What does the BDI measure in chronic pain?

Patients With Chronic Pain: The Aspect Of Negative Body Image

OBJECTIVE

Negative body image is an increasingly important factor in chronic pain disorders; particularly because the two conditions mutually influence each other. Our study examines body-image-related attitudes and comorbid psychic symptoms in patients with chronic pain disorders.

METHODS AND MEASURES

188 patients with chronic pain answered the Dresden body image questionnaire (DKB-35), the Hospital Anxiety and Depression Scale (HADS) and the Beck's Depression Inventory (BDI).

RESULTS

The mean values of the DKB-35 subscales range between 2.24 und 3.29. The subscale "vitality" has the lowest mean value. BDI and HADS correlated significantly with the DKB-35 subscales. The subscale "body-acceptance" intercorrelated high with the two subscales "vitality" and "self-aggrandizement".

CONCLUSION

Our findings verify that chronic pain is strongly associated with negative body image. The issues of vitality and psychological symptoms seem particularly central in this complex interaction. The biopsycho-social model and the avoidance-endurance approach to chronic pain offer important ideas for explanation and treatment.

Reframing pain: the power of individual and societal factors to enhance pain treatment

The effectiveness of analgesics can be increased if synergistic behavioural, psychological, and pharmacological interventions are provided within a supportive environment.

Fibromyalgia and Depression: A Literature Review of Their Shared Aspects

Fibromyalgia (FM) is a chronic pain syndrome characterized by widespread, persistent pain that lasts more than three months without an evident organic lesion. FM has been considered controversial throughout history due to its validity as a diagnosis being constantly in question. Most patients diagnosed with FM are females. FM has been associated with multiple conditions, including irritable bowel and psychiatric disorders. Among all associated conditions, depression has been frequently found in patients with FM. Studies suggest that depression negatively affects the outcome of patients with FM. Moreover, a bidirectional relation between FM and depression has been depicted: depression increases the risk of FM being diagnosed later in life, as well as FM increases the risk of developing depression. In this article, we discussed aspects that FM and depression share and that might link both diseases, such as certain elements they seem to share in their pathophysiology: predisposing and triggering factors, central sensitization and kindling, areas of the brain implicated in both pain modulation and mood regulation, and hypothalamic-pituitary-adrenal axis (HPA axis) alterations. In addition, we highlighted the prevalence of depression in patients with FM, overlapping symptoms between FM and depression and how to assess them, and treatment strategies that have shown effective management of both conditions when concomitant. Due to the improvement of many aspects of FM when depression is appropriately targeted, screening for depression in patients with FM, despite its difficulty, has been encouraged.

A Narrative Review of the Assessment of Depression in Chronic Pain

OBJECTIVES

This narrative review sought to explore the main critical issues in the assessment of depression in chronic pain and to identify self-report tools that can be reliably used for measuring it.

DESIGN

Narrative review of the literature.

METHODS

Articles were obtained through a search of three databases and a hand search of the references of full-text papers. Key results within the retrieved articles were summarized and integrated to address the review objectives.

RESULTS

Criterion contamination, different ways to define and evaluate pain and depression across studies, variability in chronic pain samples and settings, pitfalls of diagnostic systems and self-reports, and reluctance to address (or difficulty of recognizing) depression in patients and healthcare providers emerged as main critical issues. The Beck Depression Inventory seems to be the more accurate tool to evaluate depression in chronic pain patients, while other instruments such as the Patient Health Questionnaire could be recommended for a rapid screening.

CONCLUSIONS

Assessment of depression comorbidity in chronic pain represents a challenge in both research and clinical practice; the choice and use of tests, as well as the score interpretation, require clinical reasoning.

NURSING PRACTICE IMPLICATIONS

Nurses play an important role in screening for depression. Cognitive contents of depression should be carefully evaluated since somatic symptoms may be confusing in the chronic pain context. Some self-reports may be useful for rapid screening. It is also advisable to consider other relevant patient information in evaluating depression.

The association of depression and painful physical symptoms–a review of the European literature

Objective:

The presence of painful physical symptoms may confound the diagnosis of major depressive disorder and may worsen patient prognosis. Epidemiological literature was reviewed to investigate the association between depression and painful physical symptoms.

Method:

MEDLINE and EMBASE database searches were conducted. Studies where a definable organic basis for pain was given were excluded. The search was unrestricted by language but limited to European studies and countries. After filters were applied, 70 eligible studies were reviewed.

Results:

The majority of studies reviewed showed an association between depression and painful physical symptoms. Over 40% of all studies examining the association between pain and depression were carried out in pain clinics in secondary care. Very few studies were conducted in psychiatric settings.

Conclusion:

The findings of this review suggest that painful physical symptoms may be an important part of the depressive syndrome. Although the relationship between depression and painful physical symptoms is not yet fully understood, findings suggest that diagnosis and treatment of depression should involve investigating and treating the full spectrum of symptoms (emotional and physical). Further research in psychiatric and generalist settings is needed to elucidate the relationship between depression and painful physical symptoms as experienced by patients and at the clinical level.

Parent Attributions of Ambiguous Symptoms in Their Children: A Preliminary Measure Validation in Parents of Children with Chronic Pain

How parents attribute cause to their child’s physical symptoms is likely important in understanding how the parent responds to the child, as well as the child’s health outcomes, especially within the context of chronic illness. Here, we adapt the Symptom Interpretation Questionnaire for parent report (SIQ-PR) and provide preliminary validation in a sample of parents of children with chronic pain (N = 311). Confirmatory factor analysis revealed that the SIQ-PR structure is consistent with the original measure, with three distinct attribution types: psychological (emotional/affective), somatic (illness/disease), and environmental (situational/transient) causes. All three subscales demonstrated satisfactory to good internal consistency, and temporal stability. Parents typically endorsed more than one attribution for each symptom, indicating that parents of children with chronic pain have a multidimensional interpretation of physical symptoms in their children. Further, parent psychological and somatic attributions, but not environmental attributions, were significantly associated with (i) parent protective responses towards their child, and (ii) the child’s self-reported somatic and psychological symptoms, indicating convergent and divergent validity. The SIQ-PR may be a useful measure for future studies investigating intergenerational and interpersonal models of pediatric chronic pain, and more broadly, to examine parent attributions of children’s ambiguous symptoms within the context of childhood chronic illness.

