Article

Comorbid Depression, Chronic Pain, and Disability in Primary Care

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Abstract

The objectives of this study were to provide estimates of the prevalence and strength of association between major depression and chronic pain in a primary care population and to examine the clinical burden associated with the two conditions, singly and together. A random sample of Kaiser Permanente patients who visited a primary care clinic was mailed a questionnaire assessing major depressive disorder (MDD), chronic pain, pain-related disability, somatic symptom severity, panic disorder, other anxiety, probable alcohol abuse, and health-related quality of life (HRQL). Instruments included the Patient Health Questionnaire, SF-8, and Graded Chronic Pain Questionnaire. A total of 5808 patients responded (54% of those eligible to participate). Among those with MDD, a significantly higher proportion reported chronic (i.e., nondisabling or disabling) pain than those without MDD (66% versus 43%, respectively). Disabling chronic pain was present in 41% of those with MDD versus 10% of those without MDD. Respondents with comorbid depression and disabling chronic pain had significantly poorer HRQL, greater somatic symptom severity, and higher prevalence of panic disorder than other respondents. The prevalence of probable alcohol abuse/dependence was significantly higher among persons with MDD compared with individuals without MDD regardless of pain or disability level. Compared with participants without MDD, the prevalence of other anxiety among those with MDD was more than sixfold greater regardless of pain or disability level. Chronic pain is common among those with MDD. Comorbid MDD and disabling chronic pain are associated with greater clinical burden than MDD alone.

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... There is growing recognition that people with more symptoms of depression tend to have greater daily limitations due to pain (Arnow et al., 2006;Bair et al., 2003). It is estimated that up to 70% of people diagnosed with a depressive disorder have persistent daily pain (Bair et al., 2003;Demyttenaere et al., 2007;Gureje et al., 2008). ...
... The lack of association of anger and activity intolerance is interesting because there is a consistent relationship between mood and thoughts, for example depression, with pain intensity and activity tolerance. (Arnow et al., 2006; Bair et al., 2003;Briet et al., 2016;De Heer et al., 2014;Demyttenaere et al., 2007;Dunn et al., 2018;Gureje et al., 2008;Hayek et al., 2017;Reiter et al., 2018;Trief et al., 2006) Although there was a significant association between anger and pain intensity in bivariate analysis, in multivariable analysis the association was negative which suggests that anger is important, but not as important as psychological distress. Anger may just be one manifestation of distress. ...
... Anger may just be one manifestation of distress. The association between symptoms of depression and worse physical function in bivariate analysis is consistent with prior research (Arnow et al., 2006;Bair et al., 2003;Dunn et al., 2018;Trief et al., 2006). For example, in a study among 5807 patients in primary care, of the patients meeting criteria for an estimated diagnosis of major depression, 41% reported having disabling pain, compared to 10% of the patients that did not (Arnow et al., 2006). ...
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This study assessed the association of anger, anxiety, and depression, and cognitive bias with pain and activity tolerance among patients with a musculoskeletal illness or injury expected to last more than a month. 102 Patients completed emotional thermometers to quantify symptoms of anger, anxiety, depression; the abbreviated Pain Catastrophizing Scale; a pain intensity scale; Patient-Reported Outcomes Measurement Information System (PROMIS) Physical Function Computer Adaptive Test; the Spielberger State-Trait Anxiety Inventory and demographic questionnaires. Controlling for potential confounding in multivariable analysis we found greater activity intolerance was associated with retired work-status and greater depressive symptoms, but not with greater symptoms of anger. In addition, greater pain intensity was associated with greater symptoms of depression and greater catastrophic thinking, but not with greater symptoms of anger. Anger emotions do not contribute to symptom intensity and activity intolerance in musculoskeletal illness. Attention can be directed at addressing psychological distress and cognitive bias.
... In the study by Bair et al. (2003) the mean prevalence of concurrent pain disorder in patients with depression in psychiatric settings was 65%. Similar results were reported by Arnow et al. (2006) who investigated the prevalence of chronic pain in MDD patients in primary care settings. More patients with MDD had additional chronic pain disorder than those without MDD (66% versus 43%, respectively). ...
... In general, negative emotions exacerbate experience of pain, whereas positive emotions have opposite effect. Unfortunately, chronic pain disorders frequently coexist with various emotional disorders, such as MDD, DYS, GAD, SAD, SP, PD, PTSD, and OCD (Arnow et al., 2006;Bair et al., 2003;Demyttenaere et al., 2007). Prevalence of emotional comorbidities in primary pain disorders is higher than in secondary pain disorders, however, in secondary pain disorders the prevalence is higher than in general population. ...
... A growing number of researchers are now suggesting that rather than viewing emotional disorders as distinct entities, they better fit a transdiagnostic model (Barlow et al., 2014b;Harris and Norton, 2018;Nolen-Hoeksema and Watkins, 2011). Considering high comorbidity between chronic pain and emotional disorders (Arnow et al., 2006;Bair et al., 2003;Demyttenaere et al., 2007), several authors have also introduced transdiagnostic models of chronic pain and emotional disorders (Asmundson and Katz, 2009;Linton, 2013). Transdiagnostic models suggests that coexistence of different disorders occurs due to common factors and pathological processes shared by these disorders. ...
Article
Although frequent coexistence of chronic pain and emotional disorders is well documented, exact mechanisms of comorbidity are not fully understood. The overarching aim of this thesis was to advance our knowledge of the mechanisms that link chronic pain and emotional disorders. Results of the literature review suggest that nosologically different conditions might coexist if they share common transdiagnostic risk factors that predispose individuals to several disorders. Using this transdiagnostic approach, a theoretical model explaining the relationships between different risk factors and how they might contribute to comorbidity between chronic pain and emotional disorders has been developed. According to the proposed model, one of the most fundamental transdiagnostic risk factors associated with both conditions is uncontrollable stress. It does not cause chronic pain or emotional disorders directly but promotes development of other risk factors, such as helplessness, negative affectivity, hypersensitivity to pain, dysregulation of stress response, and cognitive deficits. Importantly, these risk factors are not disorder specific. They equally predispose individuals to depression, anxiety, and chronic pain. Development of a specific disorder is determined by the influence of environmental and biological moderators that transform pre-existing risk factors into specific disorders. Considering that the sequence of pathological processes leading to psychopathology and/or chronic pain starts from the experience of uncontrollable stress, it is important to identify neural mechanisms that could mediate its effects. There is evidence suggesting that the frontal pole comprising of the rostromedial prefrontal cortex (rmPFC) and rostrolateral prefrontal cortex (rlPFC) plays an essential role in evaluation of controllability. Dysfunction of this area may increase the sense of uncontrollability, thereby promoting development of transdiagnostic risk factors. Both subregions of the frontal pole are parts of the neural networks that perform higher-order processing and modulation of nociceptive and emotional reactions. Thus, increased sensitivity to pain and heightened negative affect in patients with chronic pain disorders might be mediated by impaired interaction of the rmPFC and rlPFC with low-level nociceptive and emotional circuits. To test this hypothesis, resting-state functional and effective connectivity of the rmPFC and rlPFC was investigated in two chronic pain conditions: chronic low back pain (CLBP) and osteoarthritis (OA). Functional connectivity (FC) of the rmPFC and rlPFC in CLBP. CLBP patients displayed decreased FC of the rmPFC with retrosplenial cortex (RSC), posterior part of the ventral pallidum (VP), and mediodorsal (MD) thalamus. Diminished interaction with these regions may hinder retrieval of positive episodic memories of control and attribution of positive outcomes to personal actions. This may negatively influence patients’ belief about their ability to cope with stress, increase the sense of perceived uncontrollability. CLBP patients also showed reduced FC of the rmPFC with the medial pulvinar nucleus of the thalamus, midbrain reticular formation, and periaqueductal grey. These structures are parts of the ascending reticular activating system (ARAS) that regulates the level of arousal in the central nervous system. Reduced modulation of the arousal system by the rmPFC may result in development of a hyperarousal state and amplification of nociceptive and emotional responses leading to hyperalgesia and increased negative affectivity. There was no difference in FC of the rlPFC between CLBP patients and healthy controls. Effective connectivity analysis in CLBP. Causal interactions between the rmPFC, stress-related brainstem structures (dorsal raphe nucleus, ventral and dorsal periaqueductal grey), and memory systems (ventral striatum, hippocampus, amygdala) were investigated using the spectral dynamic causal modelling (spDCM). Consistent with the results of the FC analysis in CLBP, the spDCM also found altered interaction between the rmPFC and memory systems. Specifically, patients showed weaker connectivity of the rmPFC with hippocampus and stronger connectivity with the amygdala. Such pattern of connectivity may lead to inaccurate evaluation of the probability of control based on past experiences, overgeneralization and impaired extinction of fears. Patients also demonstrated hyperactivation of the dorsal raphe nucleus, ventral and dorsal periaqueductal grey (parts of the ARAS) that may contribute to hyperalgesia and increased negative affectivity. Functional connectivity of the rmPFC and rlPFC in OA. In this study FC of the rmPFC and rlPFC was compared between patients with shorter duration of OA (<7 years), patients with longer duration of OA (>7 years), and healthy volunteers. Only patients with longer duration of OA showed increased negative FC of the rmPFC with multiple brainstem nuclei, such as the parabrachial complex, locus coeruleus, dorsal and median raphe nuclei, ventral tegmental area, midbrain reticular formation, and periaqueductal grey, that together comprise the ARAS. Negative FC between the rmPFC and ARAS may reflect increased compensatory inhibition of the activating system by the rmPFC in attempts to suppress pain-induced arousal and negative affect. Despite longer duration of pain, patients did not show signs of hyperalgesia or emotional distress. Perhaps, effective suppression of the brainstem arousal system demonstrated by OA patients was due to preserved connectivity between the rmPFC and memory systems. Both groups of OA patients also showed reduced FC of the rlPFC with the multiple demand network that may contribute to development of another transdiagnostic risk factor, i.e., cognitive deficit. Results of all three studies presented in this thesis suggest that chronic stress may cause development of transdiagnostic risk factors such as negative affectivity and hyperalgesia via hyperactivation of the brainstem arousal system that augments nociceptive and emotional responses. Impaired regulation of the arousal system by the rmPFC, which evaluates controllability of the stress based on previous experiences, may contribute to hyperactivation of the ARAS. Reduced interaction between the rmPFC and memory systems may obstruct retrieval and utilization of positive memories of control, thereby increasing the sense of uncontrollability, facilitating hyperarousal, and contributing to development of transdiagnostic risk factors. In contrast, preserved connectivity between the rmPFC and memory systems may oppose the negative effects of chronic stress and help patients to maintain a belief that they are capable of coping with the stress.
