Comorbid depression, chronic pain, and disability in primary care

Spared Nerve Injury Increases the Expression of Microglia M1 Markers in the Prefrontal Cortex of Rats and Provokes Depression-Like Behaviors

Pain and depression are frequently co-existent in clinical practice, yet the underlying mechanisms remain largely to be determined. Microglia activation and subsequent pro-inflammatory responses play a crucial role in the development of neuropathic pain and depression. The process of microglia polarization to the pro-inflammatory M1 or anti-inflammatory M2 phenotypes often occurs during neuroinflammation. However, it remains unclear whether M1/M2 microglia polarization is involved in the neuropathic pain induced by spared nerve injury (SNI). In the present study, the mechanical withdrawal threshold, forced swim test, sucrose preference test, and open field test were performed. The levels of microglia markers including ionized calcium-binding adaptor molecule 1 (Iba1), cluster of differentiation 11b (CD11b), M1 markers including CD68, inducible nitric oxide synthase (iNOS), interleukin-1β (IL-1β), IL-6, tumor necrosis factor-a (TNF-α), 8-hydroxy-2-deoxyguanosine (8-OH-dG), and M2 markers including CD206, arginase 1 (Arg1), IL-4 in the prefrontal cortex were determined on day 14 after SNI. The results showed that SNI produced mechanical allodynia and depressive-like behaviors, and also increased the expressions of microglia markers (Iba1, CD11b) and M1 markers (CD68, iNOS, IL-1β, TNF-α, and 8-OH-dG) in the prefrontal cortex. Notably, minocycline administration reversed these abnormalities. In addition, minocycline also promoted M2 microglia polarization as evidenced by up-regulation of CD206 and Arg1. In conclusion, data from our study suggest that SNI can lead to depression-like behaviors, while M1 polarization and consequent overproduction of pro-inflammatory cytokines plays a key role in the pathogenesis of neuropathic pain. The data furthermore indicate that modulation of inflammation by inhibition of M1 polarization could be a strategy for treatment of neuropathic pain, and might prevent the induction of neuropathic pain-induced depression symptoms.

The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

BACKGROUND

This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes.

METHODS AND FINDINGS

We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire-2 for depression, a two-item Generalized Anxiety Disorder-2 questionnaire for anxiety, and a question about current pain intensity [0-10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]).

CONCLUSIONS

In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group.

TRIAL REGISTRATION

ISRCTN registry ISRCTN40721988.

Depression in patients with chronic pain attending a specialised pain treatment centre: prevalence and impact on health care costs

This cross-sectional study aimed to determine the prevalence and impact of depression on health care costs in patients with complex chronic pain. The sample included 1204 patients attending a tertiary pain management service for people with chronic disabling pain, unresponsive to medical treatment. As part of routine care, patients completed a web-based questionnaire assessing mental and physical health, functioning, and service use in the preceding 3 months. Depression was assessed using the 9-item Patient Health Questionnaire. Self-report health care utilisation was measured across 4 domains: general practitioner contacts, contacts with secondary/tertiary care doctors, accident and emergency department visits, and days hospitalised. The participation rate was 89%. Seven hundred and thirty-two patients (60.8%; 95% CI 58.0-63.6) met criteria for probable depression, and 407 (33.8%) met the threshold for severe depression. Patients with depression were more likely to be unable to work because of ill health and reported greater work absence, greater pain-related interference with functioning, lower pain acceptance, and more generalised pain. Mean total health care costs per 3-month period were £731 (95% CI £646-£817) for patients with depression, compared with £448 (95% CI £366-£530) for patients without depression. A positive association between severe depression and total health care costs persisted after controlling for key demographic, functional, and clinical covariates using multiple linear regression models. These findings reveal the extent, severity, and impact of depression in patients with chronic pain and make evident a need for action. Effective treatment of depression may improve patient health and functioning and reduce the burden of chronic pain on health care services.

Initiation of strong prescription opioids in Australia: cohort characteristics and factors associated with the type of opioid initiated

AIMS

To describe the characteristics of Australians initiating strong opioids and examine the factors associated with the type of opioid initiated.

METHODS

Pharmaceutical Benefits Scheme dispensing records were extracted for a 10% sample of people who initiated a strong opioid treatment episode (buprenorphine, fentanyl, hydromorphone, morphine, oxycodone) between 29 September 2009 and 31 December 2013, as evidenced by the absence of a strong opioid dispensing for at least 90 days. The cohort was restricted to people with complete medicines ascertainment. Socio-demographic characteristics, previous dispensing histories and index opioid use were examined. Multinomial logistic regression was used to calculate adjusted relative risk ratios (aRRRs) and 95% confidence intervals (CIs) to determine the factors associated with the type of opioid medicine initiated, relative to oxycodone.

RESULTS

The cohort consisted of 125 335 people: 58.3% were female and 63.7% were aged ≥65 years. The most commonly initiated strong opioid was oxycodone (72.8%), usually 5 mg immediate-release tablets (76.1%). Compared to people aged 18-44 years, those ≥85 years were 14.18 times as likely (95% CI 12.67-15.87) to initiate morphine than oxycodone. Compared to people without a cancer treatment history, those with a cancer treatment history were 2.34 times as likely (95% CI 2.11-2.60) to initiate morphine than oxycodone.

CONCLUSIONS

The most commonly initiated strong opioid was oxycodone, usually at lower strengths. Those who initiated oxycodone were more likely to be younger with no previous cancer treatment history. As these are high-risk characteristics for potential harms, a judicious approach when initiating strong opioids for this group is necessary.

Depression - A major but neglected consequence contributing to the health toll from prescription opioids?

Prescription opioid analgesic (POA) use is common especially in North America, and associated with extensive morbidity and mortality. While medical and non-medical POA use have been documented to be associated with mental health problems, and specifically depression, newly emerging epidemiological evidence suggests that incident depression post-initiation of POA use may be common. Neurobiological - specifically regarding impacts of POAs on brain functioning - and/or psycho-social processes may be relevant pathways; these must be better understood, also to guide clinical practice for interventions. Incident depression outcomes may be an added component to the extensive health toll from widespread POA use.

The role of alexithymia: An 8-year follow-up study of chronic pain patients

OBJECTIVE

The aim of this 8-year follow-up study was to ascertain changes in alexithymia, depressiveness and pain situation in a sample of chronic pain patients and to explore the impact of alexithymia and depression on the outcome.

METHODS

Participants (n=83) were chronic non-malignant pain patients who completed self-report study questionnaires before their first visit to the pain clinic and again 8years later. Study variables consisted of pain intensity measured by the Visual Analogous Scale, the Pain Disability Scale, the Toronto Alexithymia Scale and the Beck Depression Inventory. The moderate improvement in the pain situation was estimated as a decrease of 30% or more in pain intensity or pain disability.

RESULTS

In the whole sample there was a significant decrease in pain intensity, pain disability and depressiveness, but only some of the patients achieved moderate improvement in their pain situation. Alexithymia remained stable during the 8-year period. The alexithymic patients had poorer pain situation and more depressiveness both at baseline and at follow-up. Unfavorable outcome in the pain situation was connected with male gender and alexithymia at baseline but not with depressiveness. Alexithymia and depressiveness were closely related to each other and the connection strengthened during the follow-up period.

CONCLUSION

Alexithymic depressive chronic pain patients represent a special, more disabled subgroup among chronic pain patients. The authors recommend screening for and identifying alexithymia and depression in chronic pain patients. Structural treatment protocols such as cognitive-behavioral therapy may benefit these patients. More research is needed to develop treatment interventions for alexithymic patients.

