Transcript Depressive Disorders and Pain - World Psychiatric Association

The WPA Educational
Programme on the Management
of Depressive Disorders
Depressive Disorders and Pain
Hayley Pessin, Ph.D., Wendy G. Lichtenthal, Ph.D., Emily
Sachs, M.A., Elissa Kolva, M.A. and William Breitbart, M.D.
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Relationship Between Depression & Pain
• Reciprocal relationship between pain and depression
– Ratings of pain intensity influenced by psychological factors
– Mood is influenced by functional limitations associated with pain more than by pain
severity
– Presence of pain influences onset and severity of depressive symptoms
(Mystakidou et al., 2006; Serlin et al., 1995)
• Pain is subjective and vulnerable to fluctuations in mood
• Co-morbid depression and pain
– More resistant to treatment (Gallagher & Cariati, 2002)
– May require multimodal intervention (Brietbart & Holland, 1990)
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Prevalence of Comorbid Pain & Depression
• Approximately 30% of patients suffering from persistent pain develop clinical
depression (Gallagher & Cariati, 2002)
• Patients with chronic pain are 4x more likely to develop an anxiety or
depressive disorder (Gureje et al., 1998)
• 50% of patients with depression report substantial pain (e.g., headache,
abdominal, thoracic and pelvic pain)
• Medical illnesses characterized by painful symptoms (e.g., cancer, HIV,
chronic back pain) increase risk of depression
• International estimates of depression-pain syndrome range from 22% - 87%
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Symptoms Shared by Pain & Depression
Pain and depression share many symptoms (Turk et al. 2002)
• Sleep disturbance
• Mood symptoms
– anxiety, irritability, decreased pleasure, sadness
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Family stress
Reduced sexual activity
Reduced physical activity/exercise
Decreased self-esteem
Financial stress
Vocational issues
Legal concerns
Fear of injury
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Common Etiologies & Pathways
• No clear dominant causal or antecedent pattern despite established
relationship between depression and pain
• Two possible frameworks (Von Korff & Simon, 1996)
1. Genetic vulnerability to both physical and psychological symptoms  amplifies
physical discomfort
2. Stress of pain exacerbates psychological symptoms
• “Gate control theory of pain” (Melzack & Wall, 1965)
– non-nociception signals inhibit or enhance nociception signals from nerve fibers
• Neurobiological and biobehavioral processes
– Prolonged pain leads to structural CNS changes (Gallagher, 1999)
– Role of serotonin, norepinephrine in CNS pain-modulating circuit (Sawynok &
Reid, 1996)
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Assessment Issues & Risk Factors
• Assessment Issues
– Poor adherence to treatment due to mood symptoms
– Heightened risk of suicide
• Risk Factors
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Personality disorders and maladaptive coping
Higher number of pain sites
Hopelessness
Impaired cognitive functioning
Desire for hastened death
Sleep disturbances
Poor occupational functioning
Decreased quality of life
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Differentiating Mood Disorders & Pain
• Depression is underdiagnosed in primary care population
– 50% of patients with major depression are not diagnosed by their primary care
physician (Simon & VonKorff, 1995)
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Somatic symptoms underrecognized as symptom of depressive disorders
Diagnostic interview is essential
Self-report measures/ Visual analog scales are helpful
Anhedonia is a key indicator of depression in medically ill
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Cultural Considerations
• Overreliance on somatic symptoms in reporting distress
– Role of cultural stigma
– More common in patients without primary care physician
– Denial of psychological depressive symptoms (Simon et al., 1999)
• Recent findings challenge traditional view of cultural stigma surrounding
depression
– Psychological and somatic symptoms reported at similar rate in non-Western
communities (Simon et al. Ormel, 1999)
• Experience and expression of pain varies across racial, ethnic, and gender
groups
• Healthcare providers can mediate cultural barriers to healthcare access
(Bonham, 2001; Davidhizar et al., 2004)
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Treatment of Pain & Depression
• Psychiatric interventions are integral to a comprehensive clinical approach
• Important to disentangle and address underlying physical and psychological
issues
• Combination treatment approaches may have a reciprocal and/or interactive
effect
