Disclosures. Major depressive disorder (MDD) Depression and Chronic Pain: Mechanisms and Treatment

Depression and Chronic Pain: Mechanisms and Treatment Charles DeBattista, MD Professor of Psychiatry and Behavioral Sciences Director: Depression Cli...
0 downloads 2 Views 658KB Size
Depression and Chronic Pain: Mechanisms and Treatment

Charles DeBattista, MD Professor of Psychiatry and Behavioral Sciences Director: Depression Clinic and Research Program Stanford University School of Medicine

Facts about depression • Affects about 10% of the U.S. (Gemignani, 2001) • Prevalence among school age children and adolescents is 4.6% (Wagner, 2003) • Millions do not seek treatment due to inadequate benefits and the stigma associated with depression (U.S. Surgeon General, 2000) • Effective pharmacotherapy combined with psychotherapy has been shown to reduce healthcare costs and the rate of suicide attempts (Ballenger, 1999) • Average disability length as well as disability relapse are greater for depression than most comparison medical groups (Conti and Burton, 1994)

Disclosures Grant Support: NIMH, Takeda, Brain Resources,  Brainsway, Assurex,  Advisory Boards: Genentech, Pfizer

Major depressive disorder (MDD)

Depressed Patients Usually Present with  Physical Symptoms

Global Burden of Disease •Year 2020 1. Ischemic heart disease 

•69% •Presented •ONLY With Physical •Symptoms

•Other

2. 3. 4. 5.

•N = 1146 patients with major depress

•Murray and Lopez, 199

•1. Simon GE, et al. N. Engl J Med. 1999;341(18):1329-1335.

Consequences of Under‐ treatment of Chronic Pain

PAIN CRISES •

Pain accounts for 20% of all clinic visits

• Analgesics = 12% of all prescriptions (# 2) • $100 billion dollars/yr in health care costs • Excessive surgery (e.g., back pain) • Leading cause of work loss & disability • Leading reason for alternative medicine

Major Depression Traffic accidents Cerebrovascular disease COPD

• • • • •

Physiologic (CV, GI, immune) Psychological (depression, anxiety) Diminished quality of Life Impairment of activities Large impact on working age adults – Absenteeism, unemployment, and under‐ employment

Pain:  5th Vital Sign in Primary Care and Association  with Depression • • • •



Pain:  5th Vital Sign in Primary Care and Association  with Depression • • • •

301 primary care Veteran patients Mean age = 60; 91% men; 85% white Depression in 28% (PHQ‐9 ≥ 10) Pain in 76% – Mild 21% (score of  1‐3) – Moderate 31% (score of  4‐6) – Severe 22% (score of 7‐10)

Bair MJ, Williams LS, Kroenke K. J Gen Intern Med 2004;19 (Supplement 1):123.



301 primary care Veteran patients Mean age = 60; 91% men; 85% white Depression in 28% (PHQ‐9 ≥ 10) Pain in 76% – Mild 21% (score of  1‐3) – Moderate 31% (score of  4‐6) – Severe 22% (score of 7‐10)

Bair MJ, Williams LS, Kroenke K. J Gen Intern Med 2004;19 (Supplement 1):123.

Pain and Negative Depression  Outcomes

RECIPROCAL RELATIONSHIP

• PAIN ASSOCIATED WITH:

•Pain

•Depression

– – – – – –

 depressive symptoms  functional limitations  unemployment rate frequent use of opioid analgesics frequent pain‐related doctor visits worse self‐rated health

•Von Korff M. Grading the severity of chronic pain. Pain 1992; 50:133-149

Severity of Pain is Associated with Poor  Depression Outcome

What Symptoms are the Most Resistant? •N=573

•1.2

•4.1

3

•Improvement

•N=573

•*

•2.0

2

•1.5 •No effect relative to patients without pain at baseline

1 •(n=144)

•(n=170)

•(n=81)

Mild

Moderate

Severe

•1 Month

•3 Months

•6 Months

•9 Months

76%

•94% had Physical Symptoms

25%

Patients With Residual Depressive Symptoms

Patients With No Residual Depressive Symptoms

•*Based on Item 13 (general somatic symptoms) of the HAM-D17. •Paykel ES, et al. Psychol Med. 1995;25(6):1171-1180.

•Physical Symptoms

•© 2006 NogginStorm Labs

•% Relapse

•Pain somatic Sx

•0.4

Integrated Model

80

0

•Non-pain somatic Sx

•Adapted from: Greco T, et al. J Gen Intern Med. 2004;19(8):813-818.

Residual Symptoms Predict Relapse

20

•0.6

•Positive well-being

•ARTIST=A Randomized Trial Investigating SSRI Treatment.

•Bair MJ, et al. Psychosom Med. 2004;66(1):17-22.

40

•0.8

•0 •Baseline

•ARTIST=A Randomized Trial Investigating SSRI Treatment. **Poor depression treatment response defined as Symptom Checklist-20 >1.3. Pain severity was measured by the SF-36 pain severity item

60

•1.0

•Nonsomatic depressive Sx

•0.2

0

100

•Treatment Effect Size

•*

•*P

Suggest Documents