... [10][11][12][13][14] Specifically, people with comorbidities often have more severe symptomatology, higher rates of psychological problems, poorer physical health, and greater functional impairment and disability. [15][16][17][18][19][20][21] Comorbidity is also associated with a more chronic course of impairment, 22 poorer treatment outcomes, 23 increased treatment dropout, 24 and higher treatment utilization and costs. 15,11,12,25,26 Despite these trends, evidence is sometimes conflicting; for example, while some studies have found greater symptom severity in individuals with comorbid post-traumatic stress disorder (PTSD) and SUD compared to those with 1 disorder, 20,27 others have found no difference in symptom severity. ...
... [15][16][17][18][19][20][21] Comorbidity is also associated with a more chronic course of impairment, 22 poorer treatment outcomes, 23 increased treatment dropout, 24 and higher treatment utilization and costs. 15,11,12,25,26 Despite these trends, evidence is sometimes conflicting; for example, while some studies have found greater symptom severity in individuals with comorbid post-traumatic stress disorder (PTSD) and SUD compared to those with 1 disorder, 20,27 others have found no difference in symptom severity. 18,28 Studies in Veterans demonstrate that psychiatric comorbidity in patients with a mental health condition, SUD, TBI, or chronic pain is associated with negative outcomes. ...
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Takeaway Evidence from recent systematic reviews (SRs) on the treatment of comorbid conditions is sparse and inconsistent. Inconsistent findings across the included SRs may reflect different ways of defining and measuring comorbidity, heterogeneous study samples, and methodological variation across the SRs and their included studies. Context Psychiatric comorbidity in Veterans is widespread. The impact of comorbidity on treatment outcomes is not well understood, and there is debate about the optimal course of treatment of these patients. This review identifies and synthesizes evidence from recent SRs on the effect of the presence of a comorbid condition on treatment outcomes, the effect of treating a primary condition on a comorbid condition, and the effectiveness of integrated treatments designed to treat both conditions. Key Findings This rapid review of SRs published in the last 7 years included 26 reviews on the treatment of comorbid conditions. Based on data from a single study, 1 systematic review found that a baseline diagnosis of major depressive disorder significantly predicted nonresponse to posttraumatic stress disorder (PTSD) treatment. However, these findings are limited to a single, imprecise study. Treatment with antidepressants may result in improvements in certain alcohol outcomes in individuals with comorbid depression and alcohol dependence, based on 1 well-conducted SR. The effect of treatment of a primary condition on a comorbid condition reported in 10 other SRs is unclear due to inconsistent, imprecise, and/or indirect findings. The evidence on the effectiveness of integrated treatment compared to nonintegrated treatment was inconsistent among 6 SRs but was most favorable for integrated treatment of PTSD and substance use disorder. The evidence was further limited by imprecise and/or indirect findings.
... Moreover, individuals with LEP are at high risk for mental health disorders due to sociocultural stressors related to communication barriers and acculturation ( Au, 2017 ;Rhee, 2019 ;Salas-Wright et al., 2014 ;Sentell et al., 2007 ). Overall, relationships between mental health disorders and pain have been wellestablished ( Arnow et al., 2006;Bair, Robinson, Katon, & Kroenke, 2003 ;Nicholl et al., 2014 ;Pereira et al., 2017 ;Søndergård et al., 2018 ;Woo, 2010 ). Studies indicate that depression, anxiety, and mood disorders are associated with increased perception of pain severity ( Michaelides & Zis, 2019 ;Sweeney et al., 2018 ). ...
... In contrast, the presence of a mood or neurotic disorder decreased both the chances of patients reporting any pain and pain severity. We were surprised by this later finding, which appears to be driven by the large number of English-speaking pa- tients in our sample, as it is in contrast to previous literature that strongly supports relationships between mental health disorders and pain Arnow et al., 2006;Bair, Robinson, Katon, & Kroenke, 2003 ;Michaelides & Zis, 2019 ;Nicholl et al., 2014 ;Pereira et al., 2017 ;Søndergård et al., 2018 ;Sweeney et al., 2018 ;Woo, 2010 ). Our use of mental health disorder diagnosis, rather than questionnaires evaluating depressed mood and anxiety at the time of visit, may explain this discrepancy. ...
Article
Aim To explore whether the relationship between mental health diagnosis (i.e., mood or neurotic, stress-related, or somatoform disorder) and pain is moderated by language in patients with limited English proficiency (LEP). Southeast Asian languages (i.e., Hmong, Lao, Khmer) and Spanish were compared with English. Method A retrospective data mining study was conducted (n = 79,109 visits). Pain scores, language, mental health diagnoses, age, sex, race, ethnicity, and pain diagnosis were obtained from electronic medical records. Cragg two-equation hurdle regression explored: (1) the effect of patient language and mental health diagnosis on pain and (2) the interaction between language and mental health diagnosis on pain. Results Visits were primarily for female (62.45%), White (80.10%), not Hispanic/Latino (96.06%), and English-speaking (97.85%) patients. Spanish or Southeast Asian language increased chances of reporting any pain (i.e., pain score of 0 versus ≥1) and pain severity in visits with pain scores ≥1, whereas mental health diagnosis decreased chances of reporting any pain and pain severity. The combination of Southeast Asian language and mood disorder contributed to higher chances of reporting any pain (odds ratio [OR] = 1.78, p<.001) but no difference in severity. A similar trend was observed for Southeast Asian language and neurotic disorder (OR = 1.29, p=.143). In contrast, the combination of Spanish language and mood (p = .066) or neurotic (p = .289) disorder contributed to lower pain severity but did not change the chances of reporting any pain. Conclusions LEP and patient language should be considered during pain assessment within the context of mental health.
... C hronic pain and depressive symptoms are frequently encountered clinically, mutually rendering patients more difficult to treat [1][2][3] . Particularly, depressive symptoms may lead to an excessive duration and intensity of pain 1,4,5 . This tends to create a cycle of pain and depressive symptoms. ...
... Whole-cell patch-clamp recordings were obtained from visually identified DRN, CeA or LHb cells. Patch pipettes (3)(4)(5) were pulled from borosilicate glass capillaries (VitalSense Scientific Instruments Co., Ltd) with an outer diameter of 1.5 mm on a four-stage horizontal puller (P1000, Sutter Instruments). The signals were acquired via a Multiclamp 700B amplifier, low-pass filtered at 2.8 kHz, digitized at 10 kHz and analyzed with Clampfit 10.7 software (Molecular Devices). ...
