Comorbid depression, chronic pain, and disability in primary care

Deconstructing Pain Disability through Concept Analysis

OBJECTIVE

Pain disability is a complex and challenging problem that impacts the daily lives of individuals living with persistent pain. Although this concept is measured throughout pain populations, conceptual clarity is needed to identify the defining characteristics and further understand what comprises this experience for clinical translation.

DESIGN

We completed a concept analysis to identify major attributes and provide a broad framework of pain disability for improved recognition throughout the discipline of nursing.

DATA SOURCES

Literature searches in PubMed, CINAHL, PsychINFO, and Scopus identified 39 relevant cross-disciplinary articles published between January 1990 and November 2017.

REVIEW/ANALYSIS METHODS

We implemented Avant and Walker's method of concept analysis to establish the attributes, antecedents, and consequences of pain disability.

RESULTS

Two major attributes of pain disability are discussed, including (1) physical and/or psychological responses leading to a functional loss; and (2) the degree of ability to fulfill role expectations. The antecedent to the development of pain disability is a painful trigger. Three leading consequences are identified as suffering, pain reactivity, and secondary loss.

CONCLUSIONS

Pain disability is a fluid concept that is characterized by the subjective experiences of the individual. A new conceptualization of pain disability is offered as the inability to maintain role expectations due to the result of a painful trigger and subsequent physical and/or psychosocial dysfunction.

Psychology of Chronic Pelvic Pain: Prevalence, Neurobiological Vulnerabilities, and Treatment

Patients with pelvic pain suffer from psychological conditions at a disproportionately high rate compared with their peers. We review environmental, genetic, inflammatory, and neurobiological factors that increase vulnerability to developing both of these conditions. We review treatment strategies for chronic pelvic pain in patients who have comorbid psychological conditions, including both nonpharmacologic and pharmacologic options.

Naloxone prolongs abdominal constriction writhing-like behavior in a zebrafish-based pain model

The ability to detect noxious stimuli is essential to survival. However, pathological pain is maladaptive and severely debilitating. Endogenous and exogenous opioids modulate pain responses via opioid receptors, reducing pain sensibility. Due to the high genetic and physiological similarities to rodents and humans, the zebrafish is a valuable tool to assess pain responses and the underlying mechanisms involved in nociception. Although morphine attenuates pain-like responses of zebrafish, there are no data showing if the antagonism of opioid receptors prolongs pain duration in the absence of an exogenous opioid. Here, we investigated whether a common opioid antagonist naloxone affects the abdominal constriction writhing-like response, recently characterized as a zebrafish-based pain behavior. Animals were injected intraperitoneally with acetic acid (5.0%), naloxone (1.25 mg/kg; 2.5 mg/kg; 5.0 mg/kg) or acetic acid with naloxone to investigate the changes in their body curvature for 1 h. Acetic acid elicited a robust pain-like response in zebrafish, as assessed by aberrant abdominal body curvature, while no effects were observed following PBS injection. Although naloxone alone did not alter the frequency and duration of this behavior, it dose-dependently prolonged acetic acid-induced abdominal curvature response. Besides reinforcing the use of the abdominal writhing-like phenotype as a behavioral endpoint to measure acute pain responses in zebrafish models, our novel data suggest a putative role of endogenous opioids in modulating the recovery from pain stimulation in zebrafish.

Patient-reported use of medical cannabis for pain, anxiety, and depression symptoms: Systematic review and meta-analysis

RATIONALE

Certifications for medical cannabis are generally restricted to a small number of specific medical conditions, yet patients frequently report symptoms of pain, anxiety, and depression as reasons for use. This is a critical concern for researchers, healthcare providers, and policymakers, yet research in this area is currently obstructed by the lack of a focused review or empirical synthesis on patient-reported reasons for medical cannabis use.

OBJECTIVES

AND METHOD: The first aim of this project was to conduct the first systematic review and meta-analysis of empirical studies of patient-reported symptoms of pain, anxiety, and depression as reasons for medical cannabis use. The second aim was to conduct an empirical assessment of the methodological quality of extant research, test for publication bias, and test sex composition and quality scores of individual studies as possible sources of observed heterogeneity.

RESULTS

Meta-analytic results indicated that pain (64%), anxiety (50%), and depression/mood (34%) were common reasons for medical cannabis use. No evidence for publication bias was detected, despite heterogeneity in prevalence rates. A comprehensive assessment of study quality identified a number of specific methodological limitations of the existing research, including challenges in patient recruitment, use of restrictive sampling frames, and a lack of randomized recruitment methods and validated assessment measures.

CONCLUSION

Findings are discussed with regard to possible explanations for current results, clinical considerations, and areas of future research that are needed to move the field forward.

High-mobility group box 1-mediated microglial activation induces anxiodepressive-like behaviors in mice with neuropathic pain

Clinical evidence indicates that major depression is a common comorbidity of chronic pain, including neuropathic pain. However, the cellular basis for chronic pain-mediated major depression remains unclear. High-mobility group box 1 protein (HMGB1) has a key role in innate immune responses and appears to be have a role in mediating diverse disorders, including neuropathic pain and depression. The current study aimed to characterize neuropathic pain-induced changes in affect over time and to determine whether HMGB1 has a role in neuropathic pain-induced changes in affect. Neuropathic pain was induced by partial sciatic nerve ligation (PSNL) in mice. Anxiodepressive-like behaviors in mice were evaluated over 10 weeks, in the social interaction, forced swim, and novelty suppressed feeding tests. Mice developed anxiodepressive-like behavior 6 to 8 weeks after induction of neuropathy. Accompanying anxiodepressive-like behavior, increased HMGB1 protein and microglia activation were observed in frontal cortex at 8 weeks after PSNL. Intracerebroventricular administration of rHMGB1 in naïve mice induced anxiodepressive-like behavior and microglia activation. Blockage of HMGB1 in PSNL mice with glycyrrhizic acid (GZA) or anti-HMGB1 antibody reduced microglia activation and anxiodepressive-like behavior. These results indicate that PSNL-induced anxiodepressive-like behavior is likely mediated by HMGB1. Furthermore, the data indicate that inhibition of HMGB1-dependent microglia activation could be a strategy for the treatment of depression associated with neuropathic pain.

Network Alterations in Comorbid Chronic Pain and Opioid Addiction: An Exploratory Approach

The comorbidity of chronic pain and opioid addiction is a serious problem that has been growing with the practice of prescribing opioids for chronic pain. Neuroimaging research has shown that chronic pain and opioid dependence both affect brain structure and function, but this is the first study to evaluate the neurophysiological alterations in patients with comorbid chronic pain and addiction. Eighteen participants with chronic low back pain and opioid addiction were compared with eighteen age- and sex-matched healthy individuals in a pain-induction fMRI task. Unified structural equation modeling (SEM) with Lagrange multiplier (LM) testing yielded a network model of pain processing for patient and control groups based on 19 a priori defined regions. Tests of differences between groups on specific regression parameters were determined on a path-by-path basis using z-tests corrected for the number of comparisons. Patients with the chronic pain and addiction comorbidity had increased connection strengths; many of these connections were interhemispheric and spanned regions involved in sensory, affective, and cognitive processes. The affected regions included those that are commonly altered in chronic pain or addiction alone, indicating that this comorbidity manifests with neurological symptoms of both disorders. Understanding the neural mechanisms involved in the comorbidity is crucial to finding a comprehensive treatment, rather than treating the symptoms individually.

Understanding the behavioural determinants of opioid prescribing among family physicians: a qualitative study

BACKGROUND

Longstanding variation in the views of family physicians (FPs) on the role of opioids seems to translate into widely varying prescribing rates. Improvement interventions are unlikely to achieve change if they do not understand and explicitly target the factors that determine physician prescribing behaviour. The aim of this work was to understand (1) the perspectives of FPs as it relates to opioid prescribing, and (2) the perceived barriers and enablers to guideline-adherent opioid prescribing and management of chronic non-cancer pain.

METHODS

A qualitative study involving one-on-one, semi-structured interviews with a sample of FPs in Ontario, Canada. Interviews were analyzed using a directed content analysis informed by the Theoretical Domains Framework. A framework approach was used to explore interaction across behavioural determinants (factors influencing behaviour) as well as demographic sources of variation. The behaviour of interest for the current study was the prescribing of opioid medications (including initiation, renewal, and dose reduction) for patients with chronic, non-cancer pain. Associated issues in the overall management of such patients were also explored.

RESULTS

Interviews were conducted with 22 FPs. Behavioural determinants interacted with one another to influence FPs prescribing behavior. The TDF domain Beliefs about Consequences played a central role in explaining physician prescribing behaviours as they related to the management of chronic non-cancer pain. Individual beliefs about prescribing consequences and patient behaviour interacted with prescriber beliefs about capabilities and perceptions of the FP's professional role to influence prescriber behaviour. Emotion and the environmental context influenced the impact of these determinants on opioid prescribing and the management of chronic non-cancer pain.

