This review concluded that it is impossible to judge the efficacy of antidepressants in treating symptoms of inflammatory bowel disease because of a lack of reliable data. Evaluation in randomised controlled trials was recommended. The authors' main conclusion reflects the limitations of the evidence presented and appears reliable.

To assess the evidence for the efficacy of antidepressants for the control of somatic symptoms in patients with inflammatory bowel disease (IBD).

PubMed, CINAHL, PsycINFO, EMBASE, and the databases of the Cochrane Depression, Anxiety and Neurosis Group and Inflammatory Bowel Disease and Functional Bowel Disorders Group were searched for studies published between 1990 and 2005. Search terms were reported and no language restrictions were imposed. The authors also handsearched selected journals, searched unpublished Australian theses and contacted experts in the field to identify additional studies.

Studies of any design that examined the use of antidepressants in IBD were eligible for the review. Study participants had to have a diagnosis of IBD (Crohn's disease, ulcerative colitis or unspecified inflammatory disorder). Studies had to report on the efficacy of antidepressants in maintaining or inducing remission of IBD symptoms (defined in the paper).

Most of the included studies involved patients with Crohn's disease. All of the participants were adults. The participants in one included study did not have IBD diagnosed before starting antidepressant treatment. The antidepressants used were bupropion, paroxetine, amitriptyline and phenelzine. Where reported, the length of treatment ranged from 6 weeks to 2 years.

The authors did not state how the papers were selected for the review, or how many reviewers performed the selection.

Validity was assessed on the basis of length of treatment, follow-up, clear description of treatment, description of participants and use of validated instruments to assess disease status.

The authors did not state how the validity assessment was performed.

The authors did not state how the data were extracted for the review, or how many reviewers performed the data extraction.

The studies were discussed in a narrative, with reference to positive and negative impacts of antidepressants on IBD activity. Differences between the studies were presented in the tables and discussed in the text.

Twelve publications were included in the review: one non-randomised trial (n=8), six case reports (n=12), two reviews (three stated in the text), one guideline, one discussion paper and one letter.

Five studies met four or five of the quality criteria. The open-label trial and four case reports reported a positive effect of antidepressant treatment on IBD activity in 16 patients. One case report indicated that three patients treated with paroxetine for depression developed chronic diarrhoea and were subsequently diagnosed with IBD. Another case report found no effect of amitriptyline. The other publications provided no new patient data.

It is impossible to judge the efficacy of antidepressants in IBD because of a lack of reliable data.

This review had clear inclusion criteria for the participants, intervention and outcomes. Studies of all designs were eligible and some publications were included that could not provide evidence to answer the review question. The authors searched a range of relevant sources without language restrictions and sought both published and unpublished studies. The risk of publication bias was not assessed. The methods used for the study selection, validity assessment and data extraction processes were not reported, which makes it difficult to assess the risk of reviewer error and bias affecting the review. Validity was assessed using criteria appropriate for the study designs included in the review. Adequate details of the included studies were presented in the text and tables. A narrative synthesis was appropriate in view of the limited quantity and quality of studies included in the review. The review had some weaknesses, but the authors' main conclusion reflects the limitations of the evidence presented and appears reliable.

Practice: The authors did not state any implications for practice.

Research: The authors stated that the efficacy of antidepressants for the treatment of IBD should be studied in properly designed randomised controlled trials.

University of Adelaide; Royal Adelaide Hospital.

This is a critical abstract of a systematic review that meets the criteria for inclusion on DARE. Each critical abstract contains a brief summary of the review methods, results and conclusions followed by a detailed critical assessment on the reliability of the review and the conclusions drawn.