[Patient first - The impact of characteristics of target populations on decisions about therapy effectiveness of complex interventions: Psychological variables to assess effectiveness in interdisciplinary multimodal pain therapy]

INTRODUCTION

The assessment of treatment effectiveness in public health settings is ensured by indicators that reflect the changes caused by specific interventions. These indicators are also applied in benchmarking systems. The selection of constructs should be guided by their relevance for affected patients (patient reported outcomes). The interdisciplinary multimodal pain therapy (IMPT) is a complex intervention based on a biopsychosocial understanding of chronic pain. For quality assurance purposes, psychological parameters (depression, general anxiety, health-related quality of life) are included in standardized therapy assessment in pain medicine (KEDOQ), which can also be used for comparative analyses in a benchmarking system. The aim of the present study was to investigate the relevance of depressive symptoms, general anxiety and mental quality of life in patients undergoing IMPT under real life conditions.

METHODS

In this retrospective, one-armed and exploratory observational study we used secondary data of a routine documentation of IMST in routine care, applying several variables of the German Pain Questionnaire and the facility's comprehensive basic documentation. 352 participants with IMPT (from 2006 to 2010) were included, and the follow-up was performed over two years with six assessments. Because of statistically heterogeneous characteristics a complex analysis consisting of factor and cluster analyses was applied to build subgroups. These subgroups were explored to identify differences in depressive symptoms (HADS-D), general anxiety (HADS-A), and mental quality of life (SF 36 PSK) at the time of therapy admission and their development estimated by means of effect sizes. Analyses were performed using SPSS 21.0®.

RESULTS

Six subgroups were derived and mainly proved to be clinically and psychologically normal, with the exception of one subgroup that consistently showed psychological impairment for all three parameters. The follow-up of the total study population revealed medium or large effects; changes in the subgroups were consistently caused by two subgroups, while the other four showed little or no change. In summary, only a small proportion of the target population (20 %) demonstrated clinically relevant scores in the psychological parameters applied.

DISCUSSION

When selecting indicators for quality assurance, the heterogeneity of the target populations as well as conceptual and methodological aspects should be considered. The characteristics of the parameters intended, along with clinical and personal relevance of indicators for patients, should be investigated by specific procedures such as patient surveys and statistical analyses.

[Depression, anxiety and stress scales: DASS--A screening procedure not only for pain patients]

BACKGROUND

The assessment of mental distress is a central aspect in pain research and treatment. Particularly for depression the comorbidity with pain poses methodological and conceptual challenges. This study examined the psychometric properties of the short version of the depression, anxiety and stress scale (DASS), used in both pain research and treatment and constructed to overcome the particular problems by omitting somatic items and concentrating on the psychological core aspects of depression, anxiety and stress.

METHOD

The psychometric properties of the DASS-21 were compared between patients with pain and various people without any pain problems (N = 950). The DASS has three subscales, depression, anxiety and stress, each with seven items. The construct validity of the DASS was examined using the hospital anxiety and depression scale (HADS) for anxiety and depression and the general depression scale (Allgemeine Depressionsskala, ADS) for depression. The sensitivity and specificity for depression were determined against a structured interview for diagnostic and statistical manual of mental disorders (DSM-IV) and compared with the Center for Epidemiological Studies depression scale (CESD) and HADS in pain patients.

RESULTS

Cronbach's alpha of the DASS for the depression subscale was at least 0.91, while the anxiety and stress subscales had Cronbach alphas of 0.78-0.82 and 0.81-0.89, respectively. Although the depression subscale has only 7 items, it is just as reliable as the ADS with 21 items. It also has a better sensitivity and specificity than the HADS in identifying clinical patients with depression.

DISCUSSION

The DASS is a reliable questionnaire, free to use and brief to administer; therefore, it is an alternative to the previously used instruments for the screening of depression. Furthermore, the subscale stress measures irritability and tension, which are important aspects of pain experience but underused in assessment procedures for the diagnosis and treatment evaluation of patients with pain.

Pain-related distress and clinical depression in chronic pain: A comparison between two measures

Background and purpose

Depression is a frequent co-morbid diagnosis in chronic pain, and has been shown to predict poor outcome. Several reviews have described the difficulty in accurate and appropriate measurement of depression in pain patients, and have proposed a distinction between pain-related distress and clinical depression. Aims of the current study were to compare (a) the overlap and differential categorisation of pain patients as depressed, and (b) the relationship to disability between the Structured Interview for DSM-IV (SCID-Depression module) and the Hospital Anxiety and Depression Scale (HADS-D).

Methods

Seventy-eight chronic back pain patients were administered the SCID-D, the HADS-D and the Pain Disability Index (PDI).

Results

Significantly more patients were categorised with possible and probable depression by the HADS than the SCID-D. Results from Receiver Operating Characteristic (ROC) curve analysis suggested that the HADS-D provided better discriminatory ability to detect disability, demonstrating a better balance between sensitivity and specificity compared to the SCID-D, although a direct comparison between the two measurements showed no difference.

Conclusions

The HADS-D is a reasonably accurate indicator of pain-related distress in chronic pain patients, and captures the link between disability and mood.

Implications

It is likely that the SCID-D is better suited to identifying sub-groups with more pronounced psychiatric disturbance.

Perspective

Several reviews have proposed a distinction between pain-related distress and clinical depression. This study compared the overlap and differential categorisation of pain patients as depressed and the relationship to disability between the Structured Interview for DSM-IV (SCID-D; Depression module) and the Hospital Anxiety and Depression Scale (HADS-D).

© 2016 Scandinavian Association for the Study of Pain. Published by Elsevier B.V. All rights reserved.