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... Prevalence of chronic pain and chronic pain disorders is higher in populations with a range of psychiatric disorders compared to those without (Table 1 & Supplemental Information). Some of these relationships are more well-studied and understood than others -for example, there is a large body of literature on the relationship between major depression and chronic pain [1,[9][10][11][12][13][14][15][16][17][18]. In contrast, chronic pain comorbid with personality disorders such as borderline personality disorder, and neurodevelopmental disorders such as ADHD and autism spectrum disorder, is less well understood. ...
Article
Chronic pain is a common condition with high socioeconomic and public health burden. A wide range of psychiatric conditions are often comorbid with chronic pain and chronic pain conditions, negatively impacting successful treatment of either condition. The psychiatric condition receiving most attention in the past with regards to chronic pain comorbidity has been major depressive disorder, despite the fact that many other psychiatric conditions also demonstrate epidemiological and genetic overlap with chronic pain. Further understanding potential mechanisms involved in psychiatric and chronic pain comorbidity could lead to new treatment strategies both for each type of disorder in isolation, and in scenarios of comorbidity. This article provides an overview of relationships between DSM-5 psychiatric diagnoses and chronic pain, with particular focus on PTSD, ADHD and BPD, disorders which are less commonly studied in conjunction with chronic pain. We also discuss potential mechanisms that may drive comorbidity, and present new findings on the genetic overlap of chronic pain and ADHD, and chronic pain and BPD.
... Primary care is an optimal place to identify individuals with depression. First, due to the association between psychiatric disorders and physical diseases, primary care practices serve individuals with elevated rates of depression compared to the general population [17][18][19][20][21]. Second, patients overwhelmingly trust their primary care clinicians and may be more willing to seek treatment with their encouragement [22,23]. ...
Article
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Background Most individuals with depression go unidentified and untreated. In 2016 the US Preventive Services Task Force released guidelines recommending universal screening in primary care to identify patients with depression and to link them to treatment. Feasible, acceptable, and effective strategies to implement these guidelines are needed. Methods This three-phased study employed rapid participatory methods to design and test strategies to increase depression screening at Penn Medicine, a large health system with 90 primary care practices. First, researchers solicited ideas and barriers from stakeholders to increase screening using an innovation tournament—a crowdsourcing method that invites stakeholders to submit ideas to address a workplace challenge. Second, a panel of stakeholders and scientists deliberated over and ranked the tournament ideas. An instant runoff election was held to select the winning idea. Third, the research team piloted the winning idea in a primary care practice using rapid prototyping, an approach that quickly refines and iterates strategy designs. Results The innovation tournament yielded 31 ideas and 32 barriers from diverse stakeholders (12 primary care physicians, 10 medical assistants, 4 nurse practitioners, 2 practice managers, and 4 patient support assistants). A panel of 6 stakeholders and scientists deliberated on the ideas and voted for patient self-report (i.e., through tablet computers, text message, or an online patient portal) as the winning idea. The research team rapid prototyped tablets in one primary care practice with one physician over 5 five-hour shifts to examine the feasibility, acceptability, and effectiveness of the strategy. Most patients, the physician, and medical assistants found the tablets acceptable and feasible. However, patient support assistants struggled to incorporate them in their workflow and expressed concerns about scaling up the process. Depression screening rates were higher using tablets compared to usual care; follow-up was comparable between tablets and usual care. Conclusions Rapid participatory methods engaged and amplified the voices of diverse stakeholders in primary care. These methods helped design an acceptable and feasible implementation strategy that showed promise for increasing depression screening in a primary care setting. The next step is to evaluate the strategy in a randomized controlled trial across primary care practices.
... Approximately 50% of patients diagnosed with major depressive disorder reportedly suffer from chronic pain, and the risk of developing comorbid depression in chronic pain patients is greater among women (Radat et al., 2013). Further, patients suffering from chronic pain and depression have a poorer prognosis than patients suffering from each illness alone (Arnow et al., 2006;Munce and Stewart, 2007). Clinically, it is well known that chronic pain and depression are related; however, the neurobiological changes responsible for the co-occurrence of these conditions are not well-understood, and the sex-specific mechanisms that might help explain the high prevalence of these conditions in women remain unknown. ...
Article
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Chronic pain and depression are intimately linked; the combination of the two leads to higher health care costs, lower quality of life, and worse treatment outcomes with both conditions exhibiting higher prevalence among women. In the current study, we examined the development of depressive-like behavior in male and female mice using the spared nerve injury (SNI) model of neuropathic pain. Males displayed increased immobility on the forced-swim test – a measure of depressive-like behavior – 2 weeks following injury, while females developed depressive-like behavior at 3-week. Since the pathogenesis of chronic pain and depression may involve overlapping mechanisms including the activation of microglial cells, we explored glial cell changes in brain regions associated with pain processing and affect. Immunohistochemical analyses revealed that microglial cells were more numerous in female SNI mice in the contralateral ventral anterior cingulate cortex (ACC), a brain region important for pain processing and affect behavior, 2-week following surgery. Microglial cell activation was not different between any of the groups for the dorsal ACC or nucleus accumbens. Analysis of astrocyte density did not reveal any significant changes in glial fibrillary acidic protein (GFAP) staining in the ACC or nucleus accumbens. Overall, the current study characterized peripheral nerve injury induced depression-like behavior in male and female mice, which may be associated with different patterns of glial cell activation in regions important for pain processing and affect.
... This leads us to hypothesize that the co-presence of these symptoms could be due to a shared pathogenetic mechanism based on inflammation [21,22]. In particular, it has been observed that co-morbidity of depression and chronic pain is highly prevalent [23], and it has been proposed that chronic inflammation is a common mediator of these co-morbidities [24]. This aspect was investigated by evaluating the possible correlation of these symptoms with blood concentrations of noradrenaline and adrenaline as an index for sympathetic nervous system activity and cortisol and adrenocorticotropic hormone for hypothalamic-pituitary-adrenal activity in 104 women with advanced breast cancer. ...
Article
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After breast surgery, women frequently develop chronic post-mastectomy pain (PMP). PMP refers to the occurrence of pain in and around the area of the mastectomy lasting beyond three months after surgery. The nature of factors leading to PMP is not well known. When PMP is refractory to analgesic treatment, it negatively impacts the lives of patients, increasing emotional stress and disability. For this reason, optimizing the quality of life of patients treated for this pathology has gained more importance. On the basis of the findings and opinions above, we present an overview of risk factors and predictors to be used as potential biomarkers in the personalized management of individual PMP. For this overview, we discuss scientific articles published in peer-reviewed journals written in the English language describing risk factors, predictors, and potential biomarkers associated with chronic pain after breast surgery. Our overview confirms that the identification of women at risk for PMP is fundamental to setting up the best treatment to prevent this outcome. Clinical practice can be planned through the interpretation of genotyping data, choosing drugs, and tailoring doses for each patient with the aim to provide safer and more effective individual analgesic treatment.
... Similarly, Kwanga reported that total ODQ score was correlated with VAS score in both LBP and PGP (9). Arnow reported the rates of lumbopelvic back pain (LBPP) among 5000 patients to be 41% in patients with depression and 10% in those without depression (30). In the study by Virgara et al., it was found that the functional disability index index was lower in women who have LBP and greater anxiety and depression scale than women who have LBP but no anxiety or depression. ...
... Хроническая боль способствует развитию депрессии и тревоги, которые, в свою очередь, негативно влияют на боль [4]. Около 23% пациентов с хронической болью имеют депрессивное расстройство [5], и почти половина пациентов с депрессией испытывают боль [6]. В одном из эпидемиологических исследований (n = 190 593) обнаружено, что люди с хронической болью в спине чаще страдают депрессией (повышение на 25%) и тревогой (повышение на 19%) [7]. ...
