year, at least 200 million people in the world fall ill with depression. Perhaps these figures are even higher, since most victims of depression do not seek help, because they are not aware of the painfulness of their condition. Scientists have calculated that almost one in five people who have reached adulthood will experience at least one episode of depression during their lifetime.
In the most general sense, a depressive state is one of the possible forms of a person's response to the impact of stress factors. In some cases, depression can be triggered by external negative influences, for example, mental trauma, excessive educational or work overload, infection or other serious somatic disease, traumatic brain injury, changes in the hormonal background, which is especially important for the female body, regular certain medications, such as hormones, blood pressure medications, alcohol or other drug abuse. In other cases, depressive states develop as a manifestation of such mental illnesses, in which the main influence is heredity or characteristics of the nervous system (cyclothymia, dysthymia, manic-depressive psychosis, schizophrenia, etc.). If, based on the description of depressive symptoms set out later in our brochure, you realize that you have indeed developed a depressive state, do not fall into despair, do not “try to control yourself”, remember that depression is not a manifestation of weakness of will or character, on the contrary, weakening of volitional qualities is one of the main symptoms of depression. Depression is a disease like rheumatism, arthritis or hypertension, it responds well to treatment, resulting in almost always a full recovery. You should not blame yourself for the occurrence of depression, it does not indicate either your fault, or your weakness, or the possible development of a more severe mental pathology. Below we will tell you about the symptoms of depression, which can be extremely diverse.

Manifestations of depression

Manifestations of depression can be very different. Depressive states can be manifested by a violation of almost all aspects of mental life: mood, memory, will, activity, which is expressed in the appearance of sadness, sadness, mental and muscle retardation, lasting at least 2 weeks. Depressed mood during depression can manifest itself as mild sadness, sadness, and boundless despair. Often it is accompanied by a feeling of melancholy, unbearable heaviness in the soul, with excruciating pain behind the sternum, a feeling of hopelessness, deep depression, hopelessness, helplessness, despair and uncertainty. At the same time, the patient is completely immersed in his gloomy experiences, and external events, even the most joyful ones, do not affect him, do not affect his mood, and sometimes even worsen the latter. A constant "companion" of a depressive mood is also anxiety of varying severity: from mild anxiety or tension to violent excitement, riot. Anxiety and bad mood arise at the mere thought of the need to make some kind of decision or change your plans due to suddenly changed circumstances. Anxiety can also manifest itself on the physical (bodily) level in the form of belching, intestinal cramps, loose stools, frequent urination, shortness of breath, palpitations, headaches, increased sweating, etc.
The picture of depression is complemented by the disappearance of desires, interests, a pessimistic assessment of everything around, ideas of one's own low value and self-blame. Deficiency of vital impulses is manifested in patients with a variety of symptoms - from lethargy, physical weakness to a state of weakness, loss of energy and complete impotence. Where an important decision is required, a choice between different options, human activity is sharply hampered. Depressed people are well aware of this: they complain that insignificant everyday tasks, small issues that used to be solved almost automatically, take on the significance of complex, painful, insoluble problems. At the same time, a person feels that he began to think, act and speak slowly, notes the suppression of instincts (including food and sexual instincts), the suppression or loss of the instinct of self-preservation and the lack of the ability to enjoy life up to complete indifference to what used to be liked evoked positive emotions.
People suffering from depression often feel "stupid", "mentally retarded", "feeble-minded". Thinking in depression becomes viscous, painful, requires special efforts, one mental image is hardly forced out by the next. The sick person is oppressed by the feeling of his own intellectual insolvency, professional collapse. Depressed patients can hardly describe their painful experiences to the doctor. Only after getting out of depression, many of them say that the mood at that moment was lowered, thinking was slow, all undertakings (including treatment) seemed in vain, and the years lived were empty and useless. However, at the time of the first visit to the doctor, they could not explain this because of the almost complete absence of thoughts in their heads, “para-lich of thinking”. With depression, there are also often complaints of memory loss, which is why those suffering from it assume that they have "Alzheimer's disease", "schizophrenia", "senile dementia", which is not true. Especially often these complaints are found in depressions that develop in adolescence.
Typical story
Aleksey, 18 years old, 1st year student of a technical university, describes his condition during depression as follows:
“From childhood, I was fond of technology and modeling, I could read special literature for hours, won school and regional olympiads in mathematics and physics. After graduating from school, my dream came true - I brilliantly passed the exams to a prestigious university. Then it seemed to me that the whole world was at my feet, I flew with happiness "as if on wings." In September, I happily began to study. At the beginning, everything worked out well, but after 2 months I began to notice that it was becoming increasingly difficult for me to absorb what I read, I did not remember the simplest text, I could not solve problems that I used to “click like nuts”. Trying to achieve success through many hours of brainstorming or drinking a few cups of coffee led to the fact that I completely stopped thinking about anything. It seemed to me that I was "finally and irreversibly stupid." At night I sobbed, wrapped in a blanket and thought about how best to commit suicide. Luckily, I met a senior in the library and shared my problems with him. My new acquaintance said that he experienced something similar and advised me to contact the psychiatrist of the student clinic. After the examination, I was diagnosed with juvenile depression and sent for treatment to a specialized medical center. After 2 months, I felt completely healthy, returned to my studies and caught up with my classmates.

