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