Article
Low back pain is one of the most common reasons for seeking medical attention. Musculoskeletal (nonspecific) pain is the most common (90%) cause of chronic pain. Depressive and anxiety disorders, sleep disorders, mainly in the form of insomnia, which negatively affect the course of the disease, are often encountered as comorbid disorders in patients with chronic musculoskeletal low back pain (CMLBP). When managing patients, it is effective to use an integrated approach: drug therapy, kinesitherapy and psychological methods. Kinesitherapy uses various types of exercise and walking; it is important that they are performed regularly under the supervision of a specialist, excluding excessive physical and static loads. Cognitive-behavioral therapy is the most effective psychological effect in CMLBP, which should be directed not only to pain, but also to insomnia, depression and anxiety disorders. Non-steroidal anti-inflammatory drugs (NSAIDs) are used as drugs for chronic pain. It is important to take into account the presence of risk factors, concomitant diseases, interactions with other drugs. The use of etoricoxib (Arcoxia) for chronic low back pain is discussed. The author presents his own experience in managing 71 patients (average age 55) with CMLBP using kinesitherapy, psychological methods, and NSAIDs. As a result of treatment after 3 months, a significant decrease in VAS was achieved from 8 (6-8) to 2 (0-4) points (p < 0.0001), the depression decreased from 7 (5-9) to 4 (3-6) points in HADS (p = 0.002), the anxiety from 7 (5-10) to 5 (3-7) points in HADS (p = 0.0003), a decrease in disabilities according to the Oswestry question-naire from 46 (34-57.77) to 11.11 (4.44-26) percent (p < 0.0001), increase in physical activity according to IPAQ-SF from 11 (7-16) to 23 (15-26 ) points (p = 0.0002), decrease insomnia according to ISI from 12 (7-15) to 6 (2-10) points (p < 0.001), improvement in sleep quality according to PSQI from 9 (7-13) points up to 4 (2-9) points (p < 0.001). The widespread introduction of complex treatment of patients with CMLBP is of great medical and social importance.
... Compared with the control groups, the CP groups showed depression-like behaviour in the tail suspension test and sucrose preference test in our study. Inflammation has been increasingly recognized as an important contributor to CNS injury [59,60]. CP and depression-like behaviour have been linked to inflammation [61]. ...
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Background Cerebral palsy (CP) is a kind of disability that influences motion, and children with CP also exhibit depression-like behaviour. Inflammation has been recognized as a contributor to CP and depression, and some studies suggest that the gut-brain axis may be a contributing factor. Our team observed that Saccharomyces boulardii (S. boulardii) could reduce the inflammatory level of rats with hyperbilirubinemia and improve abnormal behaviour. Both CP and depression are related to inflammation, and probiotics can improve depression by reducing inflammation. Therefore, we hypothesize that S. boulardii may improve the behaviour and emotions of spastic CP rats through the gut-brain axis pathway. Methods Our new rat model was produced by resecting the cortex and subcortical white matter. Seventeen-day-old CP rats were exposed to S. boulardii or vehicle control by gastric gavage for 9 days, and different behavioural domains and general conditions were tested. Inflammation was assessed by measuring the inflammatory markers IL-6 and TNF-α. Hypothalamic–pituitary–adrenal (HPA) axis activity was assessed by measuring adrenocorticotropic hormone and corticosterone in the serum. Changes in the gut microbiome were detected by 16S rRNA. Results The hemiplegic spastic CP rats we made with typical spastic paralysis exhibited depression-like behaviour. S. boulardii treatment of hemiplegic spastic CP rats improves behaviour and general conditions and significantly reduces the level of inflammation, decreases HPA axis activity, and increases gut microbiota diversity. Conclusions The model developed in this study mimics a hemiplegic spastic cerebral palsy. Damage to the cortex and subcortical white matter of 17-day-old Sprague–Dawley (SD) rats led to spastic CP-like behaviour, and the rats exhibited symptoms of depression-like behaviour. Our results indicate that S. boulardii might have potential in treating hemiplegic spastic CP rat models or as an add-on therapy via the gut-brain axis pathway.
... Regarding pain, previous studies have shown that individuals with depression are more likely to report chronic pain, and more than half of patients with chronic pain experience depression. [1,2] Among patients with osteoarthritis, depression was found to be associated with increased pain sensitivity and less effective coping with the illness. [3] Osteoarthritic pain is associated with an increased risk of depressive symptoms as a result of fatigue and disability. ...
... Neuropathic pain is frequently comorbid with psychiatric disorders, such as anxiety and depression, rendering it more resistant to classical treatment (1)(2)(3)(4). In particular, aberrant psychiatric conditions may lead to an exaggerated duration and intensity of pain and drive a vicious cycle of pain and emotional aversion (2,5,6). Thus, development of a new and effective treatment for comorbid psychiatric disorders in neuropathic pain remains a major challenge (7). ...
Article
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Patients with neuropathic pain often experience comorbid psychiatric disorders. Cellular plasticity in the anterior cingulate cortex (ACC) is assumed as a critical interface for pain perception and emotion. However, substantial efforts thus far are focused on intracellular mechanisms of plasticity rather than extracellular alterations that might trigger and facilitate intracellular changes. Laminin is a key element of extracellular matrix (ECM) consisting of one α-, β- and γ-chain and implicated in several pathophysiological processes. Here we showed that Laminin β1 (LAMB1) in ACC is significantly downregulated upon peripheral neuropathy. Knocking down ACC LAMB1 exacerbated pain sensitivity and induced anxiety and depression. Mechanistic analysis revealed that loss of LAMB1 causes actin dysregulation via interaction with integrin beta1 and subsequent Src-dependent RhoA/LIMK/cofilin pathway, leading to increased presynaptic transmitter release probability and abnormal postsynaptic spine remodeling, which in turn orchestrates structural and functional plasticity of pyramidal neurons and eventually results in pain hypersensitivity and anxiodepression. This study shed new light on the functional capability of ECM, LAMB1 in modulating pain plasticity and revealed a mechanism that conveys extracellular alterations to intracellular plasticity. Moreover, we identified cingulate LAMB1/integrin β1 as a promising therapeutic strategy for treatment of neuropathic pain and associated anxiodepression.
... In addition, the prevalence of one condition co-occurring with the other is higher than the presence of only one condition [10]. Generally, depressed patients report more physical comorbidities, including chronic pain than the general population [5,10,84]. On the other hand, mood and anxiety disorders have been shown to be highly prevalent in patients suffering from chronic pain [28]. Comorbid depression and chronic pain leads to greater health care costs and burden including disability and poorer health outcomes [10,69], and substantial clinical challenges remain for physicians to recognize the high comorbidity and to provide effective treatment [39]. ...
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Abnormalities in pain processing have been observed in patients with chronic pain conditions and in individuals who engage in self-harm, specifically nonsuicidal self-injurious behaviors (NSSI). Both increased and decreased pain sensitivity have been described in chronic pain patients, while decreased pain sensitivity is consistently observed in individuals with NSSI. The objective of the study was to identify the differential effects of chronic pain and NSSI on experimental pain sensitivity, specifically pressure pain threshold, in depressed patients. Moreover, the role that hopelessness may play between depression severity and pain sensitivity was also examined. Depressed patients with and without chronic pain, and with and without lifetime self-harm behaviors were analyzed into four groups. Group 1 (N = 42) included depressed patients with both Chronic pain ( +) and Self-harm ( +), Group 2 (N = 53) included depressed patients with Chronic pain ( +) but no Self-harm (−), Group 3 (N = 64) included depressed patients without Chronic pain (−), but Self-harm ( +), and Group 4 (N = 81) included depressed patients with neither Chronic pain (−) nor Self-harm (−). Healthy controls (N = 45) were also recruited from the community. Depressed patients with both Chronic pain ( +) and Self-harm ( +) reported higher pressure pain threshold measures when compared with the other groups. Mediation analysis indicated that hopelessness mediates the relationship between depression severity and pressure pain threshold. Our findings suggest that a multiprong approach including adequate mental health services and pain control for depressed patients with comorbid chronic pain and nonsuicidal self-harm is needed to yield effective outcomes.
... Additionally, comorbid diagnoses were beyond the scope of the current review. Many individuals with depression also have comorbid disorders, such as anxiety (Rapaport, 2001), chronic pain (Arnow et al., 2006) and schizophrenia (Li et al., 2020), complicating their presentation. The relationship between EMS and depression was examined in various clinical populations, such as bipolar affective disorder (Ak et al., 2012) and obsessive-compulsive disorder (Kwak & Lee, 2015) in several studies included in this review. ...