The Effects of Forest Therapy on Coping with Chronic Widespread Pain: Physiological and Psychological Differences between Participants in a Forest Therapy Program and a Control Group

This study aimed to investigate the effects of a two-day forest therapy program on individuals with chronic widespread pain. Sixty one employees of a public organization providing building and facilities management services within the Seoul Metropolitan area participated in the study. Participants were assigned to an experimental group (n = 33) who participated in a forest therapy program or a control group (n = 28) on a non-random basis. Pre- and post-measures of heart rate variability (HRV), Natural Killer cell (NK cell) activity, self-reported pain using the visual analog scale (VAS), depression level using the Beck Depression Inventory (BDI), and health-related quality of life measures using the EuroQol Visual Analog Scale (EQ-VAS) were collected in both groups. The results showed that participants in the forest therapy group, as compared to the control group, showed physiological improvement as indicated by a significant increase in some measures of HRV and an increase in immune competence as indicated by NK cell activity. Participants in the forest therapy group also reported significant decreases in pain and depression, and a significant improvement in health-related quality of life. These results support the hypothesis that forest therapy is an effective intervention to relieve pain and associated psychological and physiological symptoms in individuals with chronic widespread pain.

Stress-Related Immune Markers in Depression: Implications for Treatment

Major depression is a serious psychiatric disorder; however, the precise biological basis of depression still remains elusive. A large body of evidence implicates a dysregulated endocrine and inflammatory response system in the pathogenesis of depression. Despite this, given the heterogeneity of depression, not all depressed patients exhibit dysregulation of the inflammatory and endocrine systems. Evidence suggests that inflammation is associated with depression in certain subgroups of patients and that those who have experienced stressful life events such as childhood trauma or bereavement may be at greater risk of developing depression. Consequently, prolonged exposure to stress is thought to be a key trigger for the onset of a depressive episode. This review assesses the relationship between stress and the immune system, with a particular interest in the mechanisms by which stress impacts immune function, and how altered immune functioning, in turn, may lead to a feed forward cascade of multiple systems dysregulation and the subsequent manifestation of depressive symptomology. The identification of stress-related immune markers and potential avenues for advances in therapeutic intervention is vital. Changes in specific biological markers may be used to characterize or differentiate depressive subtypes or specific symptoms and may predict treatment response, in turn facilitating a more effective, targeted, and fast-acting approach to treatment.

Cross-sectional study on socio-demographic and clinical correlates of depression among human immunodeficiency virus-positive patients in Surat City, Western India

INTRODUCTION

Surat has the highest incidence of human immunodeficiency virus/acquired immune deficiency syndrome (HIV/AIDS) in Gujarat, the main reason being its large migrant population. Mental health in HIV/AIDS has most often been a topic of neglect all over the world. This study attempts to assess the magnitude of depression and the socio-demographic and clinical variables associated with it in HIV-positive patients.

METHODS

A cross-sectional study was conducted in 270 HIV-positive patients using Beck Depression Inventory (BDI; translated and validated in Gujarati and Hindi) along with a questionnaire for eliciting information on socio-demographic and clinical variables.

RESULTS

The prevalence of depression among HIV-positive patients was 30% with 12.22% having mild depression; 14.07% with moderate depression and 3.7% with severe depression. Bivariate analysis showed that physical pain, physical illness, Cluster of Differentiation 4 (CD4)<300 cells/mm3, HIV positive spouse, discrimination at hospital, discrimination in society, government setup as the first place of HIV test and broken relationship with spouse after HIV disclosure were significantly associated with depression among the patients. On multiple logistic regression, discrimination at hospital, physical pain and CD4<300 cells/mm3 were found to be the significant predictors of depression among the patients.

DISCUSSION

HIV-positive patients can be screened by counselors using easy-to-administer scales like BDI, which can be translated and validated into any regional language. A trained psychiatrist should be appointed at the Anti-Retroviral Therapy (ART) center to take care of the mental health issues of the patients.

Fibromyalgia is characterized by altered frontal and cerebellar structural covariance brain networks

Altered brain morphometry has been widely acknowledged in chronic pain, and recent studies have implicated altered network dynamics, as opposed to properties of individual brain regions, in supporting persistent pain. Structural covariance analysis determines the inter-regional association in morphological metrics, such as gray matter volume, and such structural associations may be altered in chronic pain. In this study, voxel-based morphometry structural covariance networks were compared between fibromyalgia patients (N = 42) and age- and sex-matched pain-free adults (N = 63). We investigated network topology using spectral partitioning, which can delineate local network submodules with consistent structural covariance. We also explored white matter connectivity between regions comprising these submodules and evaluated the association between probabilistic white matter tractography and pain-relevant clinical metrics. Our structural covariance network analysis noted more connections within the cerebellum for fibromyalgia patients, and more connections in the frontal lobe for healthy controls. For fibromyalgia patients, spectral partitioning identified a distinct submodule with cerebellar connections to medial prefrontal and temporal and right inferior parietal lobes, whose gray matter volume was associated with the severity of depression in these patients. Volume for a submodule encompassing lateral orbitofrontal, inferior frontal, postcentral, lateral temporal, and insular cortices was correlated with evoked pain sensitivity. Additionally, the number of white matter fibers between specific submodule regions was also associated with measures of evoked pain sensitivity and clinical pain interference. Hence, altered gray and white matter morphometry in cerebellar and frontal cortical regions may contribute to, or result from, pain-relevant dysfunction in chronic pain patients.

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We conducted structural covariance and tractography analyses in fibromyalgia.

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In fibromyalgia, higher correlations between cerebellar ROI volumes were found.

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In controls, higher correlations between frontal ROI volumes were found.

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Volume of cerebellum, orbitofrontal and inferior parietal areas correlated with BDI.

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WM fiber numbers connecting the areas associated with hyperalgesia and clinical pain

Factor structure of the children's depression inventory in a multisite sample of children and adolescents with chronic pain

This study examined the factor structure of the Children's Depression Inventory (CDI) among children and adolescents with chronic pain using exploratory and confirmatory factor analysis in a large, multisite sample of treatment-seeking youth. Participants included 1,043 children and adolescents (ages 8-18) with a range of chronic pain complaints who presented for initial evaluation at 1 of 3 tertiary care pediatric chronic pain clinics across the United States. They completed the CDI and reported on pain intensity and functional disability. Factor analysis was conducted using a 2-step (exploratory and confirmatory) approach. Results supported a 5-factor model for the CDI with good fit to the data. The distribution and item-total correlations of the somatic items (eg, pain complaints, fatigue) were explored in this sample. Results indicate that the CDI is a useful tool for assessing depressive symptoms in youth with chronic pain, but some caution is warranted in interpreting the clinical significance of scores in light of the overlap of specific symptoms common to both pain and depression.