Depression can also be accompanied by real setbacks: for example, a decrease in academic performance, the quality of work, family conflicts, sexual disorders and their consequences for personal relationships. As a rule, the significance of these failures is exaggerated and as a result there is a false sense of the irreparability of what happened, "the collapse of all hopes."
Another generally recognized danger of depression is the possibility of suicidal thoughts, which often lead to suicide attempts. The condition of a person suffering from depression can suddenly deteriorate sharply, which happens either without clear external causes, or under the influence of traumatic situations, unpleasant news. It is during these hours, and sometimes even minutes, that a fatal decision is made. Factors that increase the risk of suicide in depression are past suicide attempts, the severity and duration of the depressive state, the presence of anxiety in its structure, prolonged insomnia, loneliness or alienation in the family, alcohol and drug abuse, loss of work and a sharp change in lifestyle, as well as relatives commit suicide.
Typical story
Eugene E., 35 years old, leading manager of the company.
Almost all my life, my career went “on the ascending”, the goals set were clear, clear and achievable. The marriage was extremely harmonious, two beloved children grew up. He devoted almost all the time to the affairs of the company, occasionally, once every 1-2 months, he escaped with his family out of town, to the country. He often lacked sleep, stayed late at work, took home assignments, and was deeply worried about the affairs of the company. Gradually, irritability, fatigue, insomnia, difficulty concentrating appeared, more and more often he suffered a “fiasco” in intimate life. Thoughts appeared that life was lived in vain, that it is a "chain of tragic mistakes" that led to a dead end. He began to believe that the choice of work, friends, family was wrong, for which now "retribution has come." Analyzing the past years for a long time, he found more and more evidence and examples of his "duplicity, hypocrisy, insincerity, etc. " I realized that the only way to solve all problems is to voluntarily leave this life. At the same time, he believed that by this act he would free the family from the “burden”, “loser”, “loser”. I decided, having locked myself in the garage, to get poisoned by the exhaust gases of the car. However, by chance, in a semi-conscious state, he was discovered by an employee of a garage cooperative. He explained what happened as an "accident". The thought of leaving life did not leave the patient. I decided to shoot myself with a gas pistol, which I had long ago acquired for self-defense. After a shot in the mouth, in a serious condition, he was taken to the Research Institute. Sklifasovsky, from where he was discharged a week later. The alarmed wife, suspecting something was wrong, decided to consult her husband with a psychiatrist. He was admitted to the clinic. He agreed to this only out of respect for family relations, he himself believed that treatment by psychiatrists was completely useless, because. his situation is hopeless and no medicines will help here, but will only "stupefy" his psyche. However, after two weeks of taking a modern antidepressant, the patient's point of view changed. Everything began to look not so bleak and hopeless, interest in work and life in general returned, I began to feel more cheerful, more energetic, interest in intimate life appeared. He took work to the clinic, called up colleagues. After two months of treatment, he fully returned to his usual life. With bewilderment, he recalled his thoughts about insolvency, the collapse of life, suicide. He took the drug prophylactically for about six months, then, on the recommendation of a doctor, he gradually reduced the dose and stopped taking it. Over the next two years, the condition remained stable, career growth continued, another child was born.