Article
Background: Improved understanding of the specific cognitive risk factors associated with depression is needed to inform prevention and treatment approaches. Recent research has examined the relationship between Early Maladaptive Schemas (EMS) and depression, but the findings were yet to be integrated using meta-analytic methods. The aim of this review was to synthesize the evidence on the relationship between depression and EMS. Method: A systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement, by searching the PsycINFO, PubMed, and CINAHL databases. Included studies were peer-reviewed journal articles that examined the relationship between one or more EMS and depression in adulthood in participants aged 18 years or older. Results: A total of 51 studies were included (k = 743; Pooled N = 17,830). All 18 EMS were positively correlated with depression, with effect sizes ranging from small (r = .23 [.17, .29]; Entitlement) to large (r =.53 [.46, .60]; Social Isolation; r = .50, 95% CI [.45, .54]; Defectiveness/Shame). Conclusion: The evidence suggests that individuals who feel like they do not belong, or that they are flawed, bad, or unlovable, report higher levels of depression. However, most studies used cross-sectional designs and further longitudinal research is needed to establish the direction of the relationship between EMS and depression. These findings can guide preventative and treatment approaches. Focusing treatment on the Social Isolation and Defectiveness/Shame EMS may aid in relieving depressive symptoms.
... In the general population, there are strong associations between depression and (1) anxiety, 56 (2) headaches, 57,58 migraine, [59][60][61][62][63] (3) memory difficulties, [64][65][66] and (4) chronic pain. 67,68 Moreover, there are also strong associations between anxiety and (1) headaches, 69 (2) migraine, [70][71][72] (3) chronic pain, 68,73 and (4) memory problems. 74 These problems tend to be comorbid, and they can amplify each other. ...
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Objective: To examine whether middle-aged men who played high-school football experience worse mental health or cognitive functioning than men who did not play high-school football. Design: Cross-sectional cohort study. Setting: Online survey completed remotely. Participants: A total of 435 men between the ages of 35 and 55 completed the study, of whom 407 were included in the analyses after excluding participants who answered embedded validity items incorrectly (n = 16), played semiprofessional football (n = 2), or experienced a recent concussion (n = 10). Assessment of risk factors: Self-reported high school football participation, compared with those who played contact sports, noncontact sports, and no sports. Main outcome measures: A lifetime history of depression or anxiety; mental health or cognitive problems in the past year; current depression symptoms, and post-concussion-like symptoms. Results: Middle-aged men who played high-school football did not have a higher prevalence of being prescribed medication for anxiety or depression or receiving treatment from a mental health professional. Similarly, there were no significant differences between groups on the rates in which they endorsed depression, anxiety, anger, concentration problems, memory problems, headaches, migraines, neck or back pain, or chronic pain over the past year. A greater proportion of those who played football reported sleep problems over the past year and reported being prescribed medication for chronic pain and for headaches. Conclusions: Men who played high-school football did not report worse brain health compared with those who played other contact sports, noncontact sports, or did not participate in sports during high school.
... 3,4 Chronic pain is often emotionally distressing; resulting in a strong co-occurrence of mood issues such as depression and anxiety. 2,5 Health-related quality of life ratings among chronic pain patients have been reported as 28% lower than that of the general population. 6 Spinal cord stimulation (SCS) is a valuable pain management option for patients with intractable neuropathic pain of the trunk and/or limbs. ...
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Study design: Prospective, international, multicenter, single-arm, post-market study. Objective: The aim of this study was to assess long-term safety and effectiveness of spinal cord stimulation using a passive recharge burst stimulation design for chronic intractable pain in the trunk and/or limbs. Herein we present 24-month outcomes from the TRIUMPH study (NCT03082261). Summary of background data: Passive recharge burst spinal cord stimulation (B-SCS) uniquely mimics neuronal burst firing patterns in the nervous system and has been shown to modulate the affective and attentional components of pain processing. Methods: After a successful trial period, subjects received a permanent SCS implant and returned for follow-up at 6, 12, 18, and 24 months. Results: Significant improvements in physical, mental, and emotional functioning observed after 6 months of treatment were maintained at 2 years. Pain catastrophizing scale (PCS) scores dropped below the population norm. Health-related quality of life on EQ-5D improved across all domains and the mean index score was within one standard deviation of norm. Pain reduction (on NRS) was statistically significant (P < 0.001) at all timepoints. Patient reported pain relief, a stated percentage of improvement in pain, was consistent at all timepoints at 60%. Patients reported significant improvements across all measures including activity levels and impact of pain on daily life. At 24 months, 84% of subjects were satisfied and 90% would recommend the procedure. Subjects decreased their chronic pain medication intake for all categories; 38% reduced psychotropic and muscle relaxants, 46% reduced analgesic, anti-convulsant and NSAIDs, and 48% reduced opioid medication. Adverse events occurred at low rates without unanticipated events. Conclusion: Early positive results with B-SCS were maintained long term. Evidence across multiple assessment tools show that B-SCS can alleviate pain intensity, psychological distress, and improve physical function and health-related quality of life.Level of Evidence: 3.
... There is a substantial body of research on the reciprocal link between depression and pain, with pain being a significant physical and psychological stressor that worsens mood and causes depressive symptoms. Low mood, in turn, intensifies the pain experience and aggravates depressive thinking and behavior that render daily pain management difficult (Arnow et al., 2006;Bair, Robinson, Katon, & Kroenke, 2003;Banks & Kerns, 1996;Blackburn-Munro, 2004;Brown, 1990;Fishbain, Cutler, Rosomoff, & Rosomoff, 1997;Romano & Turner, 1985;Von Korff & Simon, 1996). Resultant mood changes from our thought manipulation procedure highlight this close connection between cognition and emotion. ...
Article
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In chronic pain, mental defeat is considered as a disabling type of self-evaluation triggered by repeated episodes of debilitating pain. This exploratory study experimentally tested the effect of an activated sense of defeat, as well as its interaction with pain catastrophizing, on pain and mood. Participants ( N = 71) were allocated to either high or low pain catastrophizing groups and then randomly assigned to receive either defeat or neutral manipulations. A cold pressor task administered before and after the thought manipulation measured pain threshold, alongside visual analogue scales for mental defeat, attention, pain intensity, pain anticipation as well as mood. Thought manipulation checks supported successful defeat activation. Defeat activation was associated with increased negative mood and attentional disengagement from the nociceptive stimuli, irrespective of pain catastrophizing tendency. There were no changes in pain threshold, pain or pain anticipation ratings. The results suggest that mental defeat can be experimentally activated using an autobiographical memory task and that an activated sense of defeat appears to operate independently from pain catastrophizing in influencing mood and attentional disengagement from the nociceptive stimuli. Future research can utilize our experimental approach to evaluate the effect of an activated sense of mental defeat in people with chronic pain, for whom the magnitude of pain, mood and attentional responses may be stronger and broader.
... In western countries, depression is the leading cause of sick leave, and further costs are attributable to healthcare and drug utilization (Sandelin et al., 2013). Furthermore, it is well established that patients with depression often have comorbidities, such as anxiety disorders (Lamers et al., 2011;Steffen et al., 2020) and pain disorders (Bair et al., 2003;Bondesson et al., 2018), further adding to their suffering and disability (Arnow et al., 2006;Bair et al., 2003;Bair et al., 2008;DeVeaugh-Geiss et al., 2010). ...
Article
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Depression is a common, recurrent disorder. There is a need for readily available treatments with few negative side effects, that demands little resources and that are effective both in the short- and long term. Our aim was to investigate the long-term effectiveness of two different interventions; physical exercise and internet-based cognitive behavioural therapy (internet-CBT), compared to usual care in patients with mild to moderate depression in a Swedish primary care setting. We performed a register-based 3-year follow-up study of participants in the randomized controlled trial REGASSA (n=940) using healthcare utilization and dispensed medicines as outcomes. We found no difference between the three groups regarding proportion of participants consulting healthcare due to mental illness or pain during follow-up. Regarding number of consultations, there was no difference between the groups, except for consultations related to pain. For this outcome both treatment arms had significantly fewer consultations compared to usual care, during year 2-3, the risk ratio (RR) for physical exercise and internet-CBT was 0.64 (95% CI=0.43-0.95) and 0.61 (95% CI=0.41-0.90), respectively. A significantly lower proportion of patients in both treatment arms were dispensed hypnotics and sedatives year 2-3 compared to the usual care arm, RR for both physical exercise and internet-CBT was 0.72 (95% CI=0.53-0.98). No other differences between the groups were found. In conclusion, considering long-term effects, both physical exercise and internet-CBT, being resource-efficient treatments, could be considered as appropriate additions for patients with mild to moderate depression in primary care settings. Trial registration: The original RCT was registered with the German Clinical Trial Register (DRKS study ID: DRKS00008745).