PERSPECTIVE

The CDI can be considered a valid tool for assessing mood symptoms in children with chronic pain. Caution is encouraged when interpreting the clinical significance of scores due to symptom overlap between chronic pain and depression.

Personal experience of osteoarthritis and pain questionnaires: mapping items to themes

PURPOSE

The aim of this study was to examine the correspondence between qualitative and quantitative methods of coding experience of pain reported by participants with osteoarthritis (OA) of the knee.

METHODS

A mapping grid was produced to record the correspondence between subthemes that emerged from thematic analysis of interviews with 24 participants with knee OA, and from questionnaire items which were used in a study of 192 knee OA participants. Items were rated according to their degree of correspondence between subthemes and questionnaire items, and an overall correspondence score was produced for each subtheme and questionnaire measure.

RESULTS

The subthemes that corresponded well with the questionnaire items were those that related to socio-emotional functioning, the overall experience of pain and the impact of pain on physical functioning. The questionnaire items did not relate to participants' knowledge about their condition and their experience of the medical system.

CONCLUSIONS

The study indicated that many aspects of pain experience reported by patients in qualitative interviews are also assessed by commonly used questionnaire outcome measures for people with pain. However, although participants reported that knowledge about their condition and their experience of the medical system were important aspects of the overall pain experience, these are rarely used as outcome measures. Questionnaires that address these additional aspects of the pain experience could be useful to further evaluate the experience of pain and may help to address important concerns raised by patients with OA of the knee.

Does dysphoric mood really predict the outcome of lumbar surgery? Methodological pitfalls in psychological research

This study investigates the relationship between depression and continuous pain after lumbar surgery by means of the Beck Depression Inventory (BDI). To assess the possibility that some somatic symptoms are confounded with pain, the items of the inventory were divided into a cognitive-affective and somatic subscale. Data analysis is based on two assumptions: (1) continuous pain after surgery is more closely related to the somatic subscale than to the cognitive-affective subscale of the BDI; and (2) postsurgical pain can be better predicted by the somatic than by the cognitive-affective subscale presurgery. The sample consisted of 61 patients with lumbar nucleotomy and 107 patients with lumbar spondylodesis. Treatment outcome was evaluated 6 months after surgery in the nucleotomy patients and 9 months after surgery in the spondylodesis patients. At follow-up, subjects conducted a pain diary over a period of 2 weeks. Correlational methodology was applied. Data analysis of both samples confirms the first assumption, whereas the second assumption is only partly confirmed. Only in the spondylodesis sample was pain intensity at follow-up predicted by the total BDI score. Regarding the subscales, the cognitive-affective scale, but not the somatic scale, was related to surgical outcome in this sample. The relationship between presurgical depression and pain at follow-up failed to reach statistical significance in the nucleotomy sample. It is concluded that lack of awareness of the confounding effects of somatic items in questionnaires for the assessment of mood may contribute to erroneous conclusions drawn from studies reported in the literature.

The interest of gait markers in the identification of subgroups among fibromyalgia patients

BACKGROUND

Fibromyalgia (FM) is a heterogeneous syndrome and its classification into subgroups calls for broad-based discussion. FM subgrouping, which aims to adapt treatment according to different subgroups, relies in part, on psychological and cognitive dysfunctions. Since motor control of gait is closely related to cognitive function, we hypothesized that gait markers could be of interest in the identification of FM patients' subgroups. This controlled study aimed at characterizing gait disorders in FM, and subgrouping FM patients according to gait markers such as stride frequency (SF), stride regularity (SR), and cranio-caudal power (CCP) which measures kinesia.

METHODS

A multicentre, observational open trial enrolled patients with primary FM (44.1 ± 8.1 y), and matched controls (44.1 ± 7.3 y). Outcome measurements and gait analyses were available for 52 pairs. A 3-step statistical analysis was carried out. A preliminary single blind analysis using k-means cluster was performed as an initial validation of gait markers. Then in order to quantify FM patients according to psychometric and gait variables an open descriptive analysis comparing patients and controls were made, and correlations between gait variables and main outcomes were calculated. Finally using cluster analysis, we described subgroups for each gait variable and looked for significant differences in self-reported assessments.

RESULTS

SF was the most discriminating gait variable (73% of patients and controls). SF, SR, and CCP were different between patients and controls. There was a non-significant association between SF, FIQ and physical components from Short-Form 36 (p = 0.06). SR was correlated to FIQ (p = 0.01) and catastrophizing (p = 0.05) while CCP was correlated to pain (p = 0.01). The SF cluster identified 3 subgroups with a particular one characterized by normal SF, low pain, high activity and hyperkinesia. The SR cluster identified 2 distinct subgroups: the one with a reduced SR was distinguished by high FIQ, poor coping and altered affective status.

CONCLUSION

Gait analysis may provide additional information in the identification of subgroups among fibromyalgia patients. Gait analysis provided relevant information about physical and cognitive status, and pain behavior. Further studies are needed to better understand gait analysis implications in FM.

Comparison between the Beck Depression Inventory and psychiatric evaluation of distress in patients on long-term sick leave due to chronic musculoskeletal pain

Background:

Chronic musculoskeletal pain (CMP) is associated with psychological distress and long-term disability. Underlying diagnoses causing long-term sickness absence due to CMP have not been explored enough. In a somatic health care setting, it is important to identify mental health comorbidity to facilitate the selection of appropriate treatment. The objectives of this study were to compare the scores of depressed mood obtained on the Beck Depression Inventory (BDI) with the diagnosis of depression made by a psychiatrist, and to study the prevalence of undiagnosed mental health comorbidity in these patients.

