Treatment of these symptoms can pla

Treatment of these symptoms can play an important role in achiev-ing optimal outcomes, including improved remission and functioning (Fava et al., 2004; Ohayon, 2004; Robinson et al., 2013). Duloxetine has been shown to be effective in treating such painful symptoms associ-ated with depression (Fava et al., 2004; Brecht et al., 2007; Robinson et al., 2013), whereas no such evi-dence is available for SSRIs. For instance, Fava et al. (2004) examined the effect of duloxetine on depression-related PPS in a post-hoc analysis of two identically designed 9-week RCTs of duloxetine with a daily dose of 60 mg versus placebo. The study reported the superiority of duloxetine over placebo in reducing pain severity. In addition, improvements in pain severity were found to be associated with more favor-able depression treatment outcomes, including higher rates of remission and improved QoL. More recently, similar findings were also reported in a post-hoc analysis of two identically designed 8-week trials com-paring the efficacy of 60 mg/day duloxetine with that of placebo (Robinson et al., 2013). Using path analysis, the study showed that 16% of the likelihood of remis-sion in depression symptoms was attributable to the direct effect of treatment, 41% attributable to pain reduction, and the rest attributable to functional improvement. Furthermore, this trial also showed that duloxetine-treated patients with at least 30% or 50% improvement in pain severity at endpoint achieved more remission, compared with duloxetine-treated patients without these levels of improvement in pain (Gaynor et al., 2011a,b). In light of these findings, it should also be noted that although 45% of the patients included in our study had PPS at baseline, this percentage decreased to 15% at 8 weeks and 5% at 24 weeks. The improvement in these painful symptoms might have further contributed to the superiority of duloxetine over SSRIs on depression outcomes and QoL in our study. This is also supported by our obser-vation that the effects of duloxetine relative to SSRIs were greater in patients who had PPS at baseline than in those patients without such symptoms at baseline. Taken together, our findings reconfirm the importance of controlling pain symptoms in the treatment of depression and the potential advantages of duloxetine over SSRIs at least for patients with concurrent pain and depression.