CONCLUSIONS

FPs face a wide range of complex (and often interacting) challenges when prescribing opioid therapy to their patients. Solution-based strategies should target these determinants directly using evidence-based strategies that move beyond guideline dissemination and general education. Shared decision-making strategies and patient-facing decision aids are likely to decrease the tension experienced in challenging conversations.

Pre- and Early Pregnancy Onset Depression and Subsequent Rate of Gestational Weight Gain

Background: Depression is associated with weight change outside of pregnancy. We assessed associations of prepregnancy or early pregnancy onset depression with gestational weight gain (GWG) rate overall and according to Institute of Medicine (IOM) recommendations. Materials and Methods: Depression from 6 months prepregnancy through 20 weeks gestation was identified in a health care system in northern California with perinatal depression screening (2011-2016; n = 87,600). GWG rate (lbs/week) was calculated using weight at delivery and at diagnosis or depression screening ≤20 weeks. Results: Compared to women without prepregnancy or early pregnancy depression, women with prepregnancy onset depression had 11% greater risk of GWG rate <IOM recommendations (95% confidence intervals [CI]: 1.07-1.15) and 3% greater risk of GWG rate >IOM recommendations (95% CI: 1.01-1.05), with a stronger association for >IOM in normal weight women. Early pregnancy onset depression was associated with 0.04 lbs/week greater GWG rate (95% CI: 0.02-0.07) and 4% greater risk of GWG rate >IOM recommendations (95% CI: 1.02-1.07) compared to no prepregnancy or early pregnancy depression, with stronger associations in obese women. Conclusions: Women with prepregnancy onset depression may be at higher risk for GWG both below and above recommendations. Women with early onset prenatal depression may be at slightly higher risk for GWG rate above recommendations. Our results suggest that the relationship between depression and GWG may vary based on timing of depression onset, prepregnancy body mass index category, and antidepressant use. Additional research should identify factors that predict how a woman's lifestyle behaviors and weight change after depression diagnosis.

Use of the PROMIS-29® to identify subgroups of mothers with chronic pain

OBJECTIVE

Children of mothers with chronic pain are at increased risk for poor health, but few studies have examined what characteristics of maternal chronic pain may be associated with children's risk. This study identified subgroups of mothers based on patterns of pain, physical function, and emotional function on the 29-item Patient-Reported Outcomes Measurement Information System® (PROMIS-29®) and evaluated associations between maternal subgroups and children's pain and emotional functioning.

METHODS

Mothers with chronic pain (n = 334) completed the PROMIS-29® and reported on pain intensity, pain interference, physical functioning, anxiety, depression, fatigue, sleep disturbance, and participation in social activities. Mothers and their school-age children also completed measures of child pain and emotional functioning.

RESULTS

Latent profile analysis of PROMIS® domains indicated a 4-class solution (Group 1: 13.5%, Group 2: 9.9%, Group 3: 43.5%, and Group 4: 32.9%). Group 4 reported the most severe pain, psychological distress, and sleep disturbances and the lowest functioning. Group 1 reported the lowest pain, psychological distress, and sleep disturbances and the highest functioning, while Groups 2 and 3 represented moderate symptoms. Groups significantly differed on maternal reports of children's pain frequency, but not intensity, and children's self-reported somatic symptoms. Further, child depressive symptoms (mother-proxy and self-reported), anxiety (mother-proxy reported), and pain catastrophizing (self-reported) differed by maternal group.

CONCLUSIONS

Patterns of maternal symptoms and functioning were associated with pain frequency and emotional symptoms in children. Further examination of individual differences in mothers with chronic pain that may confer risk for chronic pain and psychological disorders in children is warranted. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Patient Satisfaction and Press Ganey Scores for Spine Versus Nonspine Neurosurgery Clinics

STUDY DESIGN

Retrospective survey review.

OBJECTIVE

We seek to evaluate satisfaction scores in patients seen in neurosurgical spine versus neurosurgical nonspine clinics.

SUMMARY OF BACKGROUND DATA

The Press Ganey survey is a well-established metric for measuring hospital performance and patient satisfaction. These measures have important implications in setting hospital policy and guiding interventions to improve patient perceptions of care.

METHODS

Retrospective Press Ganey survey review was performed to identify patient demographics and patient visit characteristics from January 1st, 2012 to October 10th, 2017 at Stanford Medical Center. A total of 40 questions from the Press Ganey survey were investigated and grouped in categories addressing physician and nursing care, personal concerns, admission, room, meal, operating room, treatment and discharge conditions, visitor accommodations and overall clinic assessment. Raw ordinal scores were converted to continuous scores of 100 for unpaired student t test analysis. We identified 578 neurosurgical spine clinic patients and 1048 neurosurgical nonspine clinic patients.

RESULTS

Spine clinic patients reported lower satisfaction scores in aggregate (88.2 vs. 90.1; P=0.0014), physician (89.5 vs. 92.6; P=0.0002) and nurse care (91.3 vs. 93.4; P=0.0038), personal concerns (88.2 vs. 90.9; P=0.0009), room (81.0 vs. 83.1; P=0.0164), admission (90.8 vs. 92.6; P=0.0154) and visitor conditions (87.0 vs. 89.2; P=0.0148), and overall clinic assessment (92.9 vs. 95.5; P=0.005).

CONCLUSIONS

This study is the first to evaluate the relationship between neurosurgical spine versus nonspine clinic with regards to patient satisfaction. The spine clinic cohort reported less satisfaction than the nonspine cohort in all significant questions on the Press Ganey survey. Our findings suggest that efforts should be made to further study and improve patient satisfaction in spine clinics.

LEVEL OF EVIDENCE

Level III.

Anxiety and depression in women with and without chronic pelvic pain: prevalence and associated factors

Objectives: To investigate the prevalence of anxiety, depression and mixed anxiety and depressive disorder (MADD) and factors associated with these conditions in women with chronic pelvic pain (CPP) compared to a pain-free control group.

Methods: A cross-sectional study was conducted with 100 women with CPP and 100 without CPP. The Hospital Anxiety and Depression Scale (HADS) was used to evaluate the presence of anxiety and depression. Sociodemographic, behavioral and clinical characteristics were investigated. Fisher’s exact test was used to compare characteristics between groups. A log-binomial regression model was used, with adjustment for age, skin color, schooling, body mass index and pain. Prevalence ratios (PR), together with their 95% confidence intervals (CI), were calculated to investigate factors associated with anxiety, depression and MADD.

Results: The prevalence of anxiety was 66% in the CPP group and 49% in the controls (p=0.02). Depression was identified in 63% of the women with CPP and in 38% of the controls (p<0.01). MADD was present in 54% of the CPP group and in 28% of the controls (p<0.01). In the adjusted analysis, CPP (PR=1.3; 95%CI: 1.1–1.6), physical abuse (PR=1.5; 95%CI: 1.2–1.8) and sexual abuse (PR=1.5; 95%CI: 1.1–1.8) were independently associated with anxiety. Women of 25 to 34 years of age were less likely to have anxiety (PR=0.6; 95%CI: 0.4–0.8). CPP (PR=1.6; 95%CI: 1.2–2.2), physical abuse (PR=1.3; 95%CI: 1.1–1.7) and sexual abuse (PR=1.7; 95%CI: 1.3–2.2) were independently associated with depression. CPP (PR=1.9; 95%CI: 1.3–2.7), smoking (PR=1.5; 95%CI: 1.1–2.1), physical abuse (PR=1.4; 95%CI: 1.1–1.9) and sexual abuse (PR=1.4; 95%CI: 1.1–1.8) were independently associated with MADD.

Conclusions: The prevalence of anxiety, depression and MADD was higher in women with CPP compared to the pain-free controls. Factors associated with mental disorders were identified. The independent association between CPP and anxiety, depression and MADD was noteworthy. These findings suggest that systematic management of psychological factors could contribute towards improving the mental health of these women.