Methods and patients:

83 consecutive patients on sick leave (mean duration 21 months) due to CMP who had been referred by the Social Insurance Office to an orthopedist and a psychiatrist for assessment of the patient’s diagnoses and capacity to work. The mean age was 45 (23–61) years, 58% were women and 52% were immigrants. The accuracy of measurements was calculated using the Diagnostic Statistical Manual of Mental Disorders IV as the Gold standard.

Results:

Psychiatric illness was diagnosed in 87% of the patients. The diagnosis was depression in 56%, other psychiatric illnesses in 31%, whereas 13% were mentally healthy. Of all the patients, only 10% had a previous psychiatric diagnosis. The median value of the BDI score was 26 points in depressed patients, whereas it was 23 in patients with other psychiatric diagnoses. The sensitivity of the BDI to detect depression was 87.5%. We found good agreement between the BDI score and a diagnosis of depression.

Conclusion:

Undiagnosed psychiatric disorders were commonly seen in patients with CMP. The high sensitivity of the BDI scores enables the screening of mental health comorbidity in patients with a somatic dysfunction. The test is a useful tool for detecting distress in patients who are on long-term sick leave due to CMP and who need additional treatment.

Fibromyalgia and bipolar disorder: a potential problem?

OBJECTIVE

To screen patients with fibromyalgia for bipolar disorder and to determine if there were any clinical clues, other than the Mood Disorders Questionnaire (MDQ), which might suggest a diagnosis of comorbid bipolar disorder.

METHODS

A total of 128 consecutive new fibromyalgia patients referred to a tertiary care center rheumatology practice were enrolled and assessed using a standard clinical protocol that included the completion of four screening questionnaires: (i) MDQ for bipolar disorder, (ii) Beck Depression Inventory (BDI) for depression, (iii) Epworth Sleepiness Scale (ESS) for daytime sleepiness, and (iv) Fibromyalgia Impact Questionnaire Disability Index (FIQ-DI) to assess for functional capacity.

RESULTS

A quarter of the fibromyalgia subjects, 25.19%, had a positive screen for bipolar disorder (MDQ >or= 7); 78.12% were clinically depressed (BDI >or= 10); and 52.13% reported daytime sleepiness (ESS >or= 10). Fibromyalgia subjects who screened positive for bipolar disorder had more severe depression than those with a negative screen [median BDI: 26.0 (19.0, 32.0) versus 15.0 (9.0, 24.0), p < 0.001].

CONCLUSIONS

We report a high prevalence of positive testing for bipolar disorder in this fibromyalgia cohort. Clinical data and questionnaire instruments other than nonspecific high depression severity failed to identify these patients. Since the norepinephrine serotonin reuptake inhibitors duloxetine and milnacipran have been recently approved by the U.S. Food and Drug Administration for the treatment of fibromyalgia, and because patients with bipolar disorder may experience destabilization of mood when treated with such agents, patients with fibromyalgia should be systematically screened for bipolar disorder prior to treatment.

The impact of chronic pain on the health of black and white men

Persistent pain, disability, and depression are hallmarks for chronic pain. While disparities based upon race, gender, and class are documented, little is known about pain disparities in minority men. This investigation examines black (6.2%) and white (93.8%) men (N = 1650) presenting for initial assessment at a tertiary care pain center. Racial comparisons utilized analysis of variance; all variables of interest were then placed in a theoretical model using path analysis. The model included race, age, education, neighborhood income, marital status, litigation, substance use, and high blood pressure as predictors and pain, depression, affective distress, posttraumatic stress disorder (PTSD), and disability as outcomes. Black race was associated with lower neighborhood income, education and marriage rates, and higher rates of litigation and high blood pressure. Black men also had higher pain (affective and miscellaneous), disability, and depression. Path analysis found black race was a direct predictor of greater pain, and through pain, was an indirect predictor of depression, affective distress, PTSD, and disability. Path analysis confirmed the complexity of relationships and supported using techniques to understand these relationships. Our data highlight disparities in the pain experience for black men. They also elucidate potential mechanisms through which disparities work in vulnerable and understudied populations.

Should psychological distress screening in the community account for self-perceived health status?

OBJECTIVE

Psychological distress questionnaires are often used as screening instruments for mental disorders in clinical and epidemiologic settings. Poor physical health may affect the screening properties of a questionnaire. We evaluate the effect of self-perceived health status on the screening performance of the Kessler K10 and K6 scales in a community sample.

METHODS

We used data from the Canadian Community Health Survey: Mental Health and Well-Being (CCHS 1.2). Psychological distress was measured by the 6-item (K6) and the 10-item (K10) Kessler instrument. Depression and anxiety disorders were assessed using the World Mental Health Composite International Diagnostic Interview (1-month estimates). Optimal cut-off points regarding health status were determined by finding the K6 and K10 values that allowed for the best balance between sensitivity and specificity. Stratum-specific likelihood ratios (SSLRs) were computed to define strata with discriminating power.

RESULTS

There was a strong association between the screening performance of the K6 and K10 scales and self-perceived health status: for the K10 scale, a cut-off point of 5/6 yielded the best balance between sensitivity and specificity for subjects with excellent or very good health status, while a cut-off point of 14/15 yielded the best balance between sensitivity and specificity for subjects with poor health status.

CONCLUSIONS

The combination of the K6 and K10 scales, with a self-rated health status item, may improve screening properties of the 2 scales.

Phantom Pain—Psychological Conceptualization and Treatment: A Case Report

This paper describes a case concentrating on the psychological conceptualization and treatment of phantom pain. A single session of cognitive work, teaching an “attention diversion’ strategy, was effectively utilized for the treatment of below knee phantom pain in an elderly lady. A follow-up, approximately one year later, revealed that the treatment gains had been maintained. Although a review of the literature (Sherman, Sherman and Gall, 1980) presents a rather murky picture as regards treatment prospects, the results nevertheless illustrate how a very simple cognitive strategy was successfully employed to alleviate a long standing debilitating phantom pain.

Illness behavior in patients on long-term sick leave due to chronic musculoskeletal pain

BACKGROUND AND PURPOSE

Methods for identification of patients with illness behavior in orthopedic settings are still being debated. The purpose of this study was to test the association between illness behavior, depressed mood, pain intensity, self-rated disability, and clinical status in patients with chronic musculoskeletal pain (CMP).