Leveraging Multi-Modal Sensing for Mobile Health: A Case Review in Chronic Pain

Active and passive mobile sensing has garnered much attention in recent years. In this paper, we focus on chronic pain measurement and management as a case application to exemplify the state of the art. We present a consolidated discussion on the leveraging of various sensing modalities along with modular server-side and on-device architectures required for this task. Modalities included are: activity monitoring from accelerometry and location sensing, audio analysis of speech, image processing for facial expressions as well as modern methods for effective patient self-reporting. We review examples that deliver actionable information to clinicians and patients while addressing privacy, usability, and computational constraints. We also discuss open challenges in the higher level inferencing of patient state and effective feedback with potential directions to address them. The methods and challenges presented here are also generalizable and relevant to a broad range of other applications in mobile sensing.

Patient Health Questionnaire Anxiety and Depression Scale: Initial Validation in Three Clinical Trials

OBJECTIVE

We examine the reliability and validity of the Patient Health Questionnaire Anxiety and Depression Scale (PHQ-ADS)-which combines the nine-item Patient Health Questionnaire depression scale and seven-item Generalized Anxiety Disorder scale-as a composite measure of depression and anxiety.

METHODS

Baseline data from 896 patients enrolled in two primary-care based trials of chronic pain and one oncology-practice-based trial of depression and pain were analyzed. The internal reliability, standard error of measurement, and convergent, construct, and factor structure validity, as well as sensitivity to change of the PHQ-ADS were examined.

RESULTS

The PHQ-ADS demonstrated high internal reliability (Cronbach α values of .8 to .9) in all three trials. PHQ-ADS scores can range from 0 to 48 (with higher scores indicating more severe depression/anxiety), and the estimated standard error of measurement was approximately 3 to 4 points. The PHQ-ADS showed strong convergent (most correlations, 0.7-0.8 range) and construct (most correlations, 0.4-0.6 range) validity when examining its association with other mental health, quality of life, and disability measures. PHQ-ADS cutpoints of 10, 20, and 30 indicated mild, moderate, and severe levels of depression/anxiety, respectively. Bifactor analysis showed sufficient unidimensionality of the PHQ-ADS score. PHQ-ADS change scores at 3 months differentiated (p < .0001) between individuals classified as worse, stable, or improved by a reference measure, providing preliminary evidence for sensitivity to change.

CONCLUSIONS

The PHQ-ADS may be a reliable and valid composite measure of depression and anxiety which, if validated in other populations, could be useful as a single measure for jointly assessing two of the most common psychological conditions in clinical practice and research.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT00926588 (SCOPE); NCT00386243 (ESCAPE); NCT00313573 (INCPAD).

Challenges and Solutions for Depression Prevention Research: Methodology for a Depression Prevention Trial for Older Adults with Knee Arthritis and Emotional Distress

OBJECTIVE

To describe the methodology, challenges, and baseline characteristics of a prevention development trial entitled "Reducing Pain, Preventing Depression."

METHODS

A sequential multiple assignment randomized trial (SMART) compared sequences of cognitive behavioral therapy (CBT) and physical therapy for knee pain and prevention of depression and anxiety. Participants were randomized to CBT, physical therapy, or enhanced usual care and followed for 12 months for new-episode depression or anxiety. Participants were age ≥ 60 with knee osteoarthritis and subsyndromal depression, defined as 9-item Patient Health Questionnaire (PHQ-9) score ≥1 (which included the endorsement of one of the cardinal symptoms of depression [low mood or anhedonia]) and no diagnosis of major depressive disorder per the Structured Clinical Interview for DSM-IV. Depression and anxiety severity and characterization of new episodes were assessed with the PHQ-9, Generalized Anxiety Disorder-7, and the PRIME-MD. Knee pain was characterized with the Western Ontario McMaster Arthritis Index. Response was defined as at least "Very Much Better" on a Patient Global Impression of Change.

RESULTS

At baseline there were 99 patients with an average age of 71; 61.62% were women and 81.8% white. The average PHQ-9 was 5.6 and average Generalized Anxiety Disorder-7, was 3.2. Most were satisfied with the interventions and study procedures. The challenges and solutions described here will also be used in a confirmatory clinical trial of efficacy.

CONCLUSION

A SMART design for depression and anxiety prevention, using both CBT and physical therapy, appears to be feasible and acceptable to participants. The methodologic innovations of this project may advance the field of late-life depression and anxiety prevention.

Chronic Disease Self-Management by People With HIV

As HIV has transitioned into a chronic disease, reappraisal of clinical management has occurred with chronic disease self-management (CDSM) as one possibility. However, despite extensive work on CDSM across a range of diseases, little attention has focused on psychosocial contexts of the lives of people for whom programs are intended. This article reports semi-structured interviews used to explore health practices and motivations of 33 people with HIV (PWHIV) in Australia. Within participants' accounts, different forms of subjectivity and agency emerged with implications for how they understood and valued health-related behaviors. Four themes arose: health support and disclosure, social support and stigma, employment/structure, and health decisions beyond HIV. The experience of stigma and its intersection with CDSM remains relatively un-chartered. This study found stigma shapes agency and engagement with health. Decisions concerning health behaviors are often driven by perceived social and emotional benefit embedded in concerns of disclosure and stigma.

Diagnosing Depression in Chronic Pain Patients: DSM-IV Major Depressive Disorder vs. Beck Depression Inventory (BDI)

Background

Diagnosing depression in chronic pain is challenging due to overlapping somatic symptoms. In questionnaires, such as the Beck Depression Inventory (BDI), responses may be influenced more by pain than by the severity of depression. In addition, previous studies have suggested that symptoms of negative self-image, a key element in depression, are uncommon in chronic pain-related depression. The object of this study is to assess the relationship of the somatic and cognitive-emotional items of BDI with the diagnosis of depression, pain intensity, and disability.

Methods

One hundred consecutive chronic pain patients completed the Structured Clinical Interview for DSM Disorders (SCID) for the diagnosis of major depressive disorder (MDD) according to DSM-IV. Two subscales of BDI (negative view of self and somatic-physical function) were created according to the factor model presented by Morley.

Results

In the regression analysis, the somatic-physical function factor associated with MDD, while the negative view of self factor did not. Patients with MDD had higher scores in several of the BDI items when analysed separately. Insomnia and weight loss were not dependent on the depression diagnosis.

Limitations

The relatively small sample size and the selected patient sample limit the generalisability of the results.

Conclusions

Somatic symptoms of depression are also common in chronic pain and should not be excluded when diagnosing depression in pain patients. Regardless of the assessment method, diagnosing depression in chronic pain remains a challenge and requires careful interpretation of symptoms.

Real-world outcomes in patients with depression treated with duloxetine or a selective serotonin reuptake inhibitor in East Asia

INTRODUCTION

This study compared treatment outcomes in patients with major depressive disorder treated with either duloxetine with a daily dose of ≤60 mg or a selective serotonin reuptake inhibitor (SSRI) as monotherapy for up to 6 months in a naturalistic setting in East Asia. In addition, this study examined the impact of painful physical symptoms (PPS) on the effects of these treatments.

METHODS

This post-hoc analysis of data from a 6-month prospective observational study involving 1,549 major depressive disorder patients without sexual dysfunction focused on a subgroup of patients from East Asia (n = 587). Depression severity was measured using the Clinical Global Impression of Severity and the 16-item Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16 ), whereas quality of life (QoL) was measured using EuroQoL instruments. PPS were rated using the modified Somatic Symptom Inventory. Multiple regression analyses were performed to compare the treatment outcomes.