Perspective of Pain Clinicians in Three Global Cities on Local Barriers to Providing Care for Chronic Noncancer Pain Patients

An increasing proportion of the global chronic pain population is managed through services delivered by specialized pain clinics in global cities. This paper describes the results of a survey of pain clinic leaders in three global cities on barriers influencing chronic noncancer pain (CNCP) management provided by those clinics. It demonstrates a pragmatic qualitative approach for characterizing how the global city location of the clinic influences those results. A cross-sectional prospective survey design was used, and data were analyzed using quantitative and qualitative content analysis. Key informants were pain clinicians (n = 4 women and 8 men) responsible for outputs of specialized pain clinics in academic hospital settings in three global cities: Toronto, Kuwait, and Karachi. Krippendorff's thematic clustering technique was used to identify the repetitive themes in the data. All but one of the key informants had their primary pain training from Europe or North America. In Kuwait and Karachi, pain specialists were anesthesiologists and provided CNCP management services independently. In Toronto, pain clinic leaders were part of some form of the multidisciplinary team. Using the results of a question that asked informants to list their top three barriers, ten themes were identified. These themes were artificially organized in three thematic domains: infrastructure, clinical services, and education. In parallel, 31 predefined barriers identified from the literature were scored. The results showed variation in perception of barriers that not only depended on the clinic location but also demonstrated shared experiences across thematic domains. This study demonstrates a simple methodology for informing global and local efforts to improve access to and implementation of CNCP services globally.

New drug candidates for depression - a nationwide population-based study

OBJECTIVE

To investigate whether continued use of non-aspirin NSAID, low-dose aspirin, high-dose aspirin, statins, allopurinol and angiotensin agents decreases the rate of incident depression using Danish nationwide population-based registers.

METHODS

All persons in Denmark who purchased the exposure medications of interest between 1995 and 2015 and a random sample of 30% of the Danish population was included in the study. Two different outcome measures were included, (i) a diagnosis of depressive disorder at a psychiatric hospital as in-patient or out-patient and (ii) a combined measure of a diagnosis of depression or use of antidepressants.

RESULTS

A total of 1 576 253 subjects were exposed to one of the six drugs of interest during the exposure period from 2005 to 2015. Continued use of low-dose aspirin, statins, allopurinol and angiotensin agents was associated with a decreased rate of incident depression according to both outcome measures. Continued uses of non-aspirin NSAIDs as well as high-dose aspirin were associated with an increased rate of incident depression.

CONCLUSION

The findings support the potential of agents acting on inflammation and the stress response system in depression as well as the potential of population-based registers to systematically identify drugs with repurposing potential.

Cognitive behavioural therapy in pain and psychological disorders: Towards a hybrid future

Cognitive Behavioural Therapy (CBT) is a form of evidence-based talking therapy that emphasises the importance of behaviour and conscious thoughts in shaping our emotional experiences. As pain becomes increasingly accepted as not only a sensory but also an emotional experience, success in using CBT to treat emotional disorders has resulted in the incorporation of cognitive-behavioural principles into the management of chronic pain. Outcomes of CBT-informed interdisciplinary pain management programmes are modest at best, despite rapid methodological improvements in trial design and implementation. Whilst the field searches for new treatment directions, a hybrid CBT approach that seeks to simultaneously tackle pain and its comorbidities shows promise in optimising treatment effectiveness and flexibility. This article provides a brief description of the core characteristics of CBT and the transformation this therapeutic model has brought to our understanding and management of chronic pain. Current evidence on efficacy of CBT for chronic pain is then reviewed, followed by a critical consideration of the advantages and disadvantages of the new hybrid treatment approach that conceptualises and treats chronic pain in connection with its comorbidities. Recent progress made in the area of pain and insomnia is highlighted as an example to project therapeutic innovations in the near future.

Epidemiology of pain and relation to psychiatric disorders

Chronic pain is a common pain condition. Some psychiatric disorders, such as anxiety and depression, are also common in the general population. Epidemiological studies found that some psychiatric disorders are more commonly found among persons with chronic pain (e.g., headache, back pain) than those without chronic pain. Why those psychiatric disorders co-occur with chronic pain, however, is not well understood. Further, studies demonstrated that some psychiatric disorders, such as depression, increase the risk of chronic pain as well as its persistence. It is also recognized that chronic pain has a negative impact on the persistence of psychiatric disorders. The observations from clinical studies suggest that chronic pain is not a common comorbidity among individuals with other psychiatric disorders, such as dementia and schizophrenia. It is not clear if this is a consequence of any specific biological mechanism, or methodology problems in the studies. This paper provides an overview on the distribution of chronic pain and psychiatric disorders, followed by a review of studies that have demonstrated the association between psychiatric disorders and chronic pain.

Chronic pain and suicide risk: A comprehensive review

Death by suicide is one of the leading causes of mortality worldwide. Because individuals with chronic pain are at least twice as likely to report suicidal behaviors or to complete suicide, it is of utmost importance to target which risk factors contribute the most to increasing suicidality. This comprehensive review aims to provide an update on research advancements relating to the identification of potential risk factors for suicidality in individuals with chronic pain. Supporting the results of prior reviews, we found robust evidence that chronic pain itself, regardless of type, was an important independent risk factor for suicidality. The only sociodemographic factor found to be associated with suicidality in individuals with chronic pain was being unemployed/disabled. Depressive symptoms, anger problems, harmful habits (e.g. smoking, alcohol misuse, illicit drugs), childhood or adulthood adversities, and family history of depression/suicide were all also identified as general risk factors. Regarding pain-related factors, sleep problems, poorer perceived mental health, concurrent chronic pain conditions, and more frequent episodes of intermittent pain, were all found to be predictors of suicidality. Unexpectedly, pain characteristics (e.g. type, duration, and intensity/severity) and physical status (e.g. pain interference or disability) were not related to suicide risk. We also identified promising new psychosocial factors (e.g. mental defeat, pain catastrophizing, hopelessness, perceived burdensomeness and thwarted belongingness) associated with suicidality outcomes. A large number of these factors are amenable to change through targeted intervention, highlighting the importance of comprehensively assessing chronic pain patients at risk for suicide, while also incorporating a suicide prevention component into chronic pain management programs.

Enhanced facilitation and diminished inhibition characterizes the pronociceptive endogenous pain modulatory balance of persons living with HIV and chronic pain

Chronic pain in persons living with HIV (PLWH) may be related to alterations in endogenous pain modulatory processes (e.g., high facilitation and low inhibition of nociception) that promote exaggerated pain responses, known as hyperalgesia, and central nervous system (CNS) sensitization. This observational study examined differences in endogenous pain modulatory processes between 59 PLWH with chronic pain, 51 PLWH without chronic pain, and 50 controls without HIV or chronic pain. Quantitative sensory testing for temporal summation (TS) of mechanical and heat pain as well as conditioned pain modulation (CPM) were used to assess endogenous pain facilitatory and inhibitory processes, respectively. Associations among TS, CPM, and self-reported clinical pain severity were also examined in PLWH with chronic pain. Findings demonstrated significantly greater TS of mechanical and heat pain for PLWH with chronic pain compared to PLWH without chronic pain and controls. CPM effects were present in controls, but not in either PLWH with or without chronic pain. Among PLWH with chronic pain, greater TS of mechanical pain was significantly associated with greater average clinical pain severity. Results of this study suggest that enhanced facilitation and diminished inhibition characterizes the pronociceptive endogenous pain modulatory balance of persons living with HIV and chronic pain.

Chronic Pain Among Suicide Decedents, 2003 to 2014: Findings From the National Violent Death Reporting System

BACKGROUND

More than 25 million adults in the United States have chronic pain. Chronic pain has been associated with suicidality, but previous studies primarily examined nonfatal suicidal behaviors rather than suicide deaths associated with chronic pain or the characteristics of such deaths.

OBJECTIVE

To estimate the prevalence of chronic pain among suicide decedents in a large multistate sample and to characterize suicide decedents with and without chronic pain.

DESIGN

Retrospective analysis of National Violent Death Reporting System (NVDRS) data. The NVDRS links death certificate, coroner or medical examiner, and law enforcement data collected by investigators, who often interview informants who knew the decedent to gather information on precipitating circumstances surrounding the suicide. Information is abstracted by using standard coding guidance developed by the Centers for Disease Control and Prevention.

SETTING

18 states participating in the NVDRS.

PARTICIPANTS

Suicide decedents with and without chronic pain who died during 1 January 2003 to 31 December 2014.

MEASUREMENTS

Demographic characteristics, mechanism of death, toxicology results, precipitating circumstances (mental health, substance use, interpersonal problems, life stressors), and suicide planning and intent.

RESULTS

Of 123 181 suicide decedents included in the study, 10 789 (8.8%) had evidence of chronic pain, and the percentage increased from 7.4% in 2003 to 10.2% in 2014. More than half (53.6%) of suicide decedents with chronic pain died of firearm-related injuries and 16.2% by opioid overdose.

LIMITATION

The results probably underrepresent the true percentage of suicide decedents who had chronic pain, given the nature of the data and how they were captured.

CONCLUSION

Chronic pain may be an important contributor to suicide. Access to quality, comprehensive pain care and adherence to clinical guidelines may help improve pain management and patient safety.

PRIMARY FUNDING SOURCE

None.