METHODS

We examined 174 consecutive sick-listed patients (90 women). Musculoskeletal function was estimated by range of motion, muscle strength, and motor and sensory function. The degree of illness behavior was measured by Waddell signs (WS), RESULTS: WS were observed in 47/174 (27%) of the patients, 16% of whom manifested excessive illness behaviour. In general, more patients with WS were depressed (OR = 4.4; 95% CI: 1.8-11) and experienced greater pain (OR = 2.9; CI: 1.1-7.7). No abnormal physical function could be observed in two-thirds of the patients. Other predictive factors for manifesting WS at the clinical examinations were longer sick leave and previous full sick leave (p < 0.05).

INTERPRETATION

Excessive illness behavior is related to psychological distress in patients with CMP and long-term disability. Thus, some patients may also require psychological assessment. Looking for WS during consultation is useful for targeting other factors that may be important in the diagnostic process.

The utility of the Beck Depression Inventory in a bariatric surgery population

BACKGROUND

The Beck Depression Inventory (BDI) is commonly used in bariatric surgery psychological assessments. However, several items may be measuring physical consequences of obesity (e.g., sleep disturbance, chronic pain, or sexual dysfunction) rather than depressive symptoms.

METHODS

Bariatric surgery candidates (n = 210) completed a series of assessments including the BDI, a chronic pain assessment, and a semistructured clinical interview. Total BDI scores, subscale scores, and endorsement patterns of somatic versus cognitive-affective items were examined based on (1) the presence or absence of a depressive diagnosis or (2) the presence or absence of chronic pain, and optimal cut points were determined.

RESULTS

Both the total BDI and cognitive-affective subscale had good discriminating accuracy between participants with and without depression, with an optimal cut point of 12 for the BDI and 7 for the cognitive-affective subscale. Bariatric surgery candidates with chronic pain had significantly higher mean total scores on the BDI (M = 12.5 +/- 7.5) than those without chronic pain (M = 9.02 +/- 6.7; p < 0.01), and those with chronic pain were significantly more likely to endorse many of the physical items than those without chronic pain.

CONCLUSIONS

The BDI, with or without the somatic items, appears to be a reasonable screening measure for depressive symptoms among bariatric surgery candidates and the subpopulation of those with chronic pain, although future investigations may wish to examine whether other measures would have improved discrimination accuracy.

Psychometric properties of the Beck Depression Inventory--second edition (BDI-II) in individuals with chronic pain

Given the high prevalence of depression in individuals with chronic pain and the negative outcomes associated with such comorbidity, the importance of assessing depressive symptoms is widely acknowledged by chronic pain specialists. The BDI-II is a commonly employed measure of depressive symptomatology at pain centres; however, little is known about its psychometric properties in this population. This study evaluated factorial validity, internal consistency, and gender invariance of the BDI-II in 481 patients with chronic pain. Four competing models of the BDI-II factor structure were examined and confirmatory factor analysis supported the conceptualization of depression as a singular latent construct, within a hierarchical factor structure consisting of three first-order factors--Negative Attitude, Performance Difficulty, and Somatic Elements. Factor structure, item-total correlations, and correlations between subscale means and subjective pain experience support the inclusion of somatic items despite concerns regarding their overlap with pain symptoms. Internal consistency was good. Mean total scores were in the moderately severe range. Given the evidence of partial measurement invariance, an examination of mean gender differences was warranted. In contrast to the general population, the average scores of women and men were similar. Overall, results support the construct validity and internal consistency of the BDI-II for assessing depressive symptoms in both women and men with chronic pain. Results support the appropriateness of computing a total score and/or subscale scores. These results impact chronic pain researchers and clinicians, particularly given current trends toward empirically supported assessment.

Pain intensity and severe pain in young immigrant patients with long-standing back pain

The aim of this study was to explore if self-rated pain intensity and severe pain differed significantly between immigrants from different regions, and if other socio-economic, or clinical, characteristics could predict severe pain. A total of 129 men and 217 women at a primary health centre in Stockholm, Sweden, 27-45 years, on long-term sick leave, were recruited in consecutive order and grouped into a Turkish (n = 122), Southern European (n = 52), Middle East (n = 69) and one Mixed (n = 173) group of immigrants. All were employed in service jobs. Somatic status, depression and level of psychosocial stressors, including pain anxiety, were established by standardized procedures. All reported long-standing disabling back pain. Patients rated intensity of pain "right now" on a 0-100 mm visual analogue scale (VAS) as a last part of the consultation with two doctors. Severe pain was defined as VAS 75-100. Median values (md) with inter-quartile ranges (IQR) were calculated for interval and ordinal data. Non-parametric statistics were used to calculate significant differences between groups. Crude and age-standardized odds ratios (OR) with 95% confidence intervals (95% CI) as rating severe pain were calculated by binary and forward conditional logistic regression. Men and women were analyzed separately. Women had more tender points, (P < 0.001), and reported pain anxiety more often (P < 0.01). Frequency of depression did not differ between the immigrant groups. The VAS-values varied, but not significantly, between the immigrant groups of men and women. Men had lower VAS values than women (md 50, IQR 36-69 vs. md 72, IQR 51-85), (P < 0.001). Women had a three-fold risk to rate severe pain (OR 2.9, 95% CI 1.8-4.7). By sex, no immigrant group had significantly elevated OR to rate severe pain. Being 40-45 year old doubled the OR as rating severe pain. Men with depression, or little education, had high risks as rating severe pain (age-standardized ORs 4.1; 95% CI 1.7-10.0 and 2.7; 95% CI 1.1-6.8, respectively), and so had depressed women (age-standardized OR 1.9; 95% CI 1.1-3.4). Women with pain anxiety had a doubled, not statistically significant, elevated risk (age-standardized OR 2.0, 95% CI 0.95-4.3). The groups did not differ significantly in pain intensity or severe pain. Severe pain was predicted by depressed mood and probably linked to gender, age and sick roles.

