Pharmacological treatment of depression in geriatric chronic pain patients: a biopsychosocial approach integrating functional restoration

INTRODUCTION

A recent literature review concluded that the comorbidity of chronic pain and depression in adults is approximately 50%-65%. Physical and cognitive declines, concurrent multiple health conditions, and complex medication regimens add to the unique and complex challenges of effectively treating pain in particularly geriatric populations. Interdisciplinary medical intervention and monitoring for psychiatric sequelae, such as depression, cognitive change, and synergistic physical side effects are necessary. Areas covered: This review covers an extensive multi-database wide search of the pharmacotherapy of pain and depression in older adults, including biopsychosocial approaches. One of these, on which this review focuses, is Functional Restoration, an interdisciplinary application of quantified physical rehabilitation, case management, and cognitive behavioral and educational therapies to achieve improved well- being and better physical functioning. The biopsychosocial model incorporates an overview of the overlapping and interactive dimensions of a patient's life and addresses them within a comprehensive plan of treatment. Expert commentary: A multifactorial, rather than a single factor approach to the treatment of complicated health care problems such as chronic pain in an elderly patient is emphasized as an important change in perspective for the health care provider.

Torture survivors' symptom load compared to chronic pain and psychiatric in-patients

Before their entry into the rehabilitation program at the Rehabilitation and Research Centre for Torture Victims ('RCT') in Copenhagen, the degree of symptoms of a group of resettled traumatized refugees was assessed by means of two rating scales: the Disability Rating Index (DRI) (n=197), measuring pain-related functional disability, and the Hospital Anxiety and Depression Scale (HADS) (n=147). The results obtained were compared with other patient populations, which included (1) a large Swedish mixed pain group and (2) various groups of pain patients previously investigated in the validation study of the DRI scale. The DRI scores of the refugee group were comparable to, or higher than, those of the pain groups, except for patients suffering from multiple sclerosis. The degree of anxiety and depression was found to be considerably greater in the refugee group than in the pain groups. Another recently published Danish study comparing traumatized refugees with psychiatric in-patients in terms of Health of Nation Outcome Scores (HoNOS) documented a higher degree of psychiatric disability for refugees. Based on the hypothesis that the observed differences in this study were underestimated due to the exclusion of refugees with psychotic symptoms and substance abuse, a partial re-analysis of the data was carried out by calculating effect sizes with and without the items measuring these symptoms. Controlling for the exclusion of the critical items resulted in a more pronounced difference between the refugees and psychiatric inpatients. Based on the data compared in this study, traumatized refugees are shown to suffer from multiple problems, including chronic pain, at a high symptom-level. This challenges prior clinical assumptions that single factors like PTSD can explain all symptoms.

Testimonial Therapy: Impact on social participation and emotional wellbeing among Indian survivors of torture and organized violence

INTRODUCTION

Traumatizing events, such as torture, cause considerable impairments in psycho-social functioning. In developing countries, where torture is often perpetrated, few resources exist for the provision of therapeutic or rehabilitating interventions. The current study investigated the effectiveness of Testimonial Therapy (TT) as a brief psycho-social intervention to ameliorate the distress of Indian survivors of torture and related violence.

METHOD

Three outcome measures (the WHO-5 Well-Being Scale, Social Participation-Scale and Pain and Anger Analogue) were compared before and after receiving TT, and semi structured interviews were conducted with survivors who had previously received TT.

FINDINGS

Participants showed significant improvements in emotional well-being, social participation, and self-perceived pain and anger. Furthermore, three qualitative interviews with survivors indicated that TT had a positive impact at the community level.

DISCUSSION

Although the study was conducted without a control group for comparison, TT appeared to be an effective method for improving well-being and ameliorating distress among survivors of torture. Furthermore, TT can potentially promote community empowerment. However, more research on this aspect is needed.