Persistent inflammatory pain alters sexually-motivated behavior in male rats

Urine from pro-œstrus female rodents evokes increased levels of sexually-motivated behaviors in males, including sniffing and scent marking of the urine spot as well as activation of brain reward regions. Stressors such as social defeat can adversely impact urine scent marking behavior in male rodents, an effect that can be mitigated with anti-depressant drugs. Persistent pain is also known to be a potent stressor, producing elevated levels of plasma corticosterone as well as reduced sucrose preference and reduced social interaction. However, the effect of persistent pain on sexually-motivated behavior is unknown. Here, we compared urine scent marking behavior in male rats for up to 3 weeks following intra-articular injection of Complete Freund’s Adjuvant (CFA) or sham injection. CFA-injected rats exhibited profound and ongoing deficits in static weight bearing capacity. CFA-induced persistent inflammatory pain increased plasma corticosterone levels and reduced urine scent marking behavior in male rats. Moreover, while the vast majority of injured rats showed decreased urine scent marking preference for the pro-œstrus female urine spot, male rats with higher baseline scent marking preference also exhibited higher post-injury scent marking preference, more sniffing behavior and lower levels of plasma corticosterone, compared to those with lower baseline scent marking preference. Overall, scent marking behavior may be an ethologically relevant behavioral predictor of persistent pain-induced stress in rats, representing a novel translational approach to understanding chronic pain comorbidities.

The Impact of Perceived Social Support on Anxiety, Depression and Severity of Pain and Burnout Among Turkish Females With Fibromyalgia

Objectives

This study aims to assess the impact of perceived social support on burnout, severity of pain and comorbid anxiety and depression among Turkish females with fibromyalgia syndrome (FMS).

Patients and methods

A total of 117 females including 65 patients with FMS (mean age 33.5±8.1 years; range 20 to 60 years) and 52 healthy controls (mean age 33.6±7.3 years; range 23 to 48 years) were included between January 2017 and May 2017. Following a semi-structured psychiatric interview by a psychiatrist, Sociodemographic Data Form, Mood and Anxiety Disorders Modules of Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders fourth edition Axis I Disorders (SCID-I), Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HARS), Visual Analog Scale (VAS), Maslach Burnout Inventory (MBI) and Multidimensional Scale of Perceived Social Support (MSPSS) were applied to participants.

Results

As a result of the semi-structured clinical interview conducted by a psychiatrist, the prevalence of any mood or anxiety disorder was found to be significantly more common in the FMS group. The proportion of patients diagnosed with any mood or anxiety disorder using SCID-I was significantly different among FMS (n=50, 76.92%) and healthy control (n=14, 33.33%) groups (p<0.001). Correlations between these variables were examined within the FMS group. There was a significant negative correlation between VAS and MSPSS. There were significant negative correlations between MSPSS and HDRS, HARS, all subscales of MBI. There were significant positive correlations between VAS and HDRS, HARS, all subscales of MBI.

Conclusion

In conclusion, perceived social support was found to be strongly associated with depression, anxiety, burnout and severity of pain in patients with FMS. Our study provided support to emphasize the importance of perceived social support among females with FMS. Considering that FMS is associated with many physical and cognitive complaints in addition to pain, it can be considered as a multi-systemic disease requiring a multidisciplinary approach.

The interaction of depression and prior opioid use on pain and opioid requirements after total joint arthroplasty

Background

Preoperative opioid use causes increased pain and opioid requirements after total joint arthroplasty (TJA), but the effect of depression on this relationship is not well defined.

Methods

We conducted a retrospective review of primary TJA patients using an institutional database. Demographic variables, inpatient opioid requirements, and discharge prescription quantities were collected and compared between patients with and without a prior diagnosis of depression in both the prior opioid-using and nonusing cohorts.

Results

Four hundred and three patients were analyzed between August 1, 2016, and July 31, 2017. Among prior opioid users, patients with depression experienced higher inpatient pain levels (4 vs 3; P = .001), required more inpatient opioids (117 oral morphine equivalents [OMEs] vs 70 OMEs; P = .022), were prescribed more opioids at discharge (1163 OMEs vs 750 OMEs; P = .02), and required more long-term opioid refills (57.7% vs 15.4%; P < .001) than patients without depression. However, depression was not associated with increased pain, opioid requirements, prescription quantities, or refill rates among opioid-naive patients.

Conclusions

Depression is not associated with increased pain or opioid requirements among opioid-naive patients after TJA but is associated with significantly higher pain and opioid requirements among patients who use opioids preoperatively. The interaction of these variables may highlight a target for preoperative counseling and risk modification in the arthroplasty population.

The Impact of Exercise in Rodent Models of Chronic Pain

PURPOSE OF REVIEW

Physical activity is increasingly recommended for chronic pain. In this review, we briefly survey recent, high-quality meta-analyses on the effects of exercise in human chronic pain populations, followed by a critical discussion of the rodent literature.

RECENT FINDINGS

Most meta-analytical studies on the effects of exercise in human chronic pain populations describe moderate improvements in various types of chronic pain, despite substantial variability in the outcomes reported in the primary literature. The most consistent findings suggest that while greater adherence to exercise programs produces better outcomes, there is minimal support for the superiority of one type of exercise over another. The rodent literature similarly suggests that while regular exercise reduces hypersensitivity in rodent models of chronic pain, exercise benefits do not appear to relate to either the type of injury or any particular facet of the exercise paradigm. Potential factors underlying these results are discussed, including the putative involvement of stress-induced analgesic effects associated with certain types of exercise paradigms. Exercise research using rodent models of chronic pain would benefit from increased attention to the role of stress in exercise-induced analgesia, as well as the incorporation of more clinically relevant exercise paradigms.

The comorbidity of low back pelvic pain and risk of depression and anxiety in pregnancy in primiparous women

Background

Approximately 50% of Australian women experience low back pain in pregnancy, with somewhere between 8 and 36% of women suffering from pregnancy related depression/anxiety. Both low back and pelvic pain and depression and anxiety are associated with poor maternal health outcomes, including increased sick leave, higher rates of functional disability, and increased access to healthcare. It also impacts upon time and mode of delivery with an increase in inductions and elective caesarean sections. For babies of women with depression and anxiety preterm birth, low birth weight and intrauterine growth restriction are all common complications. Given these poor health outcomes, it is important to determine the co-morbidity of low back and pelvic pain and depression/anxiety in pregnancy.

Methods

A cross sectional study of a hospital based sample of 96 nulliparous women were assessed at 28 weeks as part of their routine antenatal appointment. Data was collected via interview and clinical records and included the Edinburgh Depression Scale (EDS), the Numerical Rating Scale (NRS) and the Modified Oswestry Low Back Pain Disability Questionnaire (MODQ). Spearman’s correlation co-efficients, prevalence ratios and ANOVA were used to determine comorbidity.

Results

96 women consented to participation in the study. All study outcomes were moderately correlated. There were three main findings: One, there was a positive correlation between low back and pelvic girdle pain (LBPP) and depression/anxiety was rho = 0.39, p < 0.001, between LBPP and functional disability was rho = 0.51, p < 0.001 and between risk of depression/anxiety and functional disability was rho = 0.54, p < 0.001. Two, a woman with LBPP was 13 times more likely to have increased risk of depression/anxiety, whilst a woman with increased risk of depression/anxiety was 2.2 times more likely to have LBPP and finally three, amongst women who reported LBPP, the level of disability experienced was significantly higher in women who had concurrent increased risk of depression/anxiety (p = 0.003). This occurred even though the severity of pain did not differ between groups (NRS score mean p = 0.38).

Conclusions

This study found a high level of co-occurrence of LBPP, functional disability and depression/anxiety in women in their third trimester of pregnancy. Importantly women who reported higher depression/anxiety symptoms appeared to experience higher levels of functional disability in relation to their LBPP, than women with lower depression/anxiety symptoms and LBPP.

Optimal primary care management of clinical osteoarthritis and joint pain in older people: a mixed-methods programme of systematic reviews, observational and qualitative studies, and randomised controlled trials

Background

Osteoarthritis (OA) is the most common long-term condition managed in UK general practice. However, care is suboptimal despite evidence that primary care and community-based interventions can reduce OA pain and disability.

Objectives

The overall aim was to improve primary care management of OA and the health of patients with OA. Four parallel linked workstreams aimed to (1) develop a health economic decision model for estimating the potential for cost-effective delivery of primary care OA interventions to improve population health, (2) develop and evaluate new health-care models for delivery of core treatments and support for self-management among primary care consulters with OA, and to investigate prioritisation and implementation of OA care among the public, patients, doctors, health-care professionals and NHS trusts, (3) determine the effectiveness of strategies to optimise specific components of core OA treatment using the example of exercise and (4) investigate the effect of interventions to tackle barriers to core OA treatment, using the example of comorbid anxiety and depression in persons with OA.