Low intensity permanent magnets in the treatment of chronic lumbar radicular pain

We assessed the pain-relieving efficacy of static magnetic fields produced by 200 Gauss (G) magnets compared with 50G magnets in a double-blind, randomized, two-phase crossover study in patients with chronic lumbar radicular pain. The surface field strengths of the magnets were 200 and 50G. Phase I included four random periods of two-week duration: two periods with 200G, one period with 50G, and one period of "no treatment." The magnets were positioned either vertically or horizontally in standard lumbosacral elastic corsets. Phase II consisted of two five-week periods with the most effective magnet from Phase I and its corresponding 50 or 200G device. The primary outcome was average daily leg pain score (0-10 scale) in each period of Phase II. Thirty-eight of 40 randomized patients completed Phase I, and 28 of 31 Phase II participants completed the study. In Phase I, pain scores did not differ significantly between 200 and 50G magnets. Phase II average leg pain scores tended to be lower with 200 vs. 50G magnets (3.2+/-2.1 for 200G vs. 3.9+/-2.2 for 50G magnets [P=0.08]) after excluding one unblinded patient. The relative treatment effect of the 200G magnets appeared to increase throughout the five-week period. Although these data cannot rule out a chance effect, the positive trends suggest that larger, longer-duration, sham-controlled trials with 200G magnets be considered in patients with chronic lumbar radicular pain.

Depression rating scales in Parkinson's disease: critique and recommendations

Depression is a common comorbid condition in Parkinson's disease (PD) and a major contributor to poor quality of life and disability. However, depression can be difficult to assess in patients with PD due to overlapping symptoms and difficulties in the assessment of depression in cognitively impaired patients. As several rating scales have been used to assess depression in PD (dPD), the Movement Disorder Society commissioned a task force to assess their clinimetric properties and make clinical recommendations regarding their use. A systematic literature review was conducted to explore the use of depression scales in PD and determine which scales should be selected for this review. The scales reviewed were the Beck Depression Inventory (BDI), Hamilton Depression Scale (Ham-D), Hospital Anxiety and Depression Scale (HADS), Zung Self-Rating Depression Scale (SDS), Geriatric Depression Scale (GDS), Montgomery-Asberg Depression Rating Scale (MADRS), Unified Parkinson's Disease Rating Scale (UPDRS) Part I, Cornell Scale for the Assessment of Depression in Dementia (CSDD), and the Center for Epidemiologic Studies Depression Scale (CES-D). Seven clinical researchers with clinical and research experience in the assessment of dPD were assigned to review the scales using a structured format. The most appropriate scale is dependent on the clinical or research goal. However, observer-rated scales are preferred if the study or clinical situation permits. For screening purposes, the HAM-D, BDI, HADS, MADRS, and GDS are valid in dPD. The CES-D and CSDD are alternative instruments that need validation in dPD. For measurement of severity of depressive symptoms, the Ham-D, MADRS, BDI, and SDS scales are recommended. Further studies are needed to validate the CSDD, which could be particularly useful for the assessment of severity of dPD in patients with comorbid dementia. To account for overlapping motor and nonmotor symptoms of depression, adjusted instrument cutoff scores may be needed for dPD, and scales to assess severity of motor symptoms (e.g., UPDRS) should also be included to help adjust for confounding factors. The HADS and the GDS include limited motor symptom assessment and may, therefore, be most useful in rating depression severity across a range of PD severity; however, these scales appear insensitive in severe depression. The complex and time-consuming task of developing a new scale to measure depression specifically for patients with PD is currently not warranted.

Morphine, nortriptyline and their combination vs. placebo in patients with chronic lumbar root pain

Although lumbar radicular pain is the most common chronic neuropathic pain syndrome, there have been few randomized studies of drug treatments. We compared the efficacy of morphine (15-90 mg), nortriptyline (25-100 mg), their combination, and a benztropine "active placebo" (0.25-1 mg) in patients with chronic sciatica. Each period consisted of 5 weeks of dose escalation, 2 weeks of maintenance at the highest tolerated doses, and 2 weeks of dose tapering. The primary outcome was the mean daily leg pain score on a 0-10 scale during the maintenance period. Secondary outcomes included a 6-point ordinal global pain relief scale, the Beck Depression Inventory (BDI), the Oswestry Back Pain Disability Index (ODI) and the SF-36. In the 28 out of 61 patients who completed the study, none of the treatments produced significant reductions in average leg pain or other leg or back pain scores. Pain reduction, relative to placebo treatment was, 14% for nortriptyline (95% CI=[-2%, 30%]), 7% for morphine (95% CI=[-8%, 22%]), and 7% for the combination treatment (95% CI=[-4%, 18%]). Mean doses were: nortriptyline alone, 84+/-24.44 (SD) mg/day; morphine alone, 62+/-29 mg/day; and combination, morphine, 49+/-27 mg/day plus nortriptyline, 55 mg+/-33.18 mg/day. Over half of the study completers reported some adverse effect with morphine, nortriptyline or their combination. Within the limitations of the modest sample size and high dropout rate, these results suggest that nortriptyline, morphine and their combination may have limited effectiveness in the treatment of chronic sciatica.

Factor Structure of the Beck Depression Inventory-II in patients With chronic pain

OBJECTIVES

To examine the factor structure of the Beck Depression Inventory version II (BDI-II) in patients seeking treatment for chronic pain, using exploratory and confirmatory factor analysis and provide comparative data for use with similar patient populations. In addition, to consider the utility of using BDI-II subscale scores to further inform the management of patients with chronic pain.

METHODS

Phase I involved analysis of responses to the BDI-II by 1227 patients assessed for a pain management program. The sample data was split into 2 halves. A series of exploratory factor analyses on the first half suggested 2 factors. Confirmatory factor analysis was then used on the second half to confirm goodness-of-fit for this 2-factor solution and compare with a 1-factor solution and factor models presented in the BDI-II handbook derived on student and psychiatric outpatient populations. Comparison was also made of derived factor scores between this pain clinic sample and the normative psychiatric outpatient and student samples. In the second phase, longitudinal data on a further 269 patients who had completed the pain management program was used to examine the amount of variance in pain and disability outcomes accounted for by total BDI-II and 2-factor subscale scores at assessment.