Testimony ceremonies in Asia: integrating spirituality in testimonial therapy for torture survivors in India, Sri Lanka, Cambodia, and the Philippines

This study explores the therapeutic implications of including culturally adapted spiritual ceremonies in the process of testimonial therapy for torture survivors in India, Sri Lanka, Cambodia, and the Philippines. Data were collected through an action research process with Asian mental health and human rights organizations, during which the testimonial method was reconceptualized and modified to include four sessions. In the first two sessions, community workers assist survivors in the writing of their testimony, which is their narrative about the human rights violations they have suffered. In the third session, survivors participate in an honour ceremony in which they are presented with their testimony documents. In the fourth session, the community workers meet with the survivors for a reevaluation of their well-being. The honour ceremonies developed during the action research process came to employ different kinds of symbolic language at each site: human rights (India), religious/Catholic (Sri Lanka), religious/Buddhist (Cambodia), and religious/Moslem (Philippines). They all used embodied spirituality in various forms, incorporating singing, dancing, and religious purification rituals in a collective gathering. We suggest that these types of ceremonies may facilitate an individual's capacity to contain and integrate traumatic memories, promote restorative self-awareness, and engage community support. Additional research is needed to determine the method's applicability in other sociopolitical contexts governed by more Western-oriented medical traditions.

The land of milk and honey: a picture of refugee torture survivors presenting for treatment in a South African trauma centre

Intake data obtained from 55 refugee torture survivors accessing trauma treatment services at a centre in Johannesburg, South Africa, paints a picture of suffering beyond the torture experience. The intake forms part of a more comprehensive monitoring and evaluation system developed for the work done with torture survivors accessing psychosocial services. The diverse sample with different nationalities highlights that torture occurs in many countries on the African continent. It also highlights South Africa's role as a major destination for refugee and asylum seekers. However, "the land of milk and honey" and the process of arriving here, often poses additional challenges for survivors of torture. This is reflected in the high levels of Post Traumatic Stress Disorder (69%), anxiety (91%), and depression (74%) for our sample, all of which were significantly correlated. The loss of employment status from before the torture experience until the time of intake was great for this sample, impacting on their recovery. In addition the presence of medical conditions (44%), disabilities (19%), and pain (74%) raise serious questions regarding interventions that focus mainly on psychosocial needs. No significant gender differences were found. The paper begins to paint a clearer picture of the bio-psycho-social state of torture survivors accessing services in South Africa, as well as highlighting many of the contextual challenges which impact on recovery.

Testimonial therapy. A pilot project to improve psychological wellbeing among survivors of torture in India

INTRODUCTION

In developing countries where torture is perpetrated, there are few resources for the provision of therapeutic assistance to the survivors. The testimonial method represents a brief cross-cultural psychosocial approach to trauma, which is relatively easy to master. The method was first described in Chile in 1983 and has since been used in many variations in different cultural contexts. In this project the method has been supplemented by culture-specific coping strategies (meditation and a delivery ceremony).

METHODS

A pilot training project was undertaken between Rehabilitation and Research Centre for Torture victims (RCT) in Copenhagen, Denmark, and People's Vigilance Committee for Human Rights (PVCHR) in Varanasi, India, to investigate the usefulness of the testimonial method. The project involved the development of a community-based testimonial method, training of twelve PVCHR community workers, the development of a manual, and a monitoring and evaluation (M&E) system comparing results of measures before the intervention and two to three months after the intervention. Twenty-three victims gave their testimonies under supervision. In the two first sessions the testimony was written and in the third session survivors participated in a delivery ceremony. The human rights activists and community workers interviewed the survivors about how they felt after the intervention.

FINDINGS

After testimonial therapy, almost all survivors demonstrated significant improvements in overall WHO-five Well-being Index (WHO-5) score. Four out of the five individual items improved by at least 40%. Items from the International Classification of Functioning, Disability and Health (ICF) showed less significant change, possibly because the M&E questionnaire had not been well understood by the community workers, or due to poor wording, formulation and/or validation of the questions. All survivors expressed satisfaction with the process, especially the public delivery ceremony, which apparently became a "turning point" in the healing process. Seemingly, the ceremonial element represented the social recognition needed and that it re-connected the survivors with their community and ensured that their private truth becomes part of social memory.