RESULTS

Duloxetine-treated patients had higher odds of achieving remission (odds ratio = 2.578, P < 0.001) and response (odds ratio = 2.704, P < 0.001) during follow-up, compared with SSRI-treated patients. They also had lower levels of disease severity and higher levels of QoL during follow-up. A similar pattern was observed in each subgroup of patients with and without PPS at baseline, but the effects of duloxetine relative to SSRIs were in general greater in patients with PPS.

DISCUSSION

Patients treated with duloxetine had better treatment outcomes in terms of remission, response, depressive symptoms, and QoL, compared with SSRIs. Treatment with duloxetine may have additional advantages for patients with concurrent PPS.

Clinical Uses of Intrathecal Therapy and Its Placement in the Pain Care Algorithm

Intrathecal drug delivery is an effective treatment option for patients with severe chronic pain who have not obtained adequate analgesia from more conservative therapies (eg, physical therapy, systemic opioids, nonsteroidal anti-inflammatory drugs, antidepressants, and anticonvulsants). This review focuses on, but is not limited to, the 2 agents currently approved by the U.S. Food and Drug Administration for intrathecal analgesia: preservative-free morphine and ziconotide (a nonopioid, selective N-type calcium channel blocker). We describe the appropriate use of intrathecal therapy in the management of severe chronic pain, based on current best practices. Topics addressed here include patient selection, trialing, dosing and titration, adverse event profiles, long-term management, intrathecal therapy for cancer-related pain, and the placement of intrathecal therapy in the pain care algorithm. In appropriately selected patients with chronic pain, intrathecal therapy can provide substantial pain relief with improved functioning and quality of life. Successful long-term management requires ongoing patient monitoring for changes in efficacy and the occurrence of adverse events, with subsequent changes in intrathecal dosing and titration, the addition of adjuvant intrathecal agents, and the use of concomitant oral medications to address side effects, as needed. Based on an infrequent but clinically concerning risk of overdose, granuloma, and other opioid-induced complications, nonopioid therapy with ziconotide may be preferred as a first-line intrathecal therapy in patients without a history of psychosis or allergy.

Is complementary and alternative medicine use associated with cancer screening rates for women with functional disabilities?

OBJECTIVES

The purpose of this study was to examine the associations of complementary and alternative medicine (CAM) use with mammogram and Pap test rates and functional disabilities (FDs).

DESIGN

Cross-sectional study.

SETTING

Data were derived from the 2012 National Health Interview Survey (n=6576).

ANALYSIS

FDs was defined as physical and/or social limitations. The weighted logistic regression models were performed using SAS software. Study covariates were age, race, education, marital status, usual source of care, and insurance.

RESULTS

Of 6576 women, a majority were Caucasian (87%), with GED or less (40%), married (50%), having usual source of care (96%) and health insurance (91%), and with FDs (56%). The results indicated that some CAM practices were negatively associated with increased mammogram and Pap test rates while other CAM practices were positively associated. The results indicated that CAM practices that contribute to musculoskeletal problems such as acupuncture and massage were associated with the increased mammogram and Pap test rates. Contrary, women who used chiropractic manipulation, biofeedback, guided imagery, and energy hearing therapy were less likely to obtain cancer screenings regularly regardless of having FDs.

CONCLUSIONS

The use of several CAM therapies was more likely to be associated with mammogram and Pap test frequency, indicating that the CAM use may be associated with better screening rates due to the improvement of musculoskeletal problems. It is important to determine how each CAM therapy improves secondary health conditions in clinical trials to increase cancer screening rates for women with FDs.

Functioning in patients with major depression treated with duloxetine or a selective serotonin reuptake inhibitor in East Asia

PURPOSE

To assess and compare the levels of functioning in patients with major depressive disorder treated with either duloxetine with a daily dose of ≤60 mg or a selective serotonin reuptake inhibitor (SSRI) as monotherapy for up to 6 months in a naturalistic setting in East Asia. In addition, this study examined the impact of painful physical symptoms (PPS) on the effects of these treatments.

PATIENTS AND METHODS

Data for this post hoc analysis were taken from a 6-month prospective observational study involving 1,549 patients with major depressive disorder without sexual dysfunction. The present analysis focused on a subgroup of patients from East Asia (n=587). Functioning was measured using the Sheehan Disability Scale (SDS). Depression severity was assessed using the 16-item Quick Inventory of Depressive Symptomatology-Self Report. PPS were rated using the modified Somatic Symptom Inventory. A mixed model with repeated measures was fitted to compare the levels of functioning between duloxetine-treated (n=227) and SSRI-treated (n=225) patients, adjusting for baseline patient characteristics.

RESULTS

The mean SDS total score was similar between the two treatment cohorts (15.46 [standard deviation =6.11] in the duloxetine cohort and 16.36 [standard deviation =6.53] in the SSRI cohort, P=0.077) at baseline. Both descriptive and regression analyses confirmed improvement in functioning in both groups during follow-up, but duloxetine-treated patients achieved better functioning. At 24 weeks, the estimated mean SDS total score was 4.48 (standard error =0.80) in the duloxetine cohort, which was statistically significantly lower (ie, better functioning) than that of 6.76 (standard error =0.77) in the SSRI cohort (P<0.001). This treatment difference was more apparent in the subgroup of patients with PPS at baseline. Similar patterns were also observed for SDS subscores (work, social life, and family life).

CONCLUSION

Depressed patients treated with duloxetine achieved better functioning compared to those treated with SSRIs. This treatment difference was mostly driven by patients with PPS at baseline.

Pain, depression and the postoperative stiff shoulder

Background

The surgical repair of shoulder pathologies, including rotator cuff disease and acromio-clavicular joint arthritis, have undergone many technical advances. However the debilitating postoperative stiff shoulder remains a common and significant complication of these surgeries, occurring in 4.9 to 23.2 % of patients undergoing rotator cuff repairs.

The pathology of the pathological postoperative stiff shoulder and its associated condition “frozen shoulder” are poorly understood and both lack formal objective clinical diagnostic criteria. Additionally, although factors associated with the development of idiopathic frozen shoulder have been well described, multiple studies looking at predictors of postoperative stiff shoulder have produced conflicting results. It has been hypothesised that increased pain in the postoperative period, and depression may be predictors of the development of postoperative stiff shoulder.

Method

A prospective cohort study involving 132 consecutive participants. Preoperatively, participants undergoing arthroscopic subacromial decompression and/or excision of the distal clavicle and/or rotator cuff repair will complete questionnaires about their levels of shoulder pain using a numerical rating scale from 0 to 10, and answer a Patient Health Questionnaire – 9 depression questionnaire. Postoperatively, the participants’ pain levels will be self-assessed at two, five and seven days and weeks four, seven and ten. They will complete the depression questionnaire twice, at the time of their routine first and final postoperative appointments with the treating surgeon. At the final appointment, approximately three months postoperatively, the treating surgeon will clinically diagnose participants as having a postoperative stiff shoulder or not. Their shoulders’ range of motion will be measured. The incidence of postoperative stiff shoulder will be determined, both pain and depression will be analysed as predictors for its development and incidences determined by different objective criteria will be compared.

Discussion

This trial will add to clinical understanding of the postoperative stiff shoulder by providing further insight into the incidence of this condition following shoulder surgery and assessing whether perioperative pain and depression can be used as clinical predictors of postoperative stiff shoulder or markers for possible early intervention. This study will also allow the comparison of incidences determined by different objective criteria in the same cohort.

