INTRODUCTION

In 1990 we asked clinicians attending a symposium during the annual meeting of the American Gastroenterological Association how many were using psychopharmacological agents, specifically antidepressants, to treat functional gastrointestinal disorders.¹ Very few raised their hands. Over the subsequent 15 years, these agents increasingly have become used in the management of functional gastrointestinal symptoms, despite a limited amount of scientific information supporting this practice. It is now estimated that at least 1 in 8 patients with irritable bowel syndrome (IBS) is offered an antidepressant.^2,3 Nearly every comprehensive current review of management strategies for IBS and other mainstream functional gastrointestinal disorders mentions their use, and prescribing among gastroenterologists has become commonplace.^3–10 In parallel with this change, primary care physicians have become sufficiently comfortable in using antidepressants for treating not only anxiety and depression but also a host of somatic symptoms and syndromes that their use has nearly tripled in the past decade.¹¹

Enhanced appreciation for the relative importance of central mechanisms (for example, signal processing alterations) in many if not most patients with IBS and other painful functional gastrointestinal disorders is an important factor responsible for prescribing shifts among gastroenterologists—more so than a new or improved understanding of the relationship of symptoms to anxiety or depression.⁸ The composite body of investigation over the past 15 years involving visceral stimulation, brain imaging, multidimensional clinical studies, and treatment trials designed to answer mechanistic questions has led us closer to understanding the pathways by which psychopharmacological agents may interrupt the symptomatic process in these common gastrointestinal disorders. Complemented by clinical observations, improved recommendations for their use have evolved.^6,12 This review describes the types of psychopharmacological agents used in functional gastrointestinal disorders, new models for their potential benefits, a summary of the reported efficacy, and practical aspects …