Depression is also characterized by sleep disturbances, which occur in approximately 80% of patients. As a rule, these are early awakenings with the inability to fall asleep, lack of a sense of sleep, difficulty falling asleep. These disorders, as well as restless sleep with unpleasant dreams, are often the very first symptoms of incipient depression.
If the depression is not deep, it is sometimes difficult to recognize it. This is due to the fact that people are ashamed to tell others about their problems, to admit to "weaknesses". Quite often, especially in Russia, depressive states are masked by alcohol abuse (“vodka heals”). In addition, often patients suffering from depression, in order to "shake themselves up", "throw into all serious", engage in casual sex, are fond of gambling or extreme sports, leave to serve on a contract in "hot spots", lead an idle lifestyle with constant attendance at entertainment events. Surrounding people, relatives who do not have psychiatric knowledge, often accuse them of debauchery, drunkenness, riotous lifestyle, parasitism. Meanwhile, this behavior is a kind of “cry for help”, an attempt to fill the spiritual emptiness brought by depression with new acquaintances and impressions.
Depressive conditions can occur in shallow forms that are easily treatable, but at least a third of depressions are more severe. Characteristics for such depressions are:
- ideas of guilt, sometimes reaching the degree of delirium, i.e. unshakable conviction in their sinfulness, low value (patients consider themselves great sinners, believe that because of them all relatives and Mankind will die, that they are “moral freaks” from birth, supposedly deprived of the foundations of morality and a sense of empathy for other people that they have no place on earth They find in their past numerous "confirmations" of what has been said above, they believe that the doctor and other patients are aware of these transgressions and express contempt and indignation with their facial expressions and gestures, but in the words “they hide, deny the obvious.” Both the patients themselves and their relatives must remember this in order to prevent the impending threat in time: remove all firearms, piercing and cutting objects, ropes, potent drugs and poisonous close household fluids, close windows or shutters, do not let the patient go anywhere alone. If these ideas become persistent and cannot be dissuaded, it is urgent to seek advice from a psychiatrist. neurological institution or call a psychiatrist at home.
- mood swings during the day: in typical cases, the patient, waking up, immediately feels longing. Sometimes, even before full awakening, through a dream he experiences a painful premonition of a heavy coming morning. In the evening, the state of health improves somewhat.
- the patient may experience a feeling of unmotivated hostility towards relatives, friends, constant internal discontent and irritation, which makes him unbearable for the family.
- in a number of people suffering from depression, constant doubts, fear for the health and well-being of loved ones, obsessive ones, come to the fore. arising against the will, ideas about the misfortunes and troubles of family members.

Typical story
Dmitry Petrovich, 58 years old, teacher.
“After minor troubles at work, I began to feel incomprehensible anxiety and agitation. Unpleasant thoughts came into my head that I did something wrong at work, because of which I double-checked everything many times and went home later than everyone else. But even at home, the anxiety did not let go: as soon as the daughter or wife lingered for at least half an hour, terrible pictures of traffic accidents or violence were drawn in the imagination. I fell asleep only in the morning, got up broken and felt sleepy all day. I took Valerian, Corvalol, but it practically did not help. At work, they hinted whether I should take a vacation. Friends advised me to consult a neuropathologist, but he did not find his pathology and sent me to a psychiatrist. I was diagnosed with anxiety depression. After a course of outpatient treatment, I completely recovered.”

- in many cases, depression is characterized by unpleasant sensations in the body, disturbances in the activity of internal organs in the absence of objective signs of true somatic, i.e. non-mental illness. At the same time, many patients constantly report pain, internal discomfort. Some complain of headaches, pains in the stomach, joints, lower back, others - of disorders in the intestines: constipation, indigestion, irritation of the colon, others pay attention to a decrease in sexual desire and potency. In women, menstruation often becomes painful and irregular. Approximately 50% of depressed people at the doctor's office complain of such physical ailments, without mentioning the depressed mood or state of mind underlying the depression. Experiencing chronic pain or other unpleasant sensations in the body, patients may not realize that they are suffering from depression, even with severe melancholy, considering the latter a reaction to painful bodily discomfort.
- some patients are convinced that they have some rare and difficult to diagnose disease and insist on numerous examinations in general medical institutions. Doctors call this condition masked (hidden) depression, in which a person may experience pain in the head, in the limbs, behind the sternum, in the abdomen and in any other parts of the body, he may be haunted by anxious fears, he may suffer from insomnia or, on the contrary, too much sleep.
- Patients may experience disturbances in the cardiovascular system, skin itching or lack of appetite. All of these are manifestations of depression.
- the pathological sensations that patients experience during such depressions are quite real, painful, but they are the result of a special mental state, and not an internal disease. It must be remembered that the frequency of latent depressions exceeds the number of explicit ones many times over.
- with such depression, patients, as a rule, also have a changed attitude towards food: they can go without food for a long time and not feel hungry, and sitting down at the table, eat only 1-2 spoons - they have neither strength nor desire for more .
- a sign of depression can serve as a weight loss of more than 5 kg. within a month. In some people, especially women, the appetite for depression, on the contrary, increases, sometimes reaching the level of excruciating hunger, accompanied by severe weakness and pain in the epigastric region. In some cases, food is taken in excess due to an increased craving for sweets or attempts to distract oneself from painful thoughts by frequent eating.
Thus, we see that depression is a disease with many different manifestations that do not go away on their own, requiring special, sometimes long-term, medical intervention. Therefore, when the symptoms described above appear, it is necessary to seek help from a psychiatrist who will prescribe and monitor antidepressant treatment.