Trial registration

Australian New Zealand Clinical Trials Registry (ANZCTR).

ACTRN12613001271796.

17-11-2013.

Electronic supplementary material

The online version of this article (doi:10.1186/s12891-015-0841-6) contains supplementary material, which is available to authorized users.

m-Trifluoromethyl-diphenyl diselenide, a multi-target selenium compound, prevented mechanical allodynia and depressive-like behavior in a mouse comorbid pain and depression model

Chronic pain and depression are two complex states that often coexist in the clinical setting and traditional antidepressants and analgesics have shown limited clinical efficacy. There is an intricate communication between the immune system and the central nervous system and inflammation has been considered a common mediator of pain-depression comorbidity. This study evaluated the effect of m-trifluoromethyl diphenyl diselenide [(m-CF3-PhSe)2], an organoselenium compound that has been reported to have both antinociceptive and antidepressant-like actions, in the comorbidity of chronic pain and depression induced by partial sciatic nerve ligation (PSNL) in an inflammatory approach. Mice were submitted to PSNL during 4weeks and treated with (m-CF3-PhSe)2 acutely (0.1-10mg/kg, i.g.) or subchronically (0.1mg/kg, i.g., once a day during the 3rd and 4th weeks). Both treatments prevented PSNL-increased pain sensitivity and depressive-like behavior observed in Von-Frey hair (VFH) and forced swimming (FST) tests, respectively. These effects could be mainly associated with an anti-inflammatory action of (m-CF3-PhSe)2 which reduced the levels of pro-inflammatory cytokines, NF-κB and COX-2, and p38 MAPK activation that were increased by PSNL. (m-CF3-PhSe)2 also increased the BDNF levels and reduced glutamate release and 5-HT uptake altered by PSNL. Although acute and subchronic treatments with (m-CF3-PhSe)2 prevented these alterations induced by PSNL, the best results were found when (m-CF3-PhSe)2 was subchronically administered to mice. Considering the potential common mechanisms involved in the comorbidity of inflammation-induced depression and chronic pain, the results found in this study indicate that (m-CF3-PhSe)2 could become an interesting molecule to treat long-lasting pathological pain associated with depression.

Ethnic differences in the association between depression and chronic pain: cross sectional results from UK Biobank

BACKGROUND

Comorbid chronic pain and depression is a challenging dyad of conditions to manage in primary care and reporting has shown to vary by ethnic group. Whether the relationship between depression and chronic pain varies by ethnicity is unclear. This study aims to explore chronic pain and depression reporting across ethnic groups and examine whether this association differs, independently of potential confounding factors.

METHODS

Cross-sectional study of UK Biobank participants with complete data on chronic pain and probable lifetime history of depression, who reported their ethnic group as White, Asian/Asian British or Black/Black British. Chronic pain classification: present if participants had ≥ 1 site of body pain (up to seven sites or "pain all over the body" could be selected) that lasted ≥ 3 months; extent of chronic pain categories: 0, 1, 2-3, 4-7 sites or pain all over the body. Probable depression classification: an algorithm of low mood, anhedonia and help-seeking behaviour. Relationship between depression and presence/extent of chronic pain assessed using logistic/multinomial regression models (odds ratio (OR); relative risk ratio (RRR), 95 % confidence intervals), adjusted for sociodemographic, lifestyle, and morbidity factors; and a final adjustment for current depressive symptoms.

RESULTS

The number of participants eligible for inclusion was 144,139: 35,703 (94 %) White, 4539 (3 %) Asian, and 3897 (3 %) Black. Chronic pain was less (40.5 %, 45.8 %, 45.0 %, respectively) and depression more (22.1 %, 12.9 %, 13.8 %, respectively) commonly reported in White participants than Asian and Black participants. Statistically significant associations between depression and presence/extent of chronic pain persisted following adjustment for potential confounding variables; this relationship was strongest for Black participants (presence of chronic pain: OR 1.86 (1.52, 2.27); RRR 1 site 1.49 (1.16, 1.91), 2-3 sites 1.98 (1.53, 2.56), 4-7 sites 3.23 (2.09, 4.99), pain all over the body 3.31 (2.05, 5.33). When current depressive symptoms were considered these relationships were attenuated.

CONCLUSIONS

Chronic pain and depression reporting varies across ethnic groups. Differences in health seeking behaviour between ethnic groups may impact on the results reported. Clinicians, particularly in primary care, need to be aware of the cultural barriers within certain ethic groups to expressing concern over mood and to consider their approach accordingly.

Pain-Related Fear, Disability, and the Fear-Avoidance Model of Chronic Pain

Chronic pain is a significant public health concern that imposes substantial burdens on individuals and healthcare systems, and factors that contribute to the development and maintenance of pain-related disability are of increasing empirical and clinical interest. Consistent with the fear-avoidance model of chronic pain, greater pain-related fear has consistently been associated with more severe disability and may predict the progression of disability over time. Recent evidence indicates that treatments designed to reduce pain-related fear are efficacious for improving disability outcomes, and several clinical trials are currently underway to test tailored intervention content and methods of dissemination. Future research in this area is needed to identify factors (e.g., substance use, comorbid psychopathology) that may influence interrelations between pain-related fear, response to treatment, and disability.

Operationalizing Pain Treatment in the Biopsychosocial Model: Take a Daily "SWEM"--Socialize, Work, Exercise, Meditate

In the United States, chronic pain is often poorly treated at an exceedingly high cost. The use of the biomedical model to manage pain is frequently ineffective, and evidence suggests that the biopsychosocial (BPS) model is a better choice. A problem with the BPS model is that it has not been operationalized in terms of patient behavior. This commentary addresses that issue by suggesting that people with chronic pain and illness participate daily in four self-management health behaviors: socialize, work, exercise, and meditation, and discusses evidence that supports these recommendations. These self-management behaviors may decrease pain and thus reduce the need for pain medications and other medical interventions. Additional topics include patient adherence and health coaching.

Influence of Dopaminergic Medication on Conditioned Pain Modulation in Parkinson's Disease Patients

Background

Pain is highly prevalent in patients with Parkinson’s disease (PD), but little is known about the underlying pathophysiological mechanisms. The susceptibility to pain is known to depend on ascending and descending pathways. Because parts of the descending pain inhibitory system involve dopaminergic pathways, dysregulations in dopaminergic transmission might contribute to altered pain processing in PD. Deficits in endogenous pain inhibition can be assessed using conditioned pain modulation (CPM) paradigms.

Methods

Applying such a paradigm, we investigated i) whether CPM responses differ between PD patients and healthy controls, ii) whether they are influenced by dopaminergic medication and iii) whether there are effects of disease-specific factors. 25 patients with idiopathic PD and 30 healthy age- and gender-matched controls underwent an established CPM paradigm combining heat pain test stimuli at the forearm and the cold pressor task on the contralateral foot as the conditioning stimulus. PD patients were tested under dopaminergic medication and after at least 12 hours of medication withdrawal.

Results

No significant differences between CPM responses of PD patients and healthy controls or between PD patients “on” and “off” medication were found. These findings suggest (i) that CPM is insensitive to dopaminergic modulations and (ii) that PD is not related to general deficits in descending pain inhibition beyond the known age-related decline. However, at a trend level, we found differences between PD subtypes (akinetic-rigid, tremor-dominant, mixed) with the strongest impairment of pain inhibition in the akinetic-rigid subtype.