DISCUSSION

Although this small pilot study without control groups or prior validation of the questionnaire does not provide high-ranking quantitative evidence or statistically significant results for the effectiveness of our version of the testimonial method, we do find it likely that it helps improve the well being in survivors of torture in this particular context. However, a more extensive study is needed to verify these results, and better measures of ICF activities and participation (A&P) functions should be used. Interviews with human rights activists reveal that it is easier for survivors who have gone through testimonial therapy to give coherent legal testimony.

Psychiatric comorbidity in chronic disabling occupational spinal disorders has minimal impact on functional restoration socioeconomic outcomes

STUDY DESIGN

A prospective study conducted at a tertiary functional restoration center for patients with chronic disabling occupational spinal disorders (CDOSDs), comparing treatment outcome status 1-year posttreatment of patients with specific diagnosed psychiatric disorders to those without.

OBJECTIVE

To evaluate if diagnosed psychopathology is a significant limiting factor in the successful interdisciplinary rehabilitation of CDOSD patients.

SUMMARY OF BACKGROUND DATA

Research has demonstrated high prevalence rates of psychiatric disorders in patients with CDOSDs. Little is known about whether these disorders are associated with less successful treatment outcomes.

METHODS

A consecutive group of CDOSD patients (n = 1323) averaging 19 months of prerehabilitation disability were evaluated for psychiatric disorders with the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). Patients participated in a functional restoration program. A structured clinical interview addressing work status, recurrent injury, healthcare utilization, and financial claims closure was administered 1 year after discharge. Logistic regression analyses were conducted to determine the unique contribution of the specific DSM-IV disorders that were significantly associated with the outcomes.

RESULTS

Patients with panic disorder, antisocial personality disorder (PD) and dependent PD were >2 times more likely to be program noncompleters. For successful program completers, those with opioid dependence disorder (ODD) were 2.7 times less likely to return to work and 2.6 times less likely to retain work. Patients with ODD were also 2.1 times more likely to seek postrehabilitation treatment from a new provider.

CONCLUSIONS

Despite intensive management of psychiatric disorders during interdisciplinary functional restoration for CDOSD, several disorders were found to be associated with less successful outcomes. Poorer work outcomes were more common with specific (and comorbid) Axis I psychiatric disorders. Opioid dependence was the single disorder associated most often with less successful outcomes. Despite these findings, the large majority of patients demonstrated successful outcomes. Depression did not independently link to less successful outcomes.

Do psychiatric disorders first appear preinjury or postinjury in chronic disabling occupational spinal disorders?

STUDY DESIGN

An epidemiologic prevalence study.

OBJECTIVES

To clarify the temporal association between work-related injury claims and psychiatric disorders in patients with chronic disabling occupational spinal disorders (CDOSDs).

SUMMARY OF BACKGROUND DATA

Few empirical data are available regarding the "chicken-or-egg" question of which occurs first: the injury or incident culminating in the painful CDOSD or the psychiatric disturbance.

METHODS

Subjects attended a tertiary interdisciplinary rehabilitation program. Psychiatric disorders were assessed using the Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders (SCID-DSM-IV). Psychiatric disorders were characterized as preexisting if they manifested themselves before the work-related injury claim (whether or not they resolved, continued, or reoccurred after injury). They were determined postinjury diagnoses only if they manifested for the first time after the injury claim.

