Cochrane for Clinicians

Putting Evidence into Practice

Selective Serotonin Reuptake Inhibitors for Fibromyalgia


Am Fam Physician. 2016 Oct 1;94(7):548-549.

Author disclosure: No relevant financial affiliations.

Clinical Question

Would a selective serotonin reuptake inhibitor (SSRI) improve worsening fatigue, pain, and depression in a patient with fibromyalgia?

Evidence-Based Answer

SSRIs may have a small to moderate effect on pain (number needed to treat [NNT] = 10), global improvement (NNT = 7), and depression (NNT = 13) in patients with fibromyalgia, but the quality of evidence is very low because of bias and small studies. SSRIs do not reduce fatigue related to fibromyalgia.1 (Strength of Recommendation: B, based on very low–quality randomized controlled trials.)

Practice Pointers

Fibromyalgia is a poorly understood disorder characterized by chronic, widespread pain that is often complicated by severe fatigue, mood disturbance, and sleep difficulties.2 It affects 2% to 8% of the population, depending on the diagnostic criteria used.2,3 The widespread nature of the pain and confirmation of a biologic basis of the disorder via brain neuroimaging have led clinicians to believe that SSRIs may be helpful in managing the symptoms of the disorder.

This Cochrane meta-analysis reviewed eight double-blind randomized controlled trials that included 383 patients.1 The only SSRIs examined were citalopram (Celexa), fluoxetine (Prozac), and paroxetine (Paxil), and the studies lasted from four to 16 weeks. The overall quality of evidence from the studies was judged to be very low because of the small number of participants as well as concerns about bias, including pharmaceutical funding in a majority of the trials. The authors evaluated seven primary outcomes and four secondary outcomes for this review.

Six of the eight studies examined whether patients had at least 30% pain reduction. SSRIs were superior to placebo, but the confidence interval (CI) was wide (NNT = 10; 95% CI, 5 to 100). SSRIs were also superior to placebo in global improvement measures (NNT = 7; 95% CI, 4 to 17). Two of the eight studies compared SSRIs with other active drugs, including amitriptyline and melatonin, for the o

Author disclosure: No relevant financial affiliations.


show all references

1. Walitt B, Urrútia G, Nishishinya MB, Cantrell SE, Häuser W. Selective serotonin reuptake inhibitors for fibromyalgia syndrome. Cochrane Database Syst Rev. 2015;(6):CD011735....

2. Clauw DJ. Fibromyalgia: a clinical review. JAMA. 2014;311(15):1547–1555.

3. American College of Rheumatology. Fibromyalgia. Accessed January 2016.

4. Department of Veterans Affairs/Department of Defense. VA/DoD clinical practice guideline for the management of chronic multisymptom illness. Accessed March 2016.

These are summaries of reviews from the Cochrane Library.

This series is coordinated by Corey D. Fogleman, MD, Assistant Medical Editor.

A collection of Cochrane for Clinicians published in AFP is available at



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