Conclusions

There were no significant differences between CPM responses of patients compared to healthy controls or between patients “on” and “off” medication. Differences between PD subtypes at a trend level point towards different pathophysiological mechanisms underlying the three PD subtypes which warrant further investigation and potentially differential therapeutic strategies in the future.

Associations Between Pain, Current Tobacco Smoking, Depression, and Fibromyalgia Status Among Treatment-Seeking Chronic Pain Patients

OBJECTIVE

As smoking impacts physiological pathways in the central nervous system, it is important to consider the association between smoking and fibromyalgia, a pain condition caused predominantly by central nervous system dysfunction. The objectives were to assess the prevalence of current smoking among treatment-seeking chronic pain patients with (FM+) and without (FM-) a fibromyalgia-like phenotype; test the individual and combined influence of smoking and fibromyalgia on pain severity and interference; and examine depression as a mediator of these processes.

METHODS

Questionnaire data from 1566 patients evaluated for a range of conditions at an outpatient pain clinic were used. The 2011 Survey Criteria for Fibromyalgia were used to assess the presence of symptoms associated with fibromyalgia.

RESULTS

Current smoking was reported by 38.7% of FM+ patients compared to 24.7% of FM- patients. FM+ smokers reported higher pain and greater interference compared to FM+ nonsmokers, FM- smokers, and FM- nonsmokers. There was no interaction between smoking and fibromyalgia. Significant indirect effects of fibromyalgia and smoking via greater depression were observed for pain severity and interference.

CONCLUSIONS

Current smoking and positive fibromyalgia status were associated with greater pain and impairment among chronic pain patients, possibly as a function of depression. Although FM+ smokers report the most negative clinical symptomatology (i.e., high pain, greater interference) smoking does not appear to have a unique association with pain or functioning in FM+ patients, rather the effect is additive. The 38.7% smoking rate in FM+ patients is high, suggesting FM+ smokers present a significant clinical challenge.

Integrated musculoskeletal service design by GP consortia

Background Musculoskeletal conditions are common in primary care and are associated with significant co-morbidity and impairment of quality of life. Traditional care pathways combined community-based physiotherapy with GP referral to hospital for a consultant opinion. Locally, this model led to only 30% of hospital consultant orthopaedic referrals being listed for surgery, with the majority being referred for physiotherapy. The NHS musculoskeletal framework proposed the use of interface services to provide expertise in diagnosis, triage and management of musculoskeletal problems not requiring surgery. The White Paper Equity and Excellence: Liberating the NHS has replaced PCT commissioning with GP consortia, who will lead future service development. Setting Primary and community care, integrated with secondary care, in the NHS in England. Question How can GP consortia lead the development of integrated musculoskeletal services?

REVIEW

The Ealing experience We explore here how Ealing implemented a 'See and Treat' interface clinic model to improve surgical conversion rates, reduce unnecessary hospital referrals and provide community treatment more efficiently than a triage model. A high-profile GP education programme enabled GPs to triage in their practices and manage patients without referral. Conclusion In Ealing, we demonstrated that most patients with musculoskeletal conditions can be managed in primary care and community settings. The integrated musculoskeletal service provides clear and fast routes to secondary care. This is both clinically effective and cost-effective, reserving hospital referral for patients most likely to need surgery. GP consortia, in conjunction with strong clinical leadership, inbuilt organisational and professional learning, and a GP champion, are well placed to deliver service redesign by co-ordinating primary care development, local commissioning of community services and the acute commissioning vehicles responsible for secondary care. The immediate priority for GP consortia is to develop a truly integrated service by facilitating consultant opinions within a community setting.

The incremental burden of pain in patients with depression: results of a Japanese survey

BACKGROUND

Major depressive disorder (MDD) is a chronic mental illness which affects an estimated 3% of the Japanese population. Many patients with MDD report painful physical symptoms, and research outside of Japan suggests such patients may represent a subtype of depression which is more severe and difficult to treat. There is no evidence available about the characteristics or incremental burden of these patients in Japan. The objective of this study was to quantify the incremental burden of physical pain among individuals in Japan diagnosed with depression.

METHODS

Data for individuals age 18 and older who reported a physician diagnosis of depression were obtained from the Japan National Health and Wellness Survey (NHWS). Respondents who also reported physical pain were matched to respondents who did not report pain using propensity scores and compared using bivariate statistics. Measures included Patient Health Questionnaire (PHQ-9) for depression severity, Medical Outcomes Study 12-Item Short Form Survey Instrument (SF-12v2) for health-related quality of life, the Work Productivity and Activity Impairment (WPAI) for work and activity impairment, and 6-month report of health care use.

RESULTS

Individuals with depression who reported physical pain had higher PHQ-9 depression scores (14.3 vs. 11.1, p<0.001), lower health-related quality of life (Mental Component Summary score [MCS] 29.1 vs. 32.0, p<0.01; Physical Component Summary score [PCS] 43.0 vs. 47.2, p<0.001; health utility [SF-6D] 0.567 vs. 0.613, p<0.001), more presenteeism (46.3% vs. 36.8%, p<0.01), more overall work impairment (51.4% vs. 42.3%, p<0.01), more activity impairment (55.4% vs. 43.9%, p<0.001), and reported using more health care provider visits in the prior 6 months (17.7 vs. 12.8, p<0.01) as well as hospitalizations (1.7 vs. 0.8, p<0.05) relative to propensity-score matched controls without pain. Absenteeism (13.1% vs. 11.4%, p=0.51) and emergency room visits (0.31 vs. 0.35, p=0.76) were not significantly different between the two matched groups.

CONCLUSIONS

Individuals whose depression is accompanied by physical pain have a higher burden of illness than those whose depression does not include physical pain. Clinicians should take the presence of pain into account and consider treating both the physical and emotional symptoms of these patients.

Peripheral indoleamine 2,3-dioxygenase 1 is required for comorbid depression-like behavior but does not contribute to neuropathic pain in mice

Chronic pain frequently co-occurs with major depressive disorder but the mechanisms are poorly understood. We investigated the contribution of indoleamine 2,3-dioxygenase-1 (IDO1), a rate-limiting enzyme in the conversion of tryptophan to neurotoxic metabolites, to this comorbidity using the spared nerve injury (SNI) model of neuropathic pain in mice. SNI resulted in unilateral mechanical allodynia, reduced social interaction, and increased immobility in the forced swim test without changes in locomotor activity. These findings indicate SNI-induced pain and comorbid depression-like behavior. These behavioral responses were accompanied by increases in plasma kynurenine/tryptophan ratios and increased expression of Ido1 and Il1b mRNA in the liver. Interestingly, SNI did not induce detectable changes in spinal cord or brain Ido1 mRNA levels. SNI was associated with spinal cord inflammatory activity as evidenced by increased Il1b mRNA expression. The SNI-induced increase of liver Ido1and Il1b mRNA was abrogated by intrathecal administration of the IL-1 inhibitor IL-1RA. Intrathecal IL-1RA also inhibited both mechanical allodynia and depression-like behavior. We also show that Ido1 is required for the development of depression-like behavior because Ido1(-/-) mice do not develop increased immobility in the forced swim test or decreased social exploration in response to SNI. Mechanical allodynia was similar in WT and Ido1(-/-) mice. In conclusion, our findings show for the first time that neuropathic pain is associated with an increase of Ido1 in liver, but not brain, downstream of spinal cord IL-1β signaling and that Ido1 mediates comorbid depression. Moreover, comorbidity of neuropathic pain and depression are only partially mediated by a common mechanism because mechanical hyperalgesia develops independently of Ido1.