RESULTS

A total of 38.7% of the present cohort had at least one preexisting major psychiatric disorder, while 98.9% developed one or more psychiatric disorders for the first time after injury onset (57.9% when pain disorder was excluded). The percentage of patients with preexisting psychiatric disorders was lower than general population base rates (48%). The first onset of certain psychiatric disorders was found to be elevated in patients only after the work-related injury; these included Pain Disorder (95.7%), Major Depressive Disorder (49.7%), and Opioid Dependence (15%). Moreover, 5 times as many patients with MDD, and 10 times as many with opioid dependence, developed these disorders for the first time after the injury.

CONCLUSIONS

In general, psychiatric disturbance is not a risk factor for developing a CDOSD. Psychiatric disorders are much more likely to develop after the onset of the work injury, indicating that such injuries and accompanying stressors are likely to be precipitants, rather than consequences, of psychopathology.

Biopsychosocial Profiles of Different Pain Diagnostic Groups

Different pain diagnoses have been examined separately in various research studies. The major aim of the present investigation was to add to the current understanding of the various groups of patients who make up the chronic pain population. This study expanded the research literature by including 7 different predominantly chronic pain syndromes (fibromyalgia, upper extremity pain, cervical pain, thoracic pain, lumbar pain, lower extremity pain, and headache). These 7 groups were examined by using a broad array of variables focusing on demographic, self-reported psychosocial, and physical/functional factors. There were 661 patients included from an interdisciplinary treatment program who had been given 1 physical pain diagnosis. Results revealed differences among the 7 groups with regard to self-reported physical/functional limitations. The headache group had less physical/functional impairment than most of the other groups. On the other hand, the lumbar, fibromyalgia, and lower extremity groups had the most physical/functional problems. On self-reported psychosocial measures, the fibromyalgia group had the most difficulties, and the lower extremity and lumbar groups had fewer problems in this area. Overall, though, besides the fibromyalgia group, there was a lack of differences among the other groups on the psychosocial measures.

PERSPECTIVE

Biopsychosocial profiles were examined for different pain diagnostic groups. Seven different pain groups were compared. It was discovered that, in general, the lumbar, fibromyalgia, and lower extremity groups reported more physical/functional limitations, and the fibromyalgia and headache groups reported more psychosocial difficulties.

Prevalence of psychiatric disorders in patients with chronic disabling occupational spinal disorders

STUDY DESIGN

A prevalence study.

OBJECTIVES

To assess the prevalence of psychiatric disorders among a large group of patients with chronic disabling occupational spinal disorders (CDOSDs), using a reliable and valid diagnostic instrument.

SUMMARY OF BACKGROUND DATA

Although unrecognized and untreated psychiatric disorders have been found to interfere with successful treatment of CDOSD patients, little data are currently available regarding the psychiatric characteristics of patients claiming work-related injuries that result in CDOSDs.

METHODS

Psychiatric disorders in a consecutive group of CDOSD patients (n = 1,323) attending a tertiary referral center for patients with CDOSD were diagnosed using the Diagnostic and Statistical Manual of Mental Disorders. RESULTS.: Overall prevalence of psychiatric disorders was found to be significantly elevated in CDOSD patients compared with base rates in the general population. A majority (65%) of patients were diagnosed with at least one current disorder (not including Pain Disorder, which is nearly universal in this population), compared with only 15% of the general population. Major Depressive Disorder (56%), Substance Use Disorders (14%), Anxiety Disorders (11%), and Axis II Personality Disorders (70%) were the most common diagnoses.

CONCLUSIONS

Clinicians treating CDOSD patients must be aware of the high prevalence of psychiatric disorders in this population. They must also be prepared to use mental health professionals to assist them in identifying and stabilizing these patients. Failure to follow a biopsychosocial approach to treatment will likely contribute to prolonged disability in a substantial number of these chronic pain patients.