TREATMENT OF DEPRESSIVE DISORDERS

To date, it can be argued that the vast majority of cases of depression respond well to treatment. According to modern views, effective treatment of depression consists of a combination of pharmacotherapy, psychotherapy and, if necessary, other types of treatment. At the same time, the main role in therapy, of course, belongs to antidepressants - drugs specially designed for the treatment of various types of depression.
The creation of antidepressants is based on the discovery of scientists that depression develops as a result of a violation of the mechanism of biochemical transmission of nerve impulses in the brain regions responsible for mood, behavior, response to stress, sleep and wakefulness, appetite and some other functions. To ensure the coordination of the work of all these functional divisions, the brain sends special "commands" to them in the form of chemical impulses transmitted from the processes of one nerve cell (neuron) to the processes of another. This transmission is carried out with the help of chemical mediators (neurotransmitters), which, after transmitting a signal, partially return to the original neuron. This process is called neurotransmitter reuptake. Thanks to him, the number of mediators in the microscopic space between the processes of neurons (in the so-called synaptic cleft) decreases, which means that the necessary signals are transmitted worse. Numerous studies have shown that mediators of various structures, in particular, norepinephrine and serotonin, are involved in the transmission of signals that ensure the normal functioning of the nervous system. The first of them has a general activating effect, maintains the level of wakefulness of the body and takes part in the formation of adaptive reactions, and the second has the main antidepressant effect, controls impulsive actions, anxiety, aggressiveness, sexual behavior, falling asleep, feeling of pain, therefore serotonin is called sometimes a "good mood" regulator. A decrease in the number of mediators in the synaptic cleft causes symptoms of depression, while an increase, on the contrary, prevents their appearance. The ability of some drugs in one way or another to increase the concentration of mediators in the synaptic cleft allows them to be used as antidepressants.
Now antidepressants are used in Russia, which can be conditionally divided into 4 generations according to the time of creation.
The first antidepressants to find wide clinical use were tricyclic drugs: amitriptyline and imipramine. They have a fairly powerful effect on most depressive states by blocking the reuptake of both norepinephrine and serotonin. However, the real clinical effect of these drugs is significantly offset by their undesirable side effects, which drastically reduce the quality of life of patients during treatment. Side effects of tricyclic antidepressants arise due to the nonspecificity of their effect on receptor structures. Acting in addition to the serotonin and norepinephrine system and other neurotransmitters (acetylcholine, histamine, dopamine), these antidepressants cause side effects such as urinary retention, dry mucous membranes, constipation, palpitations, fluctuations in blood pressure, confusion, tremor, sexual dysfunction. functions, weight gain. In such cases, it is necessary to prescribe other drugs to correct side effects or reduce the therapeutic dose of drugs, which naturally affects the effectiveness of the antidepressant action. It has been observed that up to 50% of patients refuse to take tricyclic antidepressants due to severe side effects. For the same reason, physicians are less likely to prescribe these drugs to patients on an outpatient basis.
The situation was somewhat improved by the introduction into practice of drugs of the second generation - tetracyclic antidepressants, which, along with the ability to block the reuptake of norepinephrine and serotonin, could also affect some other receptors. Being analogues of tricyclic compounds, these drugs have antidepressant activity comparable to them, but unlike their predecessors, they are safer, since they cause unwanted side effects much less often. In addition to the antidepressant, mianserin (lerivon) has a clear sedative, anti-anxiety and hypnotic effect. Maprotiline (Ludiamil) has a mild balanced antidepressant effect. In general, these drugs are able to cure mild to moderate depression, but are ineffective in patients with severe depression.