Longitudinal associations between depression, anxiety, pain, and pain-related disability in chronic pain patients

OBJECTIVE

The current study sets out to examine the longitudinal relationship between pain, pain-related disability, and symptoms of depression and anxiety. The latter symptoms are highly prevalent in chronic pain and seriously impede functioning and quality of life. Nevertheless, the direction of the relationship involving these variables among individuals with chronic pain is still unclear.

METHODS

Four-hundred twenty-eight individuals with chronic pain (238 women, mean age 54.84 years, mean pain duration 85.21 months) treated at two pain clinics completed questionnaires regarding their pain (Short-Form McGill Pain Questionnaire), depression (Center for Epidemiological Studies-Depression Scale), state anxiety (State-Trait Anxiety Inventory), and pain-related disability (Pain Disability Index) at four time points, with an average of 5 months between measurements. Cross-lagged, structural equation modeling analyses were performed, enabling the examination of longitudinal associations between the variables.

RESULTS

Significant symptoms of both depression and anxiety were reported by more than half of the sample on all waves. A latent depression/anxiety variable longitudinally predicted pain (β = .27, p < .001) and pain-related disability (β = .38, p < .001). However, neither pain (β = .10, p = .126) nor pain-related disability (β = -.01, p = .790) predicted depression/anxiety.

CONCLUSIONS

Among adult patients with chronic pain treated at specialty pain clinics, high levels of depression and anxiety may worsen pain and pain-related disability.

Supplementation of n-3 Polyunsaturated Fatty Acids for Major Depressive Disorder: A Randomized, Double-Blind, 12-Week, Placebo-Controlled Trial in Korea

BACKGROUND

Controversy over the efficacy of n-3 polyunsaturated fatty acids (PUFAs) in depression continues to this day. The present study investigated the hypothesis that n-3 PUFA supplementation reduces depressive symptoms in Korean patients with major depressive disorder.

METHODS

In a randomized, double-blind, placebo-controlled, 12-week, parallel-group trial, 35 patients with Center for Epidemiological Studies Depression Scale Korean version (CES-D-K) scores ≥25 and depression confirmed by a psychiatrist were assigned to take either 3 capsules of n-3 PUFAs (1,140 mg of EPA + 600 mg of DHA; n = 18) or placebo (olive oil + safflower oil; n = 17).

RESULTS

Supplementation with n-3 PUFAs significantly reduced Clinical Global Impression Improvement (CGI-I) scores as compared with intake of placebo using intention-to-treat analysis with last-observation-carried-forward after adjusting for energy, fat, and fish intake. However, the CES-D-K, Hamilton Depression Rating Scale-17, and Clinical Global Impression Scale scores did not significantly differ between the n-3 PUFA and placebo groups. After supplementation with n-3 PUFAs, the erythrocyte levels of n-3 PUFAs were significantly increased, but n-6 PUFA levels were decreased.

CONCLUSIONS

n-3 PUFAs demonstrated an advantage over placebo that did not reach clinical significance, although CGI-I score was significantly decreased in the n-3 PUFA group as compared with the placebo group.

Return to work after depression-related absence by employees with and without other health conditions: a cohort study

OBJECTIVE

Among employees with depression, diagnoses of other psychiatric and somatic conditions are common. However, few studies have examined whether the combined presence of depression and other psychiatric or somatic disorders adversely affects return to work after depression-related absence from work.

METHODS

We examined the association of present and recent psychiatric and somatic conditions and return to work after depression-related absence in a cohort of 9908 Finnish public sector employees with at least one such episode. The data included a total of 14,101 episodes during the period January 2005 to December 2011.

RESULTS

A total of 89% (n = 12,486) of depression-related absence episodes ended in return to work during the follow-up. For those episodes, the median length of absence was 34 days (interquartile range, 20-69 days). After adjustment for sex, age, socioeconomic status, and type of employment contract, present or recent psychiatric disorders other than depression (hazard ratio [HR] = 0.78, 95% confidence interval [CI] = 0.74-0.83), cancer (HR = 0.66, 95% CI = 0.47-0.92), diabetes (HR = 0.73, 95% CI = 0.62-0.86), cardiovascular disease (HR = 0.78, 95% CI = 0.62-0.99), hypertension (HR = 0.76, 95% CI = 0.67-0.85), musculoskeletal disorders (HR = 0.82, 95% CI = 0.77-0.87), and asthma (HR = 0.84, 95% CI = 0.75-0.94) were all associated with a lower likelihood of returning to work compared with depression episodes without other conditions.

CONCLUSIONS

Among employees with depression-related absence, return to work is delayed in the presence of other psychiatric and somatic conditions. These findings suggest that other diseases should be taken into account when evaluating the outcome of depression-related absence. Randomized controlled trials are needed to examine whether integrated treatment of mental and physical disorders improves successful return to work after depression.

Antidepressant medication use, depression, and the risk of preeclampsia

OBJECTIVE

To assess the effects of depression and antidepressant medication use during pregnancy on the risk of preeclampsia.

METHODS

We conducted a retrospective, population-based cohort study that linked automated clinical and pharmacy databases including comprehensive electronic medical records of 21,589 pregnant Kaiser Permanente Northern California members between 2010 and 2012.

RESULTS

The overall risk of preeclampsia was 4.5%. The timing of antidepressant medication exposure was an important factor. A significant increase in the risk of preeclampsia emerged for women with a depression diagnosis who took antidepressant medications during the second trimester compared to women with untreated depression (adjusted relative risk [aRR]: 1.6, 95% CI: 1.06, 2.39) and to women without depression (aRR: 1.70, 95% CI: 1.30, 2.23). Similar associations existed for women who took antidepressant medications, but without depression. In contrast, depressed women with psychotherapy showed no increased risk of preeclampsia compared to women with untreated depression or no depression. There was also a statistically significant relationship between the duration of antidepressant medication use and preeclampsia. The observed association appeared stronger for selective serotonin reuptake inhibitor (SSRI) use, although a nonsignificant trend was also noted for use of norepinephrine-dopamine reuptake inhibitors (NDRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs).

CONCLUSION

Study findings suggest that antidepressant use during pregnancy may increase the risk of preeclampsia, especially use during the second trimester.

The prevalence of pain in bipolar disorder: a systematic review and large-scale meta-analysis

OBJECTIVE

To conduct a meta-analysis investigating the prevalence of pain in people with bipolar disorder (BD).

METHOD

A systematic review and random effects meta-analysis searching major electronic databases from inception till 01/2014 in accordance with the PRISMA statement. We included articles reporting quantitative data on the prevalence of pain in people with BD with or without a healthy control group. Two independent authors conducted searches, extracted data, and completed methodological quality assessment.

RESULTS

Twenty two cross-sectional studies were included, representing 12,375,644 individuals (BD n=171,352, n controls=12,204,292). The prevalence of pain in people with BD was 28.9% (95% CI=16.4-43.4%, BD n=171,352). The relative risk (RR) of pain in BD compared to controls was 2.14 (95% CI=1.67-2.75%, n=12,342,577). The prevalence of migraine was 14.2% (95% CI=10.6-18.3%, BD n=127,905), and the RR was 3.30 (95% CI=2.27-4.80%, n=6,732,220).About 23.7% (95% CI=13.1-36.3%, n=106,214) of people with BD experienced chronic pain. Age, percentage of males, methodological quality, and method of BD classification did not explain the observed heterogeneity.

CONCLUSION

People with BD experience significantly increased levels of pain (particularly chronic pain and migraine). The assessment and treatment of pain should form an integral part of the management of BD.