Development of a self-report screening instrument for assessing potential opioid medication misuse in chronic pain patients

This study constituted the first step in the psychometric development of a self-report screening instrument for risk of opioid medication misuse among chronic pain patients. A 26-item instrument, the Pain Medication Questionnaire (PMQ), was constructed based on suspected behavioral correlates of opioid medication misuse, which heretofore have received limited empirical investigation. The PMQ was administered to 184 patients at an interdisciplinary pain treatment center. Reliability coefficients for the PMQ were found to be of moderate but acceptable strength. Construct and concurrent validity were examined through correlation of PMQ scores to measures of substance abuse, physical and psychological functioning, and physicians' risk assessments. To explore high and low cutoff points for misuse risk, subgroups were formed according to the upper and lower thirds of PMQ scores and compared on validity measures. Higher PMQ scores were associated with history of substance abuse, higher levels of psychosocial distress, and poorer functioning. Future psychometric analyses will consider predictive validity and examine shortened versions of the instrument.

A prospective one-year outcome study of interdisciplinary chronic pain management: compromising its efficacy by managed care policies

Although interdisciplinary pain management programs are both therapeutically effective as well as cost-effective, they are currently being underutilized because of managed care policies. We used this prospective comparison trial, with 1-yr follow-up of chronic pain patients, to demonstrate the short- and long-term efficacy of an interdisciplinary pain management program, and evaluate the impact of managed care's physical therapy "carve out" practices on these treatment outcomes. Consecutive chronic pain patients (n = 201) were evaluated, some of whom had their physical therapy "carved out" from this integrated program. Results revealed that successful completion of interdisciplinary pain management was therapeutically effective. Most importantly, physical therapy "carved out" practices had a negative impact on both the short-term and 1-yr follow-up outcome measures. Thus, interdisciplinary pain management is effective in treating the major health problem of chronic pain. However, insurance carrier policies of contracting treatment "carve outs" significantly compromise the efficacy of this evidence-based, best standard of medical care treatment. This raises important medico-legal and ethical issues.

IMPLICATIONS

Interdisciplinary pain management is effective and cost-effective in treating the major health problem of chronic pain. The present study demonstrated its efficacy using a prospective, 1-yr posttreatment evaluation methodology. Moreover, physical therapy "carve out" practices by insurance carriers had a negative impact on the outcomes, raising important medico-legal and ethical issues.

Prevalence of psychiatric disorders in patients with chronic work-related musculoskeletal pain disability

The cost and prevalence of chronic work-related musculoskeletal pain disability in industrialized countries are extremely high. Although unrecognized psychiatric disorders have been found to interfere with the successful rehabilitation of these disability patients, few data are currently available regarding the psychiatric characteristics of patients claiming work-related injuries that result in chronic disability. To investigate this issue, a consecutive group of patients with work-related chronic musculoskeletal pain disability (n = 1595), who started a prescribed course of tertiary rehabilitation, were evaluated. Psychiatric disorders were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders. Results revealed that overall prevalences of psychiatric disorders were significantly elevated in these patients compared with base rates in the general population. A majority (64%) of patients were diagnosed with at least one current disorder, compared with only 15% of the general population. However, prevalences of psychiatric disorders were elevated in patients only after the work-related disability. Such findings suggest that clinicians treating these patients must be aware of the high prevalence of psychiatric disorders and be prepared to use mental health professionals to assist in identifying and stabilizing these patients. Failure to follow a biopsychosocial approach to treatment will likely contribute to prolonged pain disability in a substantial number of these patients.

Screening for problematic prescription opioid use

The proper medicinal use of opioids, in light of their notorious history and current relation to social ills, continues to be debated and remains unclear in several areas of medicine. This article will review several areas and points of controversy related to screening for potential problematic opioid behavior in chronic nonmalignant pain patients. Controversy over the prescription of opioids for chronic nonmalignant pain continues, despite the growing acceptance of this practice. Indeed, past research supports the beneficial use of opioids for noncancer pain. Unfortunately, traditional definitions of abuse and dependence, with their emphasis on tolerance and withdrawal, are inappropriate for chronic pain patients prescribed opioids. The component of traditional definitions of abuse and dependence that appears most applicable to chronic pain patients centers on the criterion that the patient continue to take the drug (in this case, the opioid) despite negative and harmful effects or despite any decrease in pain level. Although clinical observations exist about risk factors for opioid misuse in chronic pain patients, there is limited research. Further, the area of prescreening for problematic drug behavior is in its infancy. However, researchers have begun to delve into this challenging area and the application of rigorous empirical research will bring us closer to identifying those patients at risk so that their pain is managed without destructive outcomes in other areas of their life.