Data sources

The North Staffordshire Osteoarthritis Project database, held by Keele University, was the source of data for secondary analyses in workstream 1.

Methods

Workstream 1 used meta-analysis and synthesis of published evidence about effectiveness of primary care treatments, combined with secondary analysis of existing longitudinal population-based cohort data, to identify predictors of poor long-term outcome (prognostic factors) and design a health economic decision model to estimate cost-effectiveness of different hypothetical strategies for implementing optimal primary care for patients with OA. Workstream 2 used mixed methods to (1) develop and test a ‘model OA consultation’ for primary care health-care professionals (qualitative interviews, consensus, training and evaluation) and (2) evaluate the combined effect of a computerised ‘pop-up’ guideline for general practitioners (GPs) in the consultation and implementing the model OA consultation on practice and patient outcomes (parallel group intervention study). Workstream 3 developed and investigated in a randomised controlled trial (RCT) how to optimise the effect of exercise in persons with knee OA by tailoring it to the individual and improving adherence. Workstream 4 developed and investigated in a cluster RCT the extent to which screening patients for comorbid anxiety and depression can improve OA outcomes. Public and patient involvement included proposal development, project steering and analysis. An OA forum involved public, patient, health professional, social care and researcher representatives to debate the results and formulate proposals for wider implementation and dissemination.

Results

This programme provides evidence (1) that economic modelling can be used in OA to extrapolate findings of cost-effectiveness beyond the short-term outcomes of clinical trials, (2) about ways of implementing support for self-management and models of optimal primary care informed by National Institute for Health and Care Excellence recommendations, including the beneficial effects of training in a model OA consultation on GP behaviour and of pop-up screens in GP consultations on the quality of prescribing, (3) against adding enhanced interventions to current effective physiotherapy-led exercise for knee OA and (4) against screening for anxiety and depression in patients with musculoskeletal pain as an addition to current best practice for OA.

Conclusions

Implementation of evidence-based care for patients with OA is feasible in general practice and has an immediate impact on improving the quality of care delivered to patients. However, improved levels of quality of care, changes to current best practice physiotherapy and successful introduction of psychological screening, as achieved by this programme, did not substantially reduce patients’ pain and disability. This poses important challenges for clinical practice and OA research.

Limitations

The key limitation in this work is the lack of improvement in patient-reported pain and disability despite clear evidence of enhanced delivery of evidence-based care.

Future work recommendations

(1) New thinking and research is needed into the achievable and desirable long-term goals of care for people with OA, (2) continuing investigation into the resources needed to properly implement clinical guidelines for management of OA as a long-term condition, such as regular monitoring to maintain exercise and physical activity and (3) new research to identify subgroups of patients with OA as a basis for stratified primary care including (i) those with good prognosis who can self-manage with minimal investigation or specialist treatment, (ii) those who will respond to, and benefit from, specific interventions in primary care, such as physiotherapy-led exercise, and (iii) develop research into effective identification and treatment of clinically important anxiety and depression in patients with OA and into the effects of pain management on psychological outcomes in patients with OA.

Trial registration

Current Controlled Trials ISRCTN06984617, ISRCTN93634563 and ISRCTN40721988.

Funding

This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research Programme and will be published in full inProgramme Grants for Applied Research Programme; Vol. 6, No. 4. See the NIHR Journals Library website for further project information.

Musculoskeletal Pain in Melancholic and Atypical Depression

Objective

Pain and depressive disorders often present together, but little is known about the prevalence of pain in depression subgroups. The objective of this study was to examine the possible differences in the prevalence of musculoskeletal pain between participants in melancholic and atypical depression subgroups.

Design

Cross-sectional study.

Setting

Depression nurse case managers where depression patients receive treatment in primary health care.

Subjects

Participants included 413 depression patients and 401 controls.

Methods

Depressive symptoms were determined with the Beck Depression Inventory (BDI-21), and diagnosis of depression was confirmed with the Mini-International Neuropsychiatric Interview (MINI). The participants were dichotomized into subgroups with melancholic depression (n = 269), atypical depression (n = 144), and controls (n = 401). Musculoskeletal pain was identified during last four weeks. Participants were enrolled in the study between 2008 and 2009.

Results

The prevalence of pain was 37% in controls, 57% in atypical depression, and 71% in melancholic depression (P < 0.001, after adjusting for sex and age). A logistic regression model showed that the odds ratio of pain after adjusting for confounding factors was 2.35 (1.56 to 3.56) with atypical depression compared with controls (P < 0.001) and 4.38 (3.03 to 6.33) with melancholic depression compared with atypical depression (P = 0.006). BDI scores were higher for those with melancholic depression than for those with atypical depression (P < 0.001).

Conclusions

Melancholic depression showed to be associated with a higher prevalence of musculoskeletal pain in comparison with atypical depression. This finding highlights the need for further studies about the mechanisms behind the association, particularly in melancholic depression.

Challenges and controversies of complex interventions in osteoarthritis management: recognizing inappropriate and discordant care

A number of controversies and challenges exist for the management of OA in health care. This paper describes the challenges and gaps in OA care, particularly in relation to population health management, complex interventions and outcomes. It sets this in the context of competing health priorities and multimorbidity, access to high quality conservative care, non-pharmacological therapies, resource limitations and models of care. The overuse of some therapies and neglect of others are discussed, as well as the potential for self-management. The roles of patient and public involvement and the healthcare team are highlighted in enhancing best care for OA and providing solutions for closing the evidence-to-practice gap. Implementation of models of care offer one solution to the challenges and progress of such implementation is described. Areas for further research are highlighted.

Automating Collection of Pain-Related Patient-Reported Outcomes to Enhance Clinical Care and Research

INTRODUCTION

Chronic pain is highly prevalent, and the ability to routinely measure patients' pain and treatment response using validated patient-reported outcome (PRO) assessments is important to clinical care. Despite this recognition, systematic use in everyday clinical care is rare.

AIMS

The aims of this study were to (1) describe infrastructure designed to automate PRO data collection, (2) compare study-enhanced PRO completion rates to those in clinical care, and (3) evaluate patient response rates by method of PRO administration and sociodemographic and/or clinical characteristics.

SETTING

The Pain Program for Active Coping and Training (PPACT) is a pragmatic clinical trial conducted within three regions of the Kaiser Permanente health care system.

PROGRAM DESCRIPTION

PPACT evaluates the effect of integrative primary care-based pain management services on outcomes for chronic pain patients on long-term opioid treatment. We implemented a tiered process for quarterly assessment of PROs to supplement clinical collection and ensure adequate trial data using three methods: web-based personal health records (PHR), automated interactive voice response (IVR) calls, and live outreach.

PROGRAM EVALUATION

Among a subset of PPACT participants examined (n = 632), the tiered study-enhanced PRO completion rates were higher than in clinical care: 96% completed ≥ 1 study-administered PRO with mean of 3.46 (SD = 0.85) vs. 74% completed in clinical care with a mean of 2.43 (SD = 2.08). Among all PPACT participants at 3 months (n = 831), PRO completion was 86% and analyses of response by key characteristics found only that participant age predicted an increased likelihood of responding to PHR and IVR outreach.

DISCUSSION

Adherence to pain-related PRO data collection using our enhanced tiered approach was high. No demographic or clinical identifiers other than age were associated with differential response by modality. Successful ancillary support should employ multimodal electronic health record functionalities for PRO administration. Using automated modalities is feasible and may facilitate better sustainability for regular PRO administration within health care systems. Clinical Trials Registration Number: NCT02113592.

Prevalence of unrecognized depression in patients with chronic pain without a history of psychiatric diseases

Background

We aimed to investigate the prevalence of unrecognized depression in patients with chronic pain, but with no history of psychiatric diseases.

Methods

Patients with chronic pain who did not have a history of psychiatric disease were selected for this study. The Beck Depression Index (BDI) was used to evaluate depression. Participants' socio-demographic characteristics and pain-related characteristics were also recorded.

Results

The study included 94 consecutive patients with chronic pain (28 men and 66 women). Based on the BDI scores, 33/94 (35.1%) patients with chronic pain had comorbid depression. The prevalence of depression was significantly higher in our cohort than it was in the general population (P < 0.001). The standardized incidence ratio, adjusted for age and sex, was 2.77 in men and 2.60 in women. Patients who were unmarried (odds ratio [OR] = 3.714, P = 0.044), and who had subjective sleep disturbance (OR = 8.885, P < 0.001), were more likely to have moderate to severe depression. Patients with high education levels (OR = 0.244, P = 0.016), and who were economically active (OR = 0.284, P = 0.023), were less likely to have moderate to severe depression.