... Assessments of quality of life in a pathological population include questions about symptom severity, daily functioning, and other subjective well-being dimensions to fully evaluate a patient's overall condition [20,21]. Depressive disorders negatively influence quality of life [10,22] and health-related quality of life [4,23]. In a +60 years old population, a relationship between depression and poorer quality of life has been proven in aged adults in both clinical and community settings [10]. ...
Article
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Introduction: Depressive disorders are mental disorders that last over time, and seriously affect the lives of the people who suffer from them, diminishing their quality of life, reducing their motor capacity, and incapacitating them in their daily lives. It is a major problem worldwide. Objective: To study the association between agility, health-related quality of life (hrqol), anthropometric status, and depression status in older adult women with depression. Design: Data collected from 685 physically active older women with depression were analyzed. Result: A moderate inverse correlation (r = -0.34) is shown between Time Up & Go (TUG) and EuroQol Five-Dimensional Three-Level Version (EQ-5D-3L). Between TUG and Geriatric Depression Scale (GDS), there is a small direct correlation (r = 0.14) between them. Between TUG and anthropometric data, all observed correlations are significant. Conclusions: There is a significant association between agility, health-related quality of life, depression, and anthropometric data in physically active older women with depression.
... In addition to chronic pain, important bi-directional relationships exist between at-risk alcohol drinking and other negative affective conditions (e.g., stress, anxiety, depression) that represent additional risks for psychiatric co-morbidities. Importantly, people with chronic pain and high negative affect report higher pain severity and pain interference compared to people with only one of the two disorders (Arnow et al., 2006). Such symptoms may precede or emerge within the development of more severe forms of AUD . ...
Article
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At-risk alcohol use is a significant risk factor associated with multisystemic pathophysiological effects leading to multiorgan injury and contributing to 5.3% of all deaths worldwide. The alcohol-mediated cellular and molecular alterations are particularly salient in vulnerable populations, such as people living with HIV (PLWH), diminishing their physiological reserve, and accelerating the aging process. This review presents salient alcohol-associated mechanisms involved in exacerbation of cardiometabolic and neuropathological comorbidities and their implications in the context of HIV disease. The review integrates consideration of environmental factors, such as consumption of a Western diet and its interactions with alcohol-induced metabolic and neurocognitive dyshomeostasis. Major alcohol-mediated mechanisms that contribute to cardiometabolic comorbidity include impaired substrate utilization and storage, endothelial dysfunction, dysregulation of the renin-angiotensin-aldosterone system, and hypertension. Neuroinflammation and loss of neurotrophic support in vulnerable brain regions significantly contribute to alcohol-associated development of neurological deficits and alcohol use disorder risk. Collectively, evidence suggests that at-risk alcohol use exacerbates cardiometabolic and neurocognitive pathologies and accelerates biological aging leading to the development of geriatric comorbidities manifested as frailty in PLWH.
... Leveraging national cross-sectional surveys of health systems and physician practices, we examine system-level and practice-level capabilities associated with organizational adoption of PROs for depression, disability, and pain, which are among the most well validated and widely used PRO domains. 8 Medical groups, hospitals, and other health care organizations increasingly operate under the umbrella of health systems to improve their positioning as part of risk-based contracts, to better manage patient care across the continuum of care, and to control spending. 9 Health systems that own physician practices and hospitals may benefit from collecting PROs to better manage care across care settings. ...
Article
Background: Patient-reported outcome measures (PROs) can help clinicians adjust treatments and deliver patient-centered care, but organizational adoption of PROs remains low. Objective: This study examines the extent of PRO adoption among health systems and physician practices nationally and examines the organizational capabilities associated with more extensive PRO adoption. Design: Two nationally representative surveys were analyzed in parallel to assess health system and physician practice capabilities associated with adoption of PROs of disability, pain, and depression. Participants: A total of 323 US health system and 2,190 physician practice respondents METHODS: Multivariable regression models separately estimated the association of health system and physician practice capabilities associated with system-level and practice-level adoption of PROs. Main measures: Health system and physician practice adoption of PROs for depression, pain, and disability. Key results: Pain (50.6%) and depression (43.8%) PROs were more commonly adopted by all hospitals and medical groups within health systems compared to disability PROs (26.5%). In adjusted analyses, systems with more advanced health IT functions were more likely to use disability (p<0.05) and depression (p<0.01) PROs than systems with less advanced health IT. Practice-level advanced health IT was positively associated with use of depression PRO (p<0.05), but not disability or pain PRO use. Practices with more chronic care management processes, broader medical and social risk screening, and more processes to support patient responsiveness were more likely to adopt each of the three PROs. Compared to independent physician practices, system-owned practices and community health centers were less likely to adopt PROs. Conclusions: Chronic care management programs, routine screening, and patient-centered care initiatives can enable PRO adoption at the practice level. Developing these practice-level capabilities may improve PRO adoption more than solely expanding health IT functions.
... In turn, a slightly older review by Cimmino et al. (2011) found that between 11% and 24% of individuals had chronic and multisite MS pain. With respect to the frequency of chronic disabling pain, estimates have generally ranged between 11% and 14% in different studies (Arnow et al., 2006;Fayaz et al., 2016). Our results are in line with previous assessments. ...
Article
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Background: It has been suggested that chronotype, the individual preference for 24-hour circadian rhythms, influences health. Sleep problems and mental distress are among the greatest risk factors for musculoskeletal (MS) pain. The aims of this study were first, to explore the associations between chronotypes and MS pain, with special reference to disabling MS pain, and second, to test whether mental distress and insomnia have a modifying role in the associations between chronotypes and MS pain. Methods: The dataset of 4,961 individuals was composed of Northern Finns surveyed on MS pain, chronotypes, and confounding factors (sex, insomnia, sleep duration, smoking, mental distress, occupational status, education level, and number of co-existing diseases) at 46 years. The relationships between chronotypes (evening [E], intermediate [I], and morning [M]) and MS pain were evaluated using multinomial logistic regression. To address the second aim, we included an interaction term (chronotype*mental distress, chronotype*insomnia) in the logistic model. Results: Compared to the M-types, both the E- and I-types had increased odds of suffering 'disabling pain' in the unadjusted model (odds ratio [OR] 1.79, 95% confidence interval [CI] 1.37-2.33; OR 1.54, 95% CI 1.29-1.84, respectively). However, the association remained statistically significant only after adjusting for all covariates among the I-types (OR 1.39, 95% CI 1.15-1.67). Neither mental distress nor insomnia was found to modify the chronotype-MS pain association. Conclusions: The results highlight the importance of chronotypes for individuals' MS health but suggest the presence of confounding factors in the interplay between these factors.
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Background: Most individuals with depression go unidentified and untreated. In 2016 the US Preventive Services Task Force released guidelines recommending universal screening in primary care to identify patients with depression and to link them to treatment. Feasible, acceptable, and effective strategies to implement these guidelines are needed. Methods: This three-phased study employed rapid participatory methods to design and test strategies to increase depression screening at Penn Medicine, a large health system with 90 primary care practices. First, researchers solicited ideas and barriers from stakeholders to increase screening using an innovation tournament—a crowdsourcing method that invites stakeholders to submit ideas to address a workplace challenge. Second, a panel of stakeholders and scientists deliberated over and ranked the tournament ideas. An instant runoff election was held to select the winning idea. Third, the research team piloted the winning idea in a primary care practice using rapid prototyping, an approach that quickly refines and iterates strategy designs. Results: The innovation tournament yielded 31 ideas and 32 barriers from diverse stakeholders (12 primary care physicians, 10 medical assistants, 4 nurse practitioners, 2 practice managers, and 4 patient support assistants). A panel of 6 stakeholders and scientists deliberated on the ideas and voted for patient self-report (i.e., through tablet computers, text message, or an online patient portal) as the winning idea. The research team rapid prototyped tablets in one primary care practice with one physician over 5 five-hour shifts to examine the feasibility, acceptability, and effectiveness of the strategy. Most patients, the physician, and medical assistants found the tablets acceptable and feasible. However, patient support assistants struggled to incorporate them in their workflow and expressed concerns about scaling up the process. Depression screening rates were higher using tablets compared to usual care; follow-up was comparable between tablets and usual care. Conclusions: Rapid participatory methods engaged and amplified the voices of diverse stakeholders in primary care. These methods helped design an acceptable and feasible implementation strategy that showed promise for increasing depression screening in a primary care setting. The next step is to evaluate the strategy in a randomized controlled trial across primary care practices.