Chronic spinal disorders and psychopathology. research findings and theoretical considerations

BACKGROUND CONTEXT

Numerous studies have documented a strong association between chronic spinal disorders and psychopathology. However, there have been methodological shortcomings associated with much of this.

PURPOSE

This article reviews the relevant research literature, including methodological refinements that have resulted in improved measurement of psychopathology, in order to provide the most updated conclusions concerning the links between spinal disorders and psychopathology.

STUDY DESIGN

A systematic review of all Medline referenced articles on this subject during the past three decades.

METHODS

Previous research has shown that chronic spinal disorders are most often associated with depressive disorders, somatoform disorders, anxiety disorders, substance use disorders, and personality disorders. In addition to reviewing this research, the relationship between chronic spinal disorders and depressive disorders is examined in more detail.

RESULTS

Although the relationship between spinal disorders and psychopathology is complex, a diathesis-stress model is emerging as the dominant overarching theoretical model. In this model, diatheses are conceptualized as pre-existing semidormant characteristics of the individual before the onset of chronic spinal disorders, which are then activated by the stress of this chronic condition, eventually resulting in a diagnosable depressive disorder.

CONCLUSIONS

In the present review, a diathesis-stress model was applied specifically to the relationship between chronic spinal disorders and depressive disorders. Such a model may also be applicable to the relationship between chronic spinal disorders and other types of psychopathology, such as anxiety and substance use disorders. However, conclusive empirical support will require a prospective research design, given that these diatheses could be validly assessed only before the onset of the chronic pain condition.

Exploration of physicians' recommendations for activities in chronic low back pain

STUDY DESIGN

A mailed survey of 142 practicing physicians (63 orthopedic spine surgeons and 79 family physicians) inquiring about their expertise and experience with chronic low back pain, their pain attitudes and beliefs, and recommendations about the appropriate level of function for chronic back pain patients.

OBJECTIVES

To explore physicians' recommendations for activity and work for patients with chronic low back pain and to determine factors that might influence these recommendations.

SUMMARY OF BACKGROUND DATA

Physicians continuously are asked to recommend the appropriate level of activities and work for patients with chronic low back pain. Although these recommendations can have a significant impact on patients' lives, little is known about the factors that shape recommendations.

METHODS

Mailed surveys included questions inquiring about the physicians' demographics, training, and experience in low back pain, the Health Care Providers' Pain and Impairment Relationship Scale, and three vignettes of work-disabled, chronic low back pain patients. After each vignette, physicians rated their perceptions of severity of symptoms and pathology and recommendations for work and daily activities through five graded responses. Three mailings were done within 4 weeks to maximize the response rate. The association of each variable with work and activity recommendations was statistically explored. To assess the influence of clinical expertise on recommendations, the responses of orthopedic spine surgeons were compared with those of family physicians. Test-retest reliability was assessed with a second mailing of the questionnaire to all initial responders.

RESULTS

Sixty-five percent of the orthopedic surgeons and 52% of the family physicians responded to the survey. Thirty-nine percent of the initial responders completed the reliability survey. The survey instrument demonstrated modest reliability, with identical recommendations for activities and work occurring 57% of the time. In general, a wide range of activities and work was recommended, with most physicians recommending avoidance of painful activities or greater restrictions. Orthopedic spine surgeons were slightly less restrictive in their activity recommendations compared with family physicians. Most physicians demonstrated some consistency in their pattern of recommendations when compared with their colleagues. Physicians' pain attitudes and belief influenced their recommendations, as did their perception of the severity of the patients' clinical symptoms.