Conclusions

Our results indicate that unrecognized depression in patients with chronic pain is common. Therefore, pain physicians should actively seek to identify these problems rather than relying on the patient to volunteer such information.

Comorbidity between pain and mental illness - Evidence of a bidirectional relationship

BACKGROUND

Pain from various locations in the body and mental illness are common and the comorbidity between the two is well-known although the temporal relationship remains to be determined. Our aim was to follow patients over time to study if pain (here dorsalgia/abdominal pain) or fibromyalgia lead to an increased risk of developing mental illness (here depression/anxiety) and/or the reverse, that is whether patients with mental illness have an increased risk to develop pain or fibromyalgia, compared to the rest of the population.

METHODS

This prospective cohort study used the Skåne Healthcare Register, covering all care in the region of Skåne, southern Sweden (population ~1.3 million). The cohort included healthcare consultations in primary care, outpatient specialized care and inpatient care between 2007 and 2016 for all patients without prior registered diagnosis of mental illness or pain, aged 18 or older (n = 504,365).

RESULTS

The incidence rate ratio (IRR) for developing mental illness after pain was 2.18 (95% CI = 2.14-2.22) compared to without pain. IRR for developing pain after mental illness was 2.02 (95% CI = 1.98-2.06) compared to without mental illness. Corresponding IRR for developing mental illness after fibromyalgia was 4.05 (95% CI = 3.58-4.59) and for developing fibromyalgia after mental illness 5.54 (95% CI = 4.99-6.16).

CONCLUSIONS

This study shows a bidirectional influence of similar magnitude of pain and mental illness, respectively. In monitoring patients with pain or mental illness, a focus on both conditions is thus important to develop appropriate, targeted interventions and may increase the likelihood of improved outcomes.

SIGNIFICANCE

We followed a population-based cohort over a period of 10 years, including incident cases of both exposure and outcome and found a bidirectional relationship between pain and mental illness. Clinicians need to pay attention on both conditions, in patients seeking care due to mental illness or pain.

Understanding the research landscape of major depressive disorder via literature mining: an entity-level analysis of PubMed data from 1948 to 2017

Objective

To analyze literature-based data from PubMed to identify diseases and medications that have frequently been studied with major depressive disorder (MDD).

Materials and methods

Abstracts of 23 799 research articles about MDD that have been published since 1948 till 2017 were analyzed using data and text mining approaches. Methods such as information extraction, frequent pattern mining, regression, and burst detection were used to explore diseases and medications that have been associated with MDD.

Results

In addition to many mental disorders and antidepressants, we identified several nonmental health diseases and nonpsychotropic medications that have frequently been studied with MDD. Our results suggest that: (1) MDD has been studied with disorders such as Pain, Diabetes Mellitus, Wounds and Injuries, Hypertension, and Cardiovascular Diseases; (2) medications such as Hydrocortisone, Dexamethasone, Ketamine, and Lithium have been studied in terms of their side effects and off-label uses; (3) the relationships between nonmental disorders and MDD have gained increased attention from the scientific community; and (4) the bursts of Diabetes Mellitus and Cardiovascular Diseases explain the psychiatric and/or depression screening recommended by authoritative associations during the periods of the bursts.

Discussion and conclusion

This study summarized and presented an overview of the previous MDD research in terms of diseases and medications that are highly relevant to MDD. The reported results can potentially facilitate hypothesis generation for future studies. The approaches proposed in the study can be used to better understand the progress and advance of the field.

Perceived Mindfulness and Depressive Symptoms Among People with Chronic Pain

The study purpose was to evaluate pain catastrophizing and psychological distress as mediators for the relationship between perceived mindfulness and depressive symptoms in people with chronic pain. We conducted an online cross-sectional survey with 211 adults with chronic musculoskeletal pain recruited from U.S. clinics and community networks. A serial multiple mediation analysis was performed using ordinary least-squares regressions and a bootstrap testing approach. Pain catastrophizing and psychological distress, independently and jointly, mediated the relationship between mindfulness and depressive symptoms. Rehabilitation counseling professionals should consider targeting mindfulness, pain catastrophizing, and psychological distress in psychosocial treatment for people with chronic pain.

Elder Abuse and Chronic Pain: Cross-Sectional and Longitudinal Results from the Preventing Elder Abuse and Neglect Initiative

OBJECTIVES

To examine the cross-sectional and longitudinal relationships between elder abuse and neglect (EAN) and chronic pain in rural older Malaysians.

DESIGN

Two-year prospective cohort study.

SETTING

Kuala Pilah, a district in Negeri Sembilan approximately 100 km from the capital city, Kuala Lumpur.

PARTICIPANTS

Community-dwelling older adults aged 60 and older. Using a multistage cluster sampling strategy, 1,927 respondents were recruited and assessed at baseline, of whom 1,189 were re-assessed 2 years later.

MEASURES

EAN was determined using the modified Conflict Tactic Scale, and chronic pain was assessed through self-report using validated questions.

RESULTS

The prevalence of chronic pain was 20.4%. Cross-sectional results revealed 8 variables significantly associated with chronic pain-age, education, income, comorbidities, self-rated health, depression, gait speed, and EAN. Abused elderly adults were 1.52 times as likely to have chronic pain (odds ratio=1.52, 95% confidence interval (CI)=1.03-2.27), although longitudinal analyses showed no relationship between EAN and risk of chronic pain (risk ratio=1.14, 95% CI=0.81-1.60). This lack of causal link was consistent when comparing analysis with complete cases with that of imputed data.

CONCLUSION

Our findings indicate no temporal relationship between EAN and chronic pain but indicated cross-sectional associations between the two. This might indicate that, although EAN does not lead to chronic pain, individuals with greater physical limitations are more vulnerable to abuse. Our study also shows the importance of cohort design in determining causal relationships between EAN and potentially linked health outcomes.

Depression increases subjective stigma of chronic pain

BACKGROUND

Individuals suffering from mental as well as physical conditions often face stigma, which can adversely affect functioning, treatment seeking, and emotional health. We compared levels of stigma experienced by individuals with depression and/or chronic pain, to contrast the perception of stigma experienced by the sufferers with that of individuals who have never experienced these conditions, and to determine whether depression is related to greater experience of stigma for chronic pain.

METHODS

Four groups of participants (N=236) took part in the study: depression only, chronic pain only, comorbid depression and chronic pain, and healthy controls. Participants underwent a clinical interview and completed a stigma measure that assessed general self-stigma, public stigma, treatment stigma, secrecy, and stigmatizing experiences.

RESULTS

Healthy controls largely underestimated the stigma experienced by individuals with depression, but were not inaccurate in estimating stigma experienced by individuals with chronic pain. Further, individuals with chronic pain alone generally perceived less stigma for their condition than did those with depression alone. However, comorbid individuals perceived worse stigma of chronic pain compared to individuals with chronic pain alone, suggesting that depression may affect the stigma felt by sufferers of conditions other than depression.

LIMITATIONS

Social desirability may have influenced stigma scores. Comparing several groups required adapting a standardized instrument.

CONCLUSIONS

Results suggest that depression may play a role in the social experience of having a health condition, as well as indicate that the general public continues to fail to appreciate the negative social pressures experienced by individuals with mental health conditions.

Psychiatry and Pain Management: at the Intersection of Chronic Pain and Mental Health

PURPOSE OF REVIEW

Chronic pain impacts millions of people in the USA. At the heart of the problem of chronic pain remains the complex psychosocial aspects associated with living with chronic pain. Given the overlap between chronic pain and mental health, a promising treatment approach is to improve how we integrate psychiatry into pain management.

RECENT FINDINGS

Treatment of chronic pain and comorbid mental health issues requires a multidisciplinary approach. Advancements in how pain is understood, especially centralized pain, have helped inform both pharmacological and behavioral interventions for pain. Given the growing concerns about the opioid epidemic and the lack of data supporting the use of opioids for long-term pain management, new treatment approaches are needed. Psychiatrist may be uniquely suited to help address comorbid mental health disorders and addiction in the context of chronic pain management. Addressing the psychiatric needs of chronic pain patients remains challenging and there is much room to improve how we address the complex issues associated with living with chronic pain. We believe psychiatrists are an important piece of the pain management puzzle.

Manage My Pain

This chapter describes the Manage My Pain digital pain management platform and its integration into the Transitional Pain Service at Toronto General Hospital. A collaboration between ManagingLife, the developer of Manage My Pain, and the Transitional Pain Service led to the creation of a patient-provider virtual community with the aim of managing complex pain after surgery so as to prevent the transition from acute post-surgical pain to chronic post-surgical pain. User engagement, motivation, and satisfaction are discussed with respect to the needs of (1) people living with pain and (2) health care providers. Challenges in implementation are described, along with new features developed for the digital platform as a result of the partnership between ManagingLife and the Transitional Pain Service.