• Psychological treatment has been found to impact nociception and
perception of pain
• Physical therapies targeting pain detecting neurons have been found to
improve psychological symptoms
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Treatment of Pain & Depression: Pharmacological
Interventions
First line treatment
• Achieve adequate pain management with analgesics
• Re-evaluate depressive symptoms, as mood symptoms may resolve with
adequate pain management
Second line treatment
• Manage mood symptoms using antidepressants
– SSRIs initially recommended due to dosing simplicity
– TCSs, SNRIs and SSRIs may have antinocieptive effects (Raison & Miller,
2003)
– Serotonergic antidepressants (trazodone, mianserin) have been effective in
relieving pain (Costa et al., 1985)
– MAOIs have adjuvant analgesic properties, but associated with myoclonus and
delirium (Breitbart, 1988)
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Treatment of Pain & Depression: Pharmacological
Interventions continued
Additional Treatments
• Psychostimulants
– As effective as antidepressants (Orr & Taylor, 2007)
– Reduce excessive sedation secondary to opioid analgesics
• Benzodiazepines
– Potent anxiolytics and anticonvulsants (Coda et al., 1992)
– Limited evidence for analgesic effects
• Atypical antipsychotics
– May have analgesic properties, particularly in cancer pain, chronic pain and
fibromyalgia (Khojanova, 2002; Freedenfeld et al., 2006; Gorski & Willis, 2003)
– Reduce depressive symptoms, particularly sadness
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Treatment of Pain and Depression: Psychosocial
Interventions
• Empirically-supported treatments for depression and pain
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Cognitive-behavioral therapy
Acceptance and commitment therapy
Relaxation, guided imagery, self-hypnosis
Biofeedback
Supportive psychotherapy
Family interventions
• Common goals of treatments
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Providing emotional support
Psychoeducation
Assistance with adaptation
Coping strategies
Problem solving
Communication skills
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Treatment of Pain and Depression: Complementary
Treatments
• Complimentary and Alternative Medicine (CAM) approaches are increasingly popular
as primary interventions or in conjunction with traditional treatments, and may improve
both pain and mood symptoms
– Massage
– Acupuncture
– Homeopathic remedies
• St. John’s Wort, Arnicia, Sam-e
• Practitioners should interview patients regarding self-care practices to avoid
the potential negative consequences associated with dietary supplements
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Other Treatment Issues:
Early Intervention
Early Intervention:
• Risk factors (presented earlier) can identify patients who may benefit from
early intervention
• Treatments are more effective
• Lower doses required to manage symptoms
• Spares patients from increased suffering
• Results in optimal treatment
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Other Treatment Issues:
Barriers to Adequate Treatment
• Lack of training in recognition, assessment, evaluation, and treatment of
comorbidity of pain and depression
• Focus on prolonging life
• Lack of patient-physician communication
• Limited expectations for pain relief
• Inadequate assessment due to impaired mental capacity
• Lack of availability of narcotics
• Physician fear of causing additional harm
– Side effects, respiratory depression, sedation
• Physician fear of increasing addiction/substance abuse
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Other Treatment Issues:
Substance Abuse
• Addiction is rare in individuals without a history of drug abuse that predates the
physical illness
• Patients may experience tolerance or physical dependence, but not addiction
• Increased use of opioids is often due to disease progression
• Fear of addiction may lead to patient noncompliance and under-medicating
• If patient has an active addiction, pain management is challenging and may
require specialized substance abuse consultation
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Conclusion
• Comorbid pain and depression is highly prevalent yet under-diagnosed and
under-treated
• The reciprocal relationship between pain and depression is well established
• Recognition and treatment of comorbid pain and depression are both
complicated and require additional training
• Assessment and treatment of pain and depression are essential components
of quality patient care
• Early detection and treatment improves patient outcomes
• Adequate treatment of pain and depression will reduce suffering and improve
patient quality of life
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