CONCLUSIONS

Physicians' recommendations for activity and work to patients with chronic back pain vary widely and frequently are restrictive. These recommendations reflect personal attitudes of the physicians as well as factors related to the patients' clinical symptoms.

The association of the SF-36 health status survey with 1-year socioeconomic outcomes in a chronically disabled spinal disorder population

STUDY DESIGN

The Short Form Health Survey (SF-36) was administered to patients with chronic spinal disorders both before and after tertiary rehabilitation. The association of the SF-36 with various socioeconomic outcomes was then examined.

OBJECTIVES

To assess the correlation of scores on SF-36 with treatment program completion and clinically meaningful 1-year socioeconomic outcomes.

SUMMARY OF BACKGROUND DATA

There has been much interest in identifying variables that can predict which disabled workers with chronic spinal disorders will have good versus poor socioeconomic outcomes after tertiary rehabilitation. Results of previous research have indicated that psychosocial factors are better predictors of such outcomes than physical factors. A more recent trend in research is assessing health-related quality of life from the health care recipient's perspective.

METHODS

The SF-36 was administered to a cohort (n = 146) of patients chronically disabled by spinal disorders before entry into a tertiary functional restoration program. Of this cohort, preprogram SF-36 scores and 1-year socioeconomic data were available for 128 program completers and 18 program noncompleters. The pre- and postprogram SF-36 scores of program completers for each of the outcome variables were compared.

RESULTS

Better scores on the preprogram SF-36 Social Functioning and Bodily Pain scales were found to be associated with successful completion of the treatment program. Postprogram SF-36 scores were more frequently associated with outcomes than were preprogram scores. Most SF-36 scores, especially the physical domain scales, were associated with the variables of return to work, work retention, and use of health care resources. The overwhelming majority of significant associations were between higher (i.e., better) SF-36 scores and "good" treatment outcomes (e.g., return-to-work).

CONCLUSIONS

The large number of associations between SF-36 scores and outcome variables highlights the importance of assessing the health-related quality of life of patients, and supports the use of the SF-36 in accomplishing this task. Among the findings, perhaps the most significant was the value of assessing health-related quality of life, particularly the subjective physical components, after completion of a functional restoration program. Prediction of long-term socioeconomic outcomes is likely to be improved if assessment is conducted at the end of the treatment process. SF-36 is recommended for assessing general health status, and more spine-specific measures are recommended for assessing spinal pain and disability variables.

Spine rehabilitation. Secondary and tertiary nonoperative care

To achieve desirable behavioral outcomes, physicians treating spinal pain patients should be aware of appropriate algorithms for conservative care. Lower cost secondary rehabilitation can be effective if deconditioning, severity of physical symptoms, surgical equivocation, or psychosocial barriers to recovery are not present. Patients who have extended disability in excess of 6 months, recognized psychosocial barriers (depression, substance abuse, personality disorders, secondary gain), or severe deconditioning have a better prognosis with tertiary care.

Fluoxetine versus trazodone in the treatment of outpatients with major depression

Fluoxetine and trazodone were compared in a double-blind, randomized, parallel, 6-week trial in 43 outpatients with major depression after a 1-week single-blind placebo period. Thirty-five patients completed at least 3 weeks of active medication, while 25 patients completed all 6 weeks. Response rates, whether defined by end-of-treatment Hamilton Rating Scale for Depression (HAM-D) score less than 10 or by a 50% reduction in HAM-D scores, were equivalent for the two medications. For fluoxetine, HAM-D scores were significantly lower at Weeks 1 and 2 compared with those of trazodone. Trazodone improved sleep significantly more than fluoxetine. Fluoxetine was associated more frequently with weight loss (p = .002) and less frequently with dizziness (p = .04) than trazodone.