Prevalence of depression and its association with sociodemographic factors in patients with chronic pain: A cross-sectional study in a tertiary care hospital in Saudi Arabia

Introduction:

Mental health issues, especially depression, are common in chronic pain patients. Depression affects these patients negatively and could lead to poor control of their pain. Some risk factors for both chronic pain and depression are known and need to be targeted as part of the management in a multidisciplinary approach. This study was conducted to estimate the prevalence of depression among chronic pain patients attending a pain clinic and to explore the association between depression in chronic pain patients and other factors such as sociodemographic features, number of pain sites, severity of pain, and types of pain.

Methods:

This is a cross-sectional study that carried out in a chronic pain clinic in a tertiary care hospital in Riyadh, Saudi Arabia (King Faisal Specialist Hospital and Research Centre). All chronic pain patients including cancer-related pain, apart from acute pain patients and children, were eligible to participate in the study. Association between depression and sociodemographic factors was assessed with univariate and multivariate methods. Main outcome measures were the prevalence of depression in chronic pain patients using the Patient Health Questionnaire-9 (PHQ-9) and the association with sociodemographic factors.

Results:

A total of 200 chronic pain patients (128 females [64%]) participated in the study. The prevalence of depression was 71% (95% confidence interval: 64.7–77.3) based on the PHQ-9 diagnostic criteria using a cutoff point of >5. Among those patients who were depressed, 9 (4.5%) had severe depression as compared to 31 (15.5%), 41 (20.5%), and 61 (30.5%) who had moderately severe, moderate, and mild depression, respectively. Depression (scored at the cutoff point of 5) in chronic pain patients was significantly associated with age, financial status, medical history of depression, and pain severity.

Conclusion:

Depression is common among chronic pain patients with several risk factors aggravating its presentation. Due to their increased risk of depression, psychiatric counseling that offers mental health assistance should be prioritized and made available as a multidisciplinary approach for the treatment of chronic pain patients.

Mood Spectrum Disorders and Perception of Pain

Evaluation of pain perception in chronic pain patients with a concomitant mood-spectrum disorder.

DESIGN

The observational retrospective study is based on patient data collected in psychosomatic consultations held at the Gift Institute for Integrative Medicine in Pisa, Italy, from 2002 to 2014. Evoked pain stimulus threshold and tolerance were evaluated using the cold pressor test. Clinical pain intensity and Sensorial, Affective, and Evaluative dimensions were assessed using the Italian Pain Questionnaire, and Anxiety and Depressive symptoms using the Hospital Anxiety Depression Scale. Mood-spectrum disorders were diagnosed via the Mini-International Neuropsychiatric Interview, and affective temperament in accordance with Akiskal and Pinto's criteria (1999). Of a total of 627 chronic pain clinic patients, 381 were diagnosed with a concomitant mood-spectrum (MS) disorder, unipolar (US) in 61.41%. Pain threshold (t = 2.28; p < 0.05) was lower, and all clinical pain dimensions (t = 2.28; p < 0.05) increased, in MS patients compared to those without psychiatric disorders. Pain intensity (F = 3.5, p < 0.05) and cognitive pain component scores (F = 7.84; p < 0.0001) were higher in US and, to a lesser extent Bipolar Spectrum, than in subjects with other (n.112) or no psychiatric disorders (n. 134). Suicide ideation was highest in US (F = 37.20; p < 0.0001), although in BS major depressive episodes had more melancholic features (F = 46.73; P < 0.0001), and a longer history of psychiatric disorders before the pain onset than US (F = 20.31; p < 0.0001). Pain management should take into account pre-existing psychiatric disorders.

The effectiveness of acupuncture for chronic pain with depression: A systematic review protocol

BACKGROUND

Chronic pain is a major public health problem and 30% to 45% of sufferers experience severe depression. Acupuncture is often used to treat both depression and a range of pain disorders. We aim to conduct a systematic review of randomized controlled trials (RCTs) to evaluate the efficacy of acupuncture for patients experiencing chronic pain with depression.

METHODS

To identify relevant RCTs, the following databases will be searched electronically from their inception to July 1, 2017: PubMed, MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, the Allied and Complementary Medicine Database, the Cumulative Index to Nursing and Allied Health Literature, Chinese medical databases, and others. Manual retrieval will also be conducted. RCTs that evaluated acupuncture as the sole or adjunct treatment for patients with chronic pain and depression will be included. The primary outcomes will be based on a visual analog pain measurement scale and the Hamilton Depression Scale. The secondary outcomes will include scores on a numerical rating scale, verbal rating scale, and the Hospital Anxiety and Depression Scale. The study selection, data extraction, and study quality evaluation will be performed independently by 2 researchers. If the data permit, meta-analysis will be performed using RevMan V5.3 statistical software. If the data are not appropriate for meta-analysis, descriptive analysis or subgroup analysis will be conducted. The methodological quality of the included trials will be assessed using the Cochrane risk-of-bias criteria and the Standards for Reporting Interventions in Controlled Trials of Acupuncture checklist.

RESULTS

This study will provide a high-quality synthesis of current evidence of acupuncture for chronic pain with depression from several scales including visual analog pain measurement scale, the Hamilton Depression Scale, a numerical rating scale, verbal rating scale and the Hospital Anxiety and Depression Scale.

CONCLUSION

The conclusion of our study will provide updated evidence to judge whether acupuncture is an effective intervention for patients suffered from chronic pain with depression.

Chronic Pain and Associated Factors in India and Nepal: A Pilot Study of the Vanderbilt Global Pain Survey

BACKGROUND

Evaluation and treatment of chronic pain worldwide are limited by the lack of standardized assessment tools incorporating consistent definitions of pain chronicity and specific queries of known social and psychological risk factors for chronic pain. The Vanderbilt Global Pain Survey (VGPS) was developed as a tool to address these concerns, specifically in the low- and middle-income countries where global burden is highest.

METHODS

The VGPS was developed using standardized and cross-culturally validated metrics, including the Brief Pain Inventory and World Health Organization Disability Assessment Scale, as well as the Pain Catastrophizing Scale, the Fibromyalgia Survey Questionnaire along with queries about pain attitudes to assess the prevalence of chronic pain and disability along with its psychosocial and emotional associations. The VGPS was piloted in both Nepal and India over a 1-month period in 2014, allowing for evaluation of this tool in 2 distinctly diverse cultures.

RESULTS

Prevalence of chronic pain in Nepal and India was consistent with published data. The Nepali cohort displayed a pain point prevalence of 48%-50% along with some form of disability present in approximately one third of the past 30 days. Additionally, 11% of Nepalis recorded pain in 2 somatic sites and 39% of those surveyed documented a history of a traumatic event. In the Indian cohort, pain point prevalence was approximately 24% to 41% based on the question phrasing, and any form of disability was present in 6 of the last 30 days. Of the Indians surveyed, 11% reported pain in 2 somatic sites, with only 4% reporting a previous traumatic event. Overall, Nepal had significantly higher chronic pain prevalence, symptom severity, widespread pain, and self-reported previous traumatic events, yet lower reported pain severity.

CONCLUSIONS

Our findings confirm prevalent chronic pain, while revealing pertinent cultural differences and survey limitations that will inform future assessment strategies. Specific areas for improvement identified in this VGPS pilot study included survey translation methodology, redundancy of embedded metrics and cultural limitations in representative sampling and in detecting the prevalence of mental health illness, catastrophizing behavior, and previous traumatic events. International expert consensus is needed.

Depression, quality of life, and medical resource utilization in sickle cell disease

Sickle cell disease (SCD) is a chronic, debilitating disorder. Chronically ill patients are at risk for depression, which can affect health-related quality of life (HRQoL), health care utilization, and cost. We performed an analytic epidemiologic prospective study to determine the prevalence of depression in adult patients with SCD and its association with HRQoL and medical resource utilization. Depression was measured by the Beck Depression Inventory and clinical history in adult SCD outpatients at a comprehensive SCD center. HRQoL was assessed using the SF36 form, and data were collected on medical resource utilization and corresponding cost. Neurocognitive functions were assessed using the CNS Vital Signs tool. Pain diaries were used to record daily pain. Out of 142 enrolled patients, 42 (35.2%) had depression. Depression was associated with worse physical and mental HRQoL scores (P < .0001 and P < .0001, respectively). Mean total inpatient costs ($25 000 vs $7487, P = .02) and total health care costs ($30 665 vs $13 016, P = .01) were significantly higher in patients with depression during the 12 months preceding diagnosis. Similarly, during the 6 months following diagnosis, mean total health care costs were significantly higher in depressed patients than in nondepressed patients ($13 766 vs $8670, P = .04). Depression is prevalent in adult patients with SCD and is associated with worse HRQoL and higher total health care costs. Efforts should focus on prevention, early diagnosis, and therapy for depression in SCD.