Article
Objective Chronic lower back pain induced by lumbar disc degeneration or herniation exerts a great impact on patients’ daily lives. Depression and anxiety often exist among patients with lower back pain. Some studies mentioned about mechanisms, such as inflammatory biomarkers, which are commonly seen in herniated intervertebral disc (HIVD) and major depressive disorder (MDD). Method: Our study used a large database from the National Health Insurance to explore the incidence rate of MDD in patients with HIVD and correlated risk factors. A total of 41,874 patients with HIVD were included in this work. The control group was matched by using propensity scores. Results: The results showed a temporal association between prior HIVD and subsequent MDD after adjusting for potential confounding factors. Patients with HIVD were at high risk of developing MDD (hazard ratio, HR: 9.00, 95% confidence interval, CI: 7.196–11.257) even after adjusting for demographic characteristics and comorbidities (HR: 8.47, 95% CI: 6.84–10.49, p < 0.0001). Conclusions: The combination of HIVD and MDD represents an important health problem that is associated with higher disability rates, socioeconomic disadvantage, and greater utilization of health care resources. Early detection and combined treatment of depressive symptoms may benefit patients with HIVD.
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Currently, ketamine is used in treating multiple pain, mental health, and substance abuse disorders due to rapid-acting analgesic and antidepressant effects. Its limited short-term durability has motivated research into the potential synergistic actions between ketamine and psychotherapy to sustain benefits. This systematic review on ketamine-assisted psychotherapy (KAP) summarizes existing evidence regarding present-day practices. Through rigorous review, seventeen articles that included 603 participants were identified. From available KAP publications, it is apparent that combined treatments can, in specific circumstances, initiate and prolong clinically significant reductions in pain, anxiety, and depressive symptoms, while encouraging rapport and treatment engagement, and promoting abstinence in patients addicted to other substances. Despite much variance in how KAP is applied (route of ketamine administration, ketamine dosage/frequency, psychotherapy modality, overall treatment length), these findings suggest psychotherapy, provided before, during, and following ketamine sessions, can maximize and prolong benefits. Additional large-scale randomized control trials are warranted to understand better the mutually influential relationships between psychotherapy and ketamine in optimizing responsiveness and sustaining long-term benefits in patients with chronic pain. Such investigations will assist in developing standardized practices and maintenance programs.
Article
Background: Preoperative depression is a risk factor for poor outcomes after spine surgery. Objective: To understand effects of depression on spine surgery outcomes and healthcare resource utilization. Methods: Using IBM's MarketScan Database, we identified 52 480 patients who underwent spinal fusion. Retained patients were classified into 6 depression phenotype groups based on International Classification of Disease, 9th/10th Revision (ICD-9/10) codes and use/nonuse of antidepressant medications: major depressive disorder (MDD), other depression (OthDep), antidepressants for other psychiatric condition (PsychRx), antidepressants for physical (nonpsychiatric) condition (NoPsychRx), psychiatric condition only (PsychOnly), and no depression (NoDep). We analyzed baseline demographics, comorbidities, healthcare utilization/payments, and chronic opioid use. Results: Breakdown of groups in our cohort: MDD (15%), OthDep (12%), PsychRx (13%), NonPsychRx (15%), PsychOnly (12%), and NoDep (33%). Postsurgery: increased outpatient resource utilization, admissions, and medication refills at 1, 2, and 5 yr in the NoDep, PsychOnly, NonPsychRx, PsychRx, and OthDep groups, and highest in MDD. Postoperative opioid usage rates remained unchanged in MDD (44%) and OthDep (36%), and reduced in PsychRx (40%), NonPsychRx (31%), and PsychOnly (20%), with greatest reduction in NoDep (13%). Reoperation rates: 1 yr after index procedure, MDD, OthDep, PsychRx, NonPsychRx, and PsychOnly had more reoperations compared to NoDep, and same at 2 and 5 yr. In NoDep patients, 45% developed new depressive phenotype postsurgery. Conclusion: EHR-defined classification allowed us to study in depth the effects of depression in spine surgery. This increased understanding of the interplay of mental health will help providers identify cohorts at risk for high complication rates, and health care utilization.
Article
Objective: Major depressive disorder (MDD) and chronic non-cancer pain conditions (CNPC) often co-occur and exacerbate one another. Treatment-resistant depression (TRD) in adults with CNPC can amplify the economic burden. This study examined the impact of TRD on direct total and MDD-related healthcare resource utilization (HRU) and costs among commercially insured patients with CNPC and MDD in the US. Methods: The retrospective longitudinal cohort study employed a claims-based algorithm to identify adults with TRD from a US claims database (January 2007 to June 2017). Costs (2018 US$) and HRU were compared between patients with and without TRD over a 12-month period after TRD/non-TRD index date. Counterfactual recycled predictions from generalized linear models were used to examine associations between TRD and annual HRU and costs. Post-regression linear decomposition identified differences in patient-level factors between TRD and non-TRD groups that contributed to the excess economic burden of TRD. Results: Of the 21,180 adults with CNPC and MDD, 10.1% were identified as having TRD. TRD patients had significantly higher HRU, translating into higher average total costs (US$21,015TRD vs US$14,712No TRD) and MDD-related costs (US$1201TRD vs US$471No TRD) compared with non-TRD patients (all p < 0.001). Prescription drug costs accounted for 37.6% and inpatient services for 30.7% of the excess total healthcare costs among TRD patients. TRD patients had a significantly higher number of inpatient (incidence rate ratio [IRR] 1.30, 95% CI 1.14-1.47) and emergency room visits (IRR 1.21, 95% CI 1.10-1.34) than non-TRD patients. Overall, 46% of the excess total costs were explained by differences in patient-level characteristics such as polypharmacy, number of CNPC, anxiety, sleep, and substance use disorders between the TRD and non-TRD groups. Conclusion: TRD poses a substantial direct economic burden for adults with CNPC and MDD. Excess healthcare costs may potentially be reduced by providing timely interventions for several modifiable risk factors.
Article
Objective: The aim of the study was to show the frequency, localisation, intensity, quality and degree of chronic pain in people with thalidomide-induced congenital defects (thalidomide embryopathy) and to investigate the association with biopsychosocial factors more closely. Methods: A group of 202 people from North Rhine-Westphalia with thalidomide embryopathy were studied for the first time both physically for the pattern of the original damage and also psychiatrically in a structured diagnostic interview (SCID I & SCID II). The results were combined with a standardized pain interview (MPSS) and questionnaires on further pain-related (SF-36, painDETECT) and sociodemographic variables and analysed. In the analysis 167 completed datasets were included. Results: The prevalence of pain in the sample population was 94%. The majority (107, 54.0%) already showed an advanced stage of chronicity in the MPSS: 63 subjects with Stage II (37.7%) and 44 with Stage III (26.3%). In 74 subjects (44.3%) the PainDetect score showed a possible or neuropathic pain component. The factors that most reliably influenced the chronicity of pain proved to be hip pain (p<0.001) and also mental health disorders (p=0.001), above major depression (p<0.001) and also somatic symptom disorders and substance-related disorders (p=0.001 in each case). Social variables proved non-significant here (p=0.094 for living alone, p=0.122 for unemployment, p=0.167 for lack of college education), as did the care situation (p=0.191 for care dependency) and the underlying pattern of organ damage (p=0.229 for damage to hearing, p=0.764 for dysmelia). Conclusions: People with thalidomide defects frequently suffer from a separate pain disorder which can be seen as secondary thalidomide-induced damage and which requires specialized and personalized multimodal pain management.
Article
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.
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Depression is a top mental health concern among college students, yet there is a lack of research exploring how online college science courses can exacerbate or alleviate their depression. We surveyed 2,175 undergraduates at a large research-intensive institution about the severity of their depression in large-enrollment online science courses. The survey also explored aspects of online science courses that exacerbate or alleviate depression and we used regression analyses to assess whether demographics predicted responses. Over 50% of undergraduates reported experiencing depression and LGBTQ+ students, financially unstable students, and lower division students were more likely to experience severe rather than mild depression compared to their counterparts. Students reported difficulty building relationships and struggling to perform well online as aspects of online science courses that exacerbated their depression and the flexible nature of online courses and caring instructors as aspects of online courses that alleviated their depression. This study provides insight into how instructors can create more inclusive online learning environments for students with depression.
