What is the role of duloxetine (cymbalta) in treating psychogenic cough?

Duloxetine for Psychogenic Cough (Somatic Cough Syndrome)

Duloxetine is not recommended as a first-line treatment for psychogenic cough (now termed somatic cough syndrome), as behavioral and psychological interventions should be prioritized according to current guidelines. 1, 2

Current Terminology and Diagnostic Considerations

• The American College of Chest Physicians (ACCP) recommends against using the term "psychogenic cough" and suggests using "somatic cough syndrome" instead 1
• Diagnosis should only be made after:
  • Extensive evaluation ruling out organic causes
  • Ruling out tic disorders and Tourette syndrome
  • Meeting DSM-5 criteria for somatic symptom disorder 1

Treatment Approach for Somatic Cough Syndrome

First-Line Treatments (Evidence-Based)

1. Non-pharmacological interventions:
   • Suggestion therapy 1, 2
   • Hypnosis 1, 2
   • Counseling and reassurance 1
   • Referral to psychologist/psychiatrist 1, 2
   • Speech therapy techniques 2
   • Behavioral modification therapy 2, 3
   • Biofeedback-assisted relaxation (reported in case studies) 4

Role of Pharmacological Treatments

• The ACCP guidelines do not specifically recommend duloxetine for somatic cough syndrome 1, 2
• Guidelines mention that "appropriate psychotropic medications" might be considered as part of combination therapy 1
• Short-term antitussive agents may help control cough initially, but no specific agent has been studied in randomized controlled trials 2

Case Evidence for Psychotropic Medications

• A case report of a 9-year-old girl with psychogenic cough and comorbid anxiety showed improvement with escitalopram (an SSRI) when added to ongoing behavioral therapy 5
• No specific case reports or studies were identified that evaluated duloxetine specifically for somatic cough syndrome

Clinical Considerations and Pitfalls

• Common pitfall: Assuming psychological manifestations are causing the cough rather than resulting from it 1

  • Patients with chronic cough often experience psychosocial and physical adverse effects
  • Depression/anxiety may develop secondary to chronic cough

• Important assessment: Evaluate for underlying psychosocial problems 1, 2

  • Anxiety
  • Depression
  • Domestic violence
  • Child abuse/neglect (in pediatric cases)

• Treatment challenges: Evidence for treating somatic cough syndrome is primarily based on case reports and expert opinion rather than high-quality randomized controlled trials 2

Practical Algorithm for Management

1. Confirm diagnosis through comprehensive evaluation ruling out organic causes

2. Begin with behavioral interventions (suggestion therapy, hypnosis, counseling)

3. Consider psychological referral for formal assessment and therapy

4. If anxiety or depression is identified as a significant comorbidity:

   • Consider appropriate psychotropic medication as adjunctive therapy
   • While duloxetine could theoretically help if anxiety or depression is contributing to the cough, there is insufficient evidence to recommend it specifically for this condition

5. Monitor response and adjust treatment approach accordingly

While duloxetine might theoretically benefit patients with somatic cough syndrome who have comorbid anxiety or depression, current guidelines do not specifically recommend it, and behavioral/psychological interventions should be prioritized as first-line treatment.