Tricyclic Antidepressants, SSRIs and Descending Serotinergic Facilitatory Pathways

Tricyclic antidepressants are a widely used method of treatment in patients with neuropathic pain and fibromyalgia. They achieve their effect by virtue of their effect on the descending serotinergic inhibitory pathways. New evidence suggests that as well as these conventionally accepted inhibitory pathways that descending bulbospinal facilitatory pathways also exist and that the potential for agents that augment the serotinergic systems to actually magnify, rather than diminish pain actually exists. The clinical implications of these findings are discussed along with suggestions as to how these descending facilitatory drives may be minimized.