RESULTS

Two correlated factors incorporating 18 items from the BDI-II gave good goodness-of-fit (0.916). Factor 1 loaded heavily onto negative cognitions about the self plus mood symptoms, factor 2 onto changes in behavior and activity plus low mood. Summed scores on factor 1 from pain clinic patients were very significantly lower than for psychiatric outpatients, indicating less negative cognitions about the self, and very significantly higher than for a student sample. Pain clinic patient scores on factor 2 were very significantly higher than those for both psychiatric outpatients and students, indicating more reporting of behavior change and affective symptoms. Subscale scores accounted for a small but significant amount of variance in both pain and disability at follow-up, with each scale predicting in opposite directions. Total BDI-II scores predicted similar amounts of variance in disability at follow-up, but were not significantly associated with pain at follow-up.

DISCUSSION

Results are consistent with studies using previous versions of the BDI in suggesting that 2-factor scores may be more clinically useful in the assessment of patients referred with chronic pain.

Effects of chronic osteoarthritis pain on neuroendocrine function in men

CONTEXT

Chronic pain has been associated with elevated cortisol, reduced LH and testosterone (T), and/or augmented circulating or excreted catecholamines. Most endocrine studies have been conducted in patients in whom the potentially confounding effects of depression, inflammatory disease, or coexistent medication use have not been controlled.

OBJECTIVE

The objective of the study was to test the hypothesis that chronic pain activates ACTH-cortisol and suppresses LH-T.

DESIGN AND SETTING

This was a case control study conducted at a clinical research center.

PARTICIPANTS

Participants included 16 opioid-naive men with chronic osteoarthritis pain, aged 35-65 yr with body mass index 20-30 kg/m2, and 12 healthy, opioid- and pain-free men of similar ages and body mass indexes.

METHODS

We compared circulating concentrations of ACTH, cortisol, LH, and T derived from every 20-min blood sampling (2000-0800 h), and 24-h urinary excretion of cortisol, epinephrine, norepinephrine, and dopamine.

RESULTS

There were no significant differences in mean or integrated concentrations of ACTH, cortisol, LH, or T, or in the corresponding approximate entropy scores in osteoarthritis patients, compared with control subjects. The 0800-h serum LH concentrations were elevated in patients vs. controls (6.42 +/- 1.65 vs. 3.99 +/- 1.54 IU/liter, mean +/- sd, P = 0.02), whereas there were no significant group differences in total or free T, SHBG, cortisol binding globulin, dehydroepiandrosterone sulfate, or urinary cortisol and catecholamines.

CONCLUSIONS

These data suggest that neuroendocrine function is not significantly altered in otherwise healthy men with chronic musculoskeletal pain and that prior reports of such hormonal abnormalities may have resulted from the confounding effects of coexistent illness or medication use.

Chronic pain couples: Perceived marital interactions and pain behaviours

Patient adjustment to chronic pain is well known to be influenced by the spouse and his or her response to patient expressions of pain. However, these responses do not occur in a vacuum, and the aim of the present study was to investigate patient-spouse interactions in chronic pain in detail. Ninety-five patient-spouse dyads completed questionnaires relating to mood, marital satisfaction and communication, and 80 couples also took part in semi-structured interviews. Data were analysed using quantitative and qualitative methods. Results showed that spouses of chronic pain patients reported engaging in a far wider repertoire of responses to pain behaviours than has been recognised to date. New response categories of 'hostile-solicitous' and 'observe only' were identified. Patients generally interpreted solicitous responses less favourably than spouse responses which encouraged task persistence. Male spouses identified fewer pain-related situations than female spouses but were more likely to report responding solicitously to patient pain behaviours. Marital satisfaction was significantly higher in patients who rated themselves as talking more frequently about their pain. Spouse perceived frequency of pain talk was not related to spouse marital satisfaction. There were no gender differences in marital satisfaction. The results of this study challenge some of the assumptions that have been held regarding chronic pain patient-spouse interactions.

Open-Label Pilot Study of Testosterone Patch Therapy in Men With Opioid-Induced Androgen Deficiency

We conducted a 24-week open-label pilot study of testosterone (T) patch therapy in 23 men with opioid-induced androgen deficiency (OPIAD). The T dosage was 5 mg/day for the first 12 weeks and 7.5 mg/day for the second 12 weeks. Seven subjects discontinued prematurely: 4 for noncompliance, 2 for skin irritation and 1 for hepatitis C treatment. In the "completers" population (n = 16), mean (SD) free T levels (normal range 52 to 280 pg/mL) were 28.5 (18.6) pg/mL at baseline, 72.8 (29.6) pg/mL on 5 mg/day (P < .001 vs. baseline), and 120.2 (69.5) pg/mL on 7.5 mg/day (P < .001 vs. baseline and P < .01 vs. 5 mg/day). Total T, dihydrotestosterone, and estradiol showed parallel changes. Sex hormone-binding globulin levels were elevated at baseline and decreased modestly with treatment (P < .05 vs. baseline at 5 mg/day; P < .01 vs. baseline at 7.5 mg/day). Luteinizing hormone levels were in the low-normal range at baseline and suppressed markedly with treatment (P < .001 vs. baseline at both doses). Androgen deficiency symptoms (ADSQ), sexual function (Watts SFQ), mood (PGWB), depression (BDI-II), and hematocrit levels showed improvement during treatment, generally more so at the 7.5 mg/day dosage (P < .001 vs. baseline for most parameters). Pain scores (BPI-SF) decreased slightly on 7.5 mg/day (interference score: P < .05 vs. baseline and 5 mg/day); the use of opioids did not change appreciably. The testosterone patches were generally well tolerated.

PERSPECTIVE

Long-acting opioid preparations suppress the hypothalamic-pituitary-gonadal axis in men and produce a symptomatic state of opioid-induced androgen deficiency (OPIAD). Testosterone patch therapy at a dose of 7.5 mg/day normalizes hormone levels and appears to improve a number of quality of life parameters (eg, sexual function, well-being, mood) in men with OPIAD.