psychologic therapies, and stress-management techniques. The committee also considered various outcomes, including symptoms, functioning, quality of life, health care use, and harms. Although the symptoms of CMI are physical, the committee embraced the need for a “whole-person” approach because of the complexity of CMI and its potential comorbidities. The nontraditional treatments were included in an effort to identify potentially effective pathways for treatment of the whole person instead of focusing on each specific symptom.

Only three studies that were identified were conducted in samples of veterans. Each reported the effects of a different intervention: cognitive rehabilitation therapy (Jakcsy, 2002), doxycycline (Donta et al., 2004), and cognitive behavioral therapy (CBT) and exercise (Donta et al., 2003; Guarino et al., 2001; Mori et al., 2006). The veteran populations were generally male (85% in Donta et al., 2003, and Mori et al., 2006; 86% in Donta et al., 2004, and 50% in Jakcsy, 2002), and the average age ranged from 37.5 years (Jakcsy, 2002) to 40.7 years (Donta et al., 2004). The committee considers those studies with others of similar interventions but different populations below.

The committee believed it necessary to consider additional evidence so that it could offer recommendations about the best treatment and management approaches for veterans who have CMI. Thus, the recommendations presented in Chapter 8 result from careful consideration of the evidence presented in the present chapter, evidence on the best treatments for comorbid and related conditions in Chapter 5, and issues surrounding patient care and communication in Chapters 6 and 7.


People who have many of the conditions described in this report are treated with pharmacologic agents that are also used to treat for other conditions. Often, the mechanisms of action of the pharmacologic agents are unknown. For example, patients who have fibromyalgia may benefit from duloxetine, which works independently of depression (which duloxetine is often prescribed for). Such agents include selective serotonin reuptake inhibitors, serotonin–norepinephrine reuptake inhibitors (for example, duloxetine), tricyclic medications (for example, amitriptyline), monoamine oxidase inhibitors (for example, phenelzine), dopaminergic blockers (for example, haloperidol), anxiolytics (for example, benzodiazepines), and medications that potentiate gaba-ergic transmission (for example, gabapentin), potentiate binding of voltage-gated calcium channels (for example, pregabalin), and potentiate voltage-dependent sodium channels (for example, topiramate). Analgesic medications include nonsteroidal anti-inflammatory analgesics, acetaminophen, opioid analgesics, and tramadol,

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