To date, antidepressants of the 3rd generation, such as fluoxetine (Prozac), fluvoxamine (Fevarin), paroxetine (Paxil), sertraline (Zoloft), citalopram (Cipralex) and some other drugs that selectively (selectively) affect the serotonin metabolism system, have received widespread recognition today. , preventing its reuptake in the synaptic cleft. Based on the mechanism of action, these antidepressants are combined into a group of selective serotonin reuptake inhibitors. In addition to treating depression, they are used to correct eating disorders, level panic disorders, so-called social phobias, various obsessive-compulsive disorders and chronic pain symptoms. These drugs have gained popularity due to the possibility of a once-daily intake, concomitant anti-anxiety effect, the presence of a psychostimulant component and a small number of side effects. In addition, they have low toxicity and are well tolerated by elderly patients. However, some researchers note their lack of effectiveness in the treatment of severe forms of depressive states, probably associated with selective activity in relation to only one neurotransmitter - serotonin. It should be noted that in recent years, some American scientists have associated the use of these drugs with an increased risk of suicide, which, however, is not proven.
Considering the high frequency of side effects in some of the above drugs and the insufficient antidepressant activity in others, psychopharmacologists have taken the path of developing more effective antidepressants - IV generation drugs that selectively block the reuptake of both serotonin and noradrenaline, without affecting other mediators. system and with minor side effects. Currently, 3 drugs meet these requirements: milnacipran (Ixel), duloxetine (Cymbalta) and venlafaxine (Effexor). Their antidepressant activity in the treatment of patients with severe and moderate depression has been confirmed in a number of specially conducted studies, which at the same time showed that these drugs are well tolerated.
It should be noted that antidepressants of plant origin (negrustin, gelarium hypericum, deprim, etc.) can be effective in mild depressive states, but there are no reliable data guaranteeing their effectiveness. The opinion of a number of doctors that all depression can be treated with herbs or, say, acupuncture, should be recognized as unfounded.
For extremely severe depressions that do not improve despite the use of the most powerful antidepressants, electroconvulsive therapy (ECT) can be effective, but this situation is extremely rare and requires careful justification by the commission of doctors and the consent of the patient.
An important additional role in antidepressant therapy, especially with concomitant anxiety, is played by tranquilizers - anti-anxiety drugs, such as Xanax, phenazepam, diazepam, nitrazepam, atarax, etc. Drugs that can, when taken systematically, prevent mood swings in various depressive disorders include so-called mood stabilizers or mood stabilizers - lithium preparations, carbamazepine, valproic acid salts, lamotrigine, topiramate. With their systematic intake in most patients, the clinical manifestations of depression either completely disappear or become rare and mild, requiring no hospitalization and not significantly affecting the ability to work.
Antipsychotics play a significant role in the treatment of certain forms of depression. These include both traditional drugs - fluanxol, triftazin, eglonil, teralen, neuleptil, sonapax, and atypical antipsychotics that are gaining more and more recognition among doctors: seroquel, solian, zeldox, rispolept, abilify, serdolect and others.
In drug therapy of depressive conditions, an unconventional, strictly individual approach is used, with the obligatory provision of fruitful cooperation between the patient and the doctor. Otherwise, there may be a violation of medical recommendations regarding doses and regimens for taking medications. The patient's faith in the possibility of recovery, the absence of prejudice against the "harm" caused by psychotropic drugs, the systematic observance of the prescriptions prescribed by the doctor largely contribute to the achievement of therapeutic success.
Drug treatment of depression takes time. You should not expect a complete cure already in the first days of taking the drug. It must be remembered that all modern antidepressants begin to act on depressive symptoms no earlier than 1-2 weeks after the start of treatment. Cancellation of an antidepressant, as well as its appointment, should be carried out only by a doctor. Cancellation is usually made no earlier than 6 months from the normalization of the mental state. Even after the complete disappearance of all symptoms of depression, do not rush to stop taking the drug yourself, as there is a risk of an exacerbation of the disease. Therefore, doctors recommend continuing to take the antidepressant for a certain period of time. A common mistake is the premature withdrawal of drugs soon after a significant improvement in the condition or due to "forgetfulness". To avoid this, try to include the drug in the list of daily urgent matters - for example, store it in the bathroom and take it after hygiene procedures.

Learn more