Health-related quality of life in patients with depression treated with duloxetine or a selective serotonin reuptake inhibitor in a naturalistic outpatient setting

PURPOSE

To assess the levels of quality of life (QoL) in major depressive disorder (MDD) patients treated with either duloxetine or a selective serotonin reuptake inhibitor (SSRI) as monotherapy for up to 6 months in a naturalistic clinical setting mostly in the Middle East, East Asia, and Mexico.

PATIENTS AND METHODS

Data for this post hoc analysis were taken from a 6-month prospective observational study involving 1,549 MDD patients without sexual dysfunction. QoL was measured using the EQ-5D instrument. Depression severity was measured using the Clinical Global Impression of Severity and the 16-item Quick Inventory of Depressive Symptomatology Self-Report (QIDS-SR16), while pain severity was measured using the pain items of the Somatic Symptom Inventory. Regression analyses were performed to compare the levels of QoL between duloxetine-treated (n=556) and SSRI-treated (n=776) patients, adjusting for baseline patient characteristics.

RESULTS

These MDD patients, on average, had moderately impaired QoL at baseline, and the level of QoL impairment was similar between the duloxetine and SSRI groups (EQ-5D score of 0.46 [SD =0.32] in the former and 0.47 [SD =0.33] in the latter, P=0.066). Both descriptive and regression analyses confirmed QoL improvements in both groups during follow-up, but duloxetine-treated patients achieved higher QoL. At 24 weeks, the estimated mean EQ-5D score was 0.90 in the duloxetine cohort, which was statistically significantly higher than that of 0.83 in the SSRI cohort (P<0.001). Notably, pain severity at baseline was also statistically significantly associated with poorer QoL during follow-up (P<0.001). In addition, this association was observed in the subgroup of SSRI-treated patients (P<0.001), but not in that of duloxetine-treated patients (P=0.479).

CONCLUSION

Depressed patients treated with duloxetine achieved higher QoL, compared to those treated with SSRIs, possibly in part due to its moderating effect on the link between pain and poorer QoL.

Association between pain severity, depression severity, and use of health care services in Japan: results of a nationwide survey

BACKGROUND

Depression is often associated with painful physical symptoms. Previous research has seldom assessed the relationship between the severity of physical symptoms and the severity of mental and emotional symptoms of depression or other health outcomes, and no such studies have been conducted previously among individuals with depression in Japan. The aim of this study was to assess the relationship between the severity of physical pain and depression and other outcomes among individuals in Japan diagnosed with depression.

METHODS

Data for individuals aged 18 and older in Japan who reported being diagnosed with depression and also reported physical pain were obtained from the Japan National Health and Wellness Survey. These respondents were characterized on sociodemographics and health characteristics, and the relationship between ratings of severity on pain in the last week and health outcomes were assessed using bivariate correlations and generalized linear models. Measures included the Patient Health Questionnaire for depression severity, Medical Outcomes Study 12-Item Short Form Survey Instrument for health-related quality of life, the Work Productivity and Activity Impairment for work and activity impairment, and 6-month report of health care use.

RESULTS

More severe physical pain in the past week was correlated with more severe depression, worse health-related quality of life, lower health utility, greater impairment at work, and more health care provider visits. These relationships remained significant after incorporating sociodemographics and health characteristics in the statistical models.

CONCLUSION

Individuals whose depression is accompanied by more severe physical pain have a higher burden of illness than those whose depression includes less severe pain, suggesting that even partially ameliorating painful physical symptoms may significantly benefit patients with depression. Clinicians should take the presence and severity of physical pain into account and consider treating both the physical and emotional symptoms of these patients.

Chronic multisite pain in major depression and bipolar disorder: cross-sectional study of 149,611 participants in UK Biobank

BACKGROUND

Chronic pain has a strong association with major depressive disorder (MDD), but there is a relative paucity of studies on the association between chronic multisite pain and bipolar disorder (BD). Such studies are required to help elucidate the complex biological and psychological overlap between pain and mood disorders. The aim of this study is to investigate the relationship between chronic multisite pain and mood disorder across the unipolar-bipolar spectrum.

METHODS

We conducted a cross-sectional study of 149,611 UK Biobank participants. Self-reported depressive and bipolar features were used to categorise participants into MDD and BD groups and a non-mood disordered comparison group. Multinomial logistic regression was used to establish whether there was an association between extent of chronic pain (independent variable) and mood disorder category (dependent variable), using no pain as the referent category, and adjusting for a wide range of potential sociodemographic, lifestyle and comorbidity confounders.

RESULTS

Multisite pain was significantly more prevalent in participants with BD and MDD, for example, 4-7 pain sites: BD 5.8%, MDD 4.5%, and comparison group 1.8% (p < 0.001). A relationship was observed between extent of chronic pain and risk of BD and persisted after adjusting for confounders (relative to individuals with no chronic pain): 2-3 sites RRR of BD 1.84 (95% CI 1.61, 2.11); 4-7 sites RRR of BD 2.39 (95% CI 1.88, 3.03) and widespread pain RRR of BD 2.37 (95% CI 1.73, 3.23). A similar relationship was observed between chronic pain and MDD: 2-3 sites RRR of MDD 1.59 (95% CI 1.54, 1.65); 4-7 sites RRR of MDD 2.13 (95% CI 1.98, 2.30); widespread pain RRR of MDD 1.86 (95% CI 1.66, 2.08).

CONCLUSIONS

Individuals who report chronic pain and multiple sites of pain are more likely to have MDD and are at higher risk of BD. These findings highlight an important aspect of comorbidity in MDD and BD and may have implications for understanding the shared neurobiology of chronic pain and mood disorders.

A public health approach to musculoskeletal health

An ageing, physically inactive and increasingly obese population, coupled with finite health and social care resources, requires a shift from treating musculoskeletal disease when it arises to a preventive approach promoting lifelong musculoskeletal health. A public health approach to musculoskeletal health ensures that people are able to live not only long, but also well. Supporting self-management, addressing common misconceptions about the inevitability of musculoskeletal conditions, and offering brief interventions to support necessary lifestyle changes are basic public health functions that all health professionals can deliver. More specialist public health skills including needs assessment, data interpretation and service planning are also needed to deliver high quality services. These will require improvements in the data collected about musculoskeletal health nationally. A public health approach would benefit individuals through reduced pain and improved function due to musculoskeletal conditions, and wider society by minimising lost economic productivity and lowering health and social care costs.

Impact of painful physical symptoms on depression outcomes in elderly Asian patients

ABSTRACT Background: Painful physical symptoms (PPS) are prevalent among elderly patients with depression. We describe the impact of PPS on depression outcomes and quality of life (QOL) of elderly Asian patients with major depressive disorder (MDD). Methods: This post hoc analysis of data from a three-month prospective observational study of East Asian MDD in- or out-patients focused on elderly patients aged ≥60 years. Depression severity was evaluated using the Hamilton depression (HAMD-17) and clinical global impression of severity (CGI-S) scales, while QOL was measured using EuroQOL (EQ-5D and EQ-VAS) instruments. PPS were rated using the modified somatic symptom inventory (SSI). Results: At baseline, depression was moderate to severe and 49% of the 146 elderly patients were painful physical symptom positive (PPS+). Bivariate analysis showed significant correlations between PPS and depression severity and QOL at baseline. Linear regression models showed the baseline factor most significantly associated with depression severity at three months was baseline PPS status. PPS+ patients had a mean increase of 2.87 points in their HAMD-17 rating and 0.77 points in their CGI-S score. Response and remission were significantly lower in PPS+ patients; response was 60% and remission was 40% in PPS+ patients while 82% and 66% in painful physical symptom negative (PPS-) patients. QOL at endpoint was lower in PPS+ patients. Conclusions: PPS are common in elderly Asian patients with MDD and negatively influence depression outcomes and QOL. Patients with PPS had lower QOL at baseline, lower response and remission rates, higher severity of depression, and lower QOL after three months of treatment.

