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Duloxetine for Depression and Pain — MRCPsych Paper B MCQ

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ModerateMood DisordersDuloxetine for Depression and PainMRCPsych Paper B

A 50-year-old woman has major depressive disorder that has not responded to two adequate SSRI trials. She also has fibromyalgia. When selecting an alternative antidepressant, the clinician wants the drug that is licensed in the UK for both major depressive disorder and diabetic peripheral neuropathic pain and also has placebo-controlled evidence of benefit in adult fibromyalgia. She is advised that prescribing specifically to treat fibromyalgia would be off-label in the UK. Which antidepressant best fits this profile?

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Correct answer: A — Duloxetine

Duloxetine is the best answer. It is a serotonin–noradrenaline reuptake inhibitor licensed in the UK for major depressive disorder and diabetic peripheral neuropathic pain. Meta-analytic evidence from placebo-controlled trials also supports benefit in adult fibromyalgia, although fibromyalgia itself is not a UK-licensed indication. Fluoxetine, sertraline, citalopram and paroxetine are SSRIs. NICE allows each of them, as well as duloxetine, to be considered off-label for chronic primary pain, so fibromyalgia alone does not uniquely distinguish the options. However, none of these SSRI distractors shares duloxetine's UK SmPC indication for diabetic peripheral neuropathic pain. The choice should still follow an individual assessment of previous treatment, contraindications, adverse effects and patient preference.

Reference: electronic Medicines Compendium. Duloxetine Zentiva 30 mg gastro-resistant hard capsules, Summary of Product Characteristics, sections 4.1 and 5.1; updated 2025. https://www.medicines.org.uk/emc/product/100749/smpc