Identifying characteristics of the most severely impaired chronic pain patients treated at a specialized inpatient pain clinic

BACKGROUND AND AIMS

Patients suffering from chronic nonmalignant pain constitute a heterogeneous population in terms of clinical presentation and treatment results. Few data are available about what distinguishes different groups in this huge population of patients with chronic persistent pain (CPP). A subgroup that is poorly studied, consists of the most severely impaired chronic pain patients. At the Uppsala University Hospital Pain Clinic, there is a specialized department accepting the most complex patients for rehabilitation. In the endeavour to improve and evaluate treatment for this subgroup, a better understanding of the complex nature of the illness is essential. This prospective study aimed to describe the characteristics of this subgroup of patients with CPP.

METHODS

Seventy-two consecutive patients enrolled in the Uppsala programme were evaluated. We collected data on demographics, type of pain and experienced symptoms other than pain using a checklist of 41 possible symptoms. Psychiatric comorbidity was assessed by a psychiatrist using a structured clinical interview. Quality of life (QoL), pain rating and medication/drug/alcohol usage were measured by validated questionnaires: SF-36, NRS, DUDIT and AUDIT. Concerning physical functioning and sick leave, a comparison was made with data from the Swedish Quality Register Registry for pain rehabilitation (SQRP).

RESULTS

The cohort consisted of 61% women and the average age was 45 (range 20-70) years. For this cohort, 74% reported being on sick leave or disability-pension. In the SQRP 59% were on sick leave at the time they entered the rehabilitation programmes [1]. On average, the study-population reported 22 symptoms other than pain, to be at a high rate of severity. Patients treated in conventional pain-rehabilitation programmes reported a mean of 10 symptoms in average. Symptoms reported with the highest frequency (>80%), were lethargy, tiredness, headache and difficulties concentrating. Seventy-six percent were diagnosed with a psychiatric disorder. Sixty-nine fulfilled the criteria for depression or depression/anxiety disorder despite that most (65%) were treated with psychotropic medication. Alcohol/drug abuse was minimal. Seventy-one percent were on opioids but the doses were moderate (<100mg) MEq. The pain rating was ≥7 (out of a maximum of 10) for 60% of the patients.

CONCLUSION

This study describes what makes the subgroup of pain patients most affected by their pain special according to associated factors and comorbidity We found that they were distinguished by a high degree of psychiatric comorbidity, low physical functioning and extreme levels of symptom preoccupation/hypervigilance. Many severe symptoms additional to pain (e.g. depression/anxiety, tiredness, disturbed sleep, lack of concentration, constipation) were reported. The group seems hypervigilant, overwhelmed with a multitude of different symptoms on a high severity level.

IMPLICATIONS

When treating this complex group, the expressions of the illness can act as obstacles to achieve successful treatment outcomes. The study provides evidence based information, for a better understanding of the needs concerning these pain patients. Our result indicates that parallel assessment and treatment of psychiatric comorbidities and sleep disorders combined with traditional rehabilitation, i.e. physical activation and cognitive reorganization are imperative for improved outcomes.

Functional Impairment and Painful Physical Symptoms in Patients with Major Depressive Disorder Treated with Antidepressants: Real-World Evidence from the Middle East

Background

The Global Burden of Disease 2010 study reported the relative size of major depressive disorder (MDD) burden to be greater in the Middle East and North Africa than anywhere else. However, little research has been carried out to examine the comparative effectiveness of antidepressants in this region.

Objective

To assess and compare functioning levels in Middle Eastern patients with MDD treated with either duloxetine or a selective serotonin reuptake inhibitor (SSRI), and to examine the impacts of depression-related pain on functioning by the type of treatment.

Method

This post-hoc analysis, which focused on Middle Eastern patients, used data from a 6-month prospective observational study that included 1,549 MDD patients without sexual dysfunction. Levels of functional impairment and depression-related pain were assessed using the Sheehan Disability Scale (SDS) and the modified Somatic Symptom Inventory, respectively. A mixed model with repeated measures (MMRM) was employed.

Results

The mean age of the patients was 37.3 (SD=8.4) years, and 34.6% were female. Patient functioning was, on average, moderately impaired at baseline, but improved substantially during follow-up in both the duloxetine (n=152) and the SSRI (n=123) cohorts. The MMRM results showed a lower level of functional impairment at 24 weeks in the duloxetine cohort than in the SSRI cohort (p<0.001). Pain severity at baseline was positively associated with functional impairment during follow-up only in the SSRI cohort (p=0.003).

Conclusion

Duloxetine-treated MDD patients achieved better functioning than SSRI-treated patients. This treatment difference was partly driven by depression-related pain.

Modulation of Glycine-Mediated Spinal Neurotransmission for the Treatment of Chronic Pain

Chronic pain constitutes a significant and expanding worldwide health crisis. Currently available analgesics poorly serve individuals suffering from chronic pain, and new therapeutic agents that are more effective, safer, and devoid of abuse liabilities are desperately needed. Among the myriad of cellular and molecular processes contributing to chronic pain, spinal disinhibition of pain signaling to higher cortical centers plays a critical role. Accumulating evidence shows that glycinergic inhibitory neurotransmission in the spinal cord dorsal horn gates nociceptive signaling, is essential in maintaining physiological pain sensitivity, and is diminished in pathological pain states. Thus, it is hypothesized that agents capable of enhancing glycinergic tone within the dorsal horn could obtund nociceptor signaling to the brain and serve as analgesics for persistent pain. This Perspective highlights the potential that pharmacotherapies capable of increasing inhibitory spinal glycinergic neurotransmission hold in providing new and transformative analgesic therapies for the treatment of chronic pain.

Psychological distress and ischaemic heart disease: cause or consequence? Evidence from a large prospective cohort study

BACKGROUND

Ischaemic heart disease (IHD) incidence is elevated in people reporting psychological distress. The extent to which this relationship is causal or related to reverse causality-that is, undiagnosed disease causing distress-is unclear. We quantified the relationship between psychological distress and IHD, with consideration of confounding and undiagnosed disease.

METHODS

Questionnaire data (2006-2009) from 151 811 cardiovascular disease-free and cancer-free Australian general population members aged ≥45years (45 and Up Study) were linked to hospitalisation and mortality data, to December 2013. A two-stage approach estimated HRs for incident IHD (IHD-related hospitalisation or death) for low (Kessler-10 scores: 10-<12), mild (12-<16), moderate (16-<22) and high (22-50) psychological distress, adjusting for demographic and behavioural characteristics, and then restricting to those with no/minor functioning limitations (likely free from undiagnosed disease).

RESULTS

Over 859 396 person-years, 5230 incident IHD events occurred (rate: 6.09/1000person-years). IHD risk was increased for mild (age-adjusted and sex-adjusted HR: 1.18, 95% CI 1.11 to 1.26), moderate (1.36, 1.25 to 1.47), and high (1.69, 1.52 to 1.88) versus low distress. HRs attenuated to 1.15 (1.08 to 1.22), 1.26 (1.16 to 1.37) and 1.41 (1.26 to 1.57) after adjustment for demographic and behavioural characteristics and were further attenuated by 35%-41% in those with no/minor limitations, leaving a significant but relatively weak dose-response relationship: 1.11 (1.02 to 1.20), 1.21 (1.08 to 1.37) and 1.24 (1.02 to 1.51) for mild, moderate and high versus low distress, respectively. The observed adjustment-related attenuation suggests measurement error/residual confounding likely contribute to the remaining association.

CONCLUSION

A substantial part of the distress-IHD association is explained by confounding and functional limitations, an indicator of undiagnosed disease. Emphasis should be on psychological distress as a marker of healthcare need and IHD risk, rather than a causative factor.

Safety and effectiveness of once-daily Hysingla extended-release tablets in patients with baseline depression or anxiety

AIM

Long-term safety and effectiveness of a once-daily, single-entity, extended-release formulation of hydrocodone bitartrate (HYD) for the treatment of moderate to severe noncancer and nonneuropathic pain among patients with and without concurrent depression/anxiety at baseline.

MATERIALS & METHODS

Post hoc analysis.

RESULTS

HYD demonstrated a safety profile consistent with μ-opioid agonists: Serious adverse events in 12% patients with depression/anxiety including four deaths; 6% without depression/anxiety including one death. All pain scores declined by ≥2 points and mean daily HYD dose remained stable in both subgroups.

CONCLUSION

More serious adverse events occurred among patients with comorbid depression/anxiety at baseline than among those without. HYD provided stable and effective analgesia for 52 weeks among chronic pain patients with and without comorbid depression/anxiety at baseline.