Chronic administration of amitriptyline differentially alters neuropathic pain-related behaviour in the presence and absence of a depressive-like phenotype

Chronic pain and depression share a complex, reciprocal relationship. Furthermore, in addition to treating depression, antidepressants such as amitriptyline are a first-line treatment for chronic pain conditions, indicating possible common neural substrates underlying both depression and pain. However, there is a paucity of studies examining the effect of antidepressant treatment on nociceptive and neuropathic pain responding in the presence of a depressive phenotype. The current study aimed to examine the effect of chronic amitriptyline administration on neuropathic pain-related behaviour and associated neuroinflammatory processes in the olfactory bulbectomised (OB) rat model of depression. Nociceptive responding to mechanical, innocuous cold or noxious heat stimuli in sham or OB rats was not altered by chronic amitriptyline administration. The induction of neuropathic pain following L5-L6 spinal nerve ligation (SNL) resulted in robust mechanical and cold allodynia and heat hyperalgesia in both sham and OB vehicle-treated animals. Chronic amitriptyline administration attenuated SNL-induced mechanical allodynia in both sham and OB rats at day 7 post-SNL, an effect which was enhanced and prolonged in OB rats. In comparison, chronic amitriptyline administration attenuated SNL-induced cold allodynia and heat hyperalgesia in sham, but not OB, rats. Evaluating the affective/motivational aspect of pain using the place escape avoidance paradigm revealed that OB-SNL rats exhibit reduced noxious avoidance behaviour when compared with sham counterparts, an effect not altered by chronic amitriptyline administration. Chronic amitriptyline administration prevented the increased expression of GFAP, IL-10 and CCL5, and enhanced the expression of TNFα, in the prefrontal cortex of OB-SNL rats. In conclusion, these data demonstrate that chronic amitriptyline differentially alters somatic nociceptive responding following peripheral nerve-injury, depending on stimulus modality and the presence or absence of a depressive-like phenotype, an effect which may involve modulation of neuroinflammatory processes.

Common mental and musculoskeletal disorders as predictors of disability retirement among Finns

BACKGROUND

The contribution of common mental disorders (CMD) co-occurring with chronic musculoskeletal disorders (MSD) to disability retirement is not known.

METHODS

A nationally representative sample (the Health 2000 survey) comprised 3943 occupationally active Finns aged 30-63. MSD and other chronic disorders were assessed by a physician in a standardized clinical examination, and CMD using the Composite International Diagnostic Interview. Disability pension data for 2000-2011 was retrieved from national pension records. Cox regression was used with censoring for death and pension other than that for disability. Covariate information was based on an interview.

RESULTS

The baseline prevalence of CMD was 9.4% and of MSD 31.1%. CMD co-occurred with MSD in 3.3% of participants. The risks inflicted by CMD and MSD were additive. Thirty-eight per cent of the co-morbid subjects, 18% of those with CMD and 19% of those with MSD retired prematurely during the average follow-up of 8.6 years. Compared with those with neither type of disorder, the hazard ratio (HR) for disability pension was 2.4 (95% CI 1.7-2.7) for CMD only, 2.2 (1.8-2.7) for MSD only, and 4.1 (2.9-5.7) for the occurrence of both, allowing for age, gender, other chronic disorders, working conditions, and socio-economic and lifestyle factors. No synergistic or antagonistic interactive effects were observed.

LIMITATIONS

The determinants were measured only once and we had no information on incident disorders during the follow-up.

CONCLUSIONS

It is important to identify subjects with both mental and musculoskeletal complaints in order to efficiently support their work ability.

Smoking behavior and motivation to quit among chronic pain patients initiating multidisciplinary pain treatment: a prospective study

OBJECTIVE

The primary aim of this study was to assess smoking characteristics and cessation motivation prior to and after initiation of multidisciplinary chronic pain treatment. A secondary aim was to identify predictors of cessation motivation among smokers initiating treatment for chronic pain.

DESIGN

We used a prospective, nonrandomized, repeated measures design.

SETTING

The study was conducted in a multidisciplinary specialty pain treatment program at a veterans hospital.

PATIENTS

Smokers (N = 90) referred to a multidisciplinary pain program for the treatment of chronic pain.

MEASURES

Patients completed questionnaires assessing pain-related and smoking-related factors prior to (baseline) and 8 weeks post (follow-up) specialty pain treatment initiation. Primary outcome measures were the Contemplation Ladder and the Stages of Change (SOC) algorithm.

RESULTS

At baseline, patients reported moderate levels of cessation motivation, and 69% were in the contemplation stage or higher on the SOC. Motivation to quit smoking was higher at follow-up compared with baseline on both continuous, t(89) = 2.11, P < 0.05, and stage-based, z = 3.69, P < 0.01, measures. At follow-up, participants reported greater interest in receiving cessation interventions, and 7.8% of patients had quit smoking. Pain-related predictors of motivation (e.g., pain intensity) were subsumed by more general predictors (e.g., nicotine dependence).

CONCLUSIONS

Patients in this sample were more motivated to quit smoking a few weeks after, as compared with before initiating specialty pain treatment. Future research into pain-specific predictors of cessation motivation is warranted to inform the development of interventions that address pain patients' unique needs.

The relationship between abuse, psychosocial factors, and pain complaints among older persons in Europe

BACKGROUND AND OBJECTIVE

Abuse and pain complaints are common among older persons. However, little is known about relationships between abuse (e.g. psychological) and pain complaints (e.g. backache) among older persons while considering other factors (e.g. depression). Therefore, the aim of this study was to determine these relationships.

MATERIALS AND METHODS

The design was cross-sectional. A total of 4467 women and men aged 60-84 years from Germany, Greece, Italy, Lithuania, Portugal, Spain, and Sweden answered questionnaires regarding various areas such as abuse, mental health (e.g. anxiety) and pain complaints (e.g. backache). The data were examined with bivariate (analyses of variance) and multivariate methods (linear regressions).

RESULTS

The bivariate analyses showed that psychological abuse was connected with all pain complaints; physical with headache and head pressure; sexual with neck or shoulder pain and headache; injury with all complaints (except pain in joints or limbs); financial with pain in joints or limbs and head pressure; and overall abuse (one or more types) with all complaints (except headache). The regressions showed that psychological abuse increased the likelihood of being affected by head pressure and heaviness or tiredness in the legs; physical abuse of being affected by headache and head pressure; financial abuse of being affected by head pressure; and overall abuse of being affected by headache and head pressure. In general, respondents from Sweden and younger (60-64 years) were less affected by the complaints than those from other countries (e.g. Germany) and older (e.g. 70-74 years), respectively. Respondents on medication (e.g. pain killers) were less affected by all pain complaints and those with high social support by pain in joints or limbs. High scores on anxiety and depression and having many diseases increased the likelihood of being affect by all pain complaints.

CONCLUSIONS

Abuse was related with certain pain complaints (e.g. headache), but other factors and in particular mental health and physical diseases impacted on all pain complaints. Medication and partly social support had a positive effect on the pain experience, i.e. the complaints interfered less with for instance the daily-life of the respondents.