Article
Downregulation of astrocytic connexin43 (Cx43) has been observed in several brain regions in rodents and patients with depression. However, its specific role in this effect remains unknown. Moreover, chronic pain can induce depressive disorders. Therefore, the current study examined the relationship between Cx43 expression and depressive-like behavior in a neuropathic pain model. Neuropathic pain was induced by spared nerve injury (SNI) in mice. Depressive-like behavior was evaluated using the forced swim test. Expression of Cx43 in the hippocampus was evaluated using Western blotting and real-time PCR. SNI downregulated Cx43 protein in the contralateral hippocampus of mice, whereas expression of hippocampal Cx43 mRNA was not altered following SNI. Although SNI mice showed longer immobility time compared with sham mice during the forced swim test, duration of depressive-like behavior was not correlated with the expression of Cx43 in the hippocampus of SNI mice. Repeated intraperitoneal administration of amitriptyline ameliorated SNI-induced depressive-like behavior. Furthermore, the antidepressant effect of amitriptyline was correlated with decreased hippocampal Cx43 expression in SNI mice. The current findings suggest that the alteration of Cx43 expression in the hippocampus may not be involved in the induction of depressive disorder but may influence the efficacy of antidepressants. Therefore, the level of Cx43 expression in the hippocampus could be a key parameter to evaluate individual differences in antidepressant effects in patients with depressive disorder.
Article
Background Emotional disorders are common comorbid affectations that exacerbate the severity and persistence of chronic pain. Specifically, depressive symptoms can lead to an excessive duration and intensity of pain. The use of antidepressant drugs is associated with pain reduction. The recent development of animal models has accelerated studies focusing on the underlying mechanisms of chronic pain and depression comorbidity. Aim This review provides an overview of the comorbid relationship of chronic pain and depression, the clinical and pre-clinical studies performed on the neurobiological aspects of pain and depression, and the use of antidepressants as analgesics. Method A systematic search of literature databases was conducted according to the pre-defined criteria. The authors independently conducted a focused analysis of the full-text articles. Results Studies suggest that pain and depression are highly-intertwined and may co-exacerbate physical and psychological symptoms. One important biochemical basis for pain and depression focuses on the serotonergic and norepinephrine system, which have been shown to play an important role in this comorbidity. Brain structures that codify pain are also involved in mood. It is evident that using serotonergic and norepinephrine antidepressants are strategies commonly employed to mitigate pain. Conclusion Literature indicates that pain and depression impact each other and play a prominent role in the development and maintenance of other chronic symptoms. Antidepressants continue to be a major therapeutic tool for managing chronic pain. Tricyclic antidepressants (TCAs) are more effective in reducing pain than selective serotonin reuptake inhibitors (SSRIs) and serotonin-noradrenaline reuptake inhibitors (SNRIs).
Article
Study design: This was a retrospective cross-sectional analysis. Objective: The objective of this study was to estimate the incremental health care costs of depression in patients with spine pathology and offer insight into the drivers behind the increased cost burden. Summary of background data: Low back pain is estimated to cost over $100 billion per year in the United States. Depression has been shown to negatively impact clinical outcomes in patients with low back pain and those undergoing spine surgery. Materials and methods: Data was collected from the Medical Expenditure Panel Survey from 2007 to 2015. Spine patients were identified and stratified based on concurrent depression International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes. Health care utilization and expenditures were analyzed between patients with and without depression using a multivariate 2-part logistic regression with adjustments for sociodemographic characteristics and Charlson Comorbidity Index. Results: A total of 37,094 patients over 18 years old with a spine condition were included (mean expenditure: $7829±241.67). Of these patients, 7986 had depression (mean expenditure: $11,455.41±651.25) and 29,108 did not have depression (mean expenditure: $6837.89±244.51). The cost of care for spine patients with depression was 1.42 times higher (95% confidence interval, 1.34-1.52; P<0.001) than patients without depression. The incremental expenditure of spine patients with depression was $3388.22 (95% confidence interval, 2906.60-3918.96; P<0.001). Comorbid depression was associated with greater inpatient, outpatient, emergency room, home health, and prescription medication utilization and expenditures compared with the nondepressed cohort. Conclusions: Spine patients with depression had significantly increased incremental economic cost of nearly $3500 more annually than those without depression. When extrapolated nationally, this translates to an additional $27.5 billion annually in incremental expenditures that can be attributed directly to depression among spine patients, which equates to roughly 10% of the total estimated spending on depression nationally. Strategies focused on optimizing the treatment of depression have the potential for dramatically reducing health care costs in spine surgery patients.
Article
Objectives: Chronic pain frequently co-exists with other distressing symptoms (depressive mood, sleep disturbance, fatigue, stress) and maladaptive beliefs (fear avoidance, pain catastrophizing) which together are linked with increased pain severity and interference, poor function and quality of life. While a tremendous amount of research has been conducted to identify risk factors and treatment targets for managing pain, too often the strategies are not combined in a way to make them useful for daily multimodal application. The purpose of this narrative review was to examine the existing literature on the co-occurring symptoms and maladaptive beliefs, lifestyle, and socio-environmental factors associated with chronic pain and the current non-pharmacological treatment strategies designed to help patients manage chronic pain. Methods: Literature databases PubMed/Medline, CINAHL and PsychInfo were searched to review the evidence on treatment strategies that have evidence to manage chronic pain and co-occurring symptoms. Conceptual models of chronic pain and non-pharmacological pain management strategies were reviewed. Results: Evidence was found in support of cognitive-behavioral, lifestyle, and socio-environmental factors and treatment strategies that are effective in managing chronic pain as well as co-occurring symptoms. The key factors identified and proposed include lifestyle factors (physical activity, diet, maintaining body weight, keeping routine, sleep habits), planned phases of activities – relaxing, pacing, meditation at regular intervals), CBT strategies (stretching, breathing, meditation, stress-reduction), socio-environmental factors - keeping a calm, peaceful, environment, and positive support system. On the basis of this evidence, a biobehavioral pain hygiene model is proposed that combines existing strategies in managing pain to make them useful for daily multimodal application and which may be used to integrate therapeutic interventions for chronic pain management. Discussion: Given the dearth of research on integrative multimodal pain management, this review and the biobehavioral pain hygiene model could drive future research in the management of chronic pain. Identification of the key strategies and combining them to be a useful multimodal application will be a first step towards identifying innovative methods that could help improve pain and function in patients with chronic pain.
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Several reports indicate either increased or decreased pain sensitivity associated with psychiatric disorders. Chronic pain is highly prevalent in many of these conditions. We reviewed the literature regarding experimental pain sensitivity in patients with major depression, bipolar disorder, posttraumatic stress disorder (PTSD), generalized anxiety disorder, panic disorder, obsessive-compulsive disorder and schizophrenia. Electronic searches were performed to identify studies comparing experimental pain in patients with these conditions and controls. Across 31 depression studies, reduced pain threshold was noted except for ischemic stimuli, where increased pain tolerance and elevated sensitivity to ischemic pain was observed. A more pervasive pattern of low pain sensitivity was found across 20 schizophrenia studies. The majority of PTSD studies (n = 20) showed no significant differences compared with controls. The limited number of bipolar disorder (n = 4) and anxiety (n = 9) studies precluded identification of clear trends. Wide data variability was observed. Awareness of psychiatric patients’ pain perception abnormalities is needed for active screening and addressing physical comorbidities, in order to enhance quality of life, life expectancy and mental health.
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Major depressive disorder (MDD) is the leading cause of disability worldwide. Patients with MDD have high rates of comorbidity with mental and physical conditions, one of which is chronic pain. Chronic pain conditions themselves are also associated with significant disability, and the large number of patients with MDD who have chronic pain drives high levels of disability and compounds healthcare burden. The management of depression in patients who also have chronic pain can be particularly challenging due to underlying mechanisms that are common to both conditions, and because many patients with these conditions are already taking multiple medications. For these reasons, healthcare providers may be reluctant to treat such patients. The Canadian Network for Mood and Anxiety Treatments (CANMAT) guidelines provide evidence-based recommendations for the management of MDD and comorbid psychiatric and medical conditions such as anxiety, substance use disorder, and cardiovascular disease; however, comorbid chronic pain is not addressed. In this article, we provide an overview of the pathophysiological and clinical overlap between depression and chronic pain and review evidence-based pharmacological recommendations in current treatment guidelines for MDD and for chronic pain. Based on clinical experience with MDD patients with comorbid pain, we recommend rapidly and aggressively treating depression according to CANMAT treatment guidelines, using antidepressant medications with analgesic properties, while addressing pain with first-line pharmacotherapy as treatment for depression is optimized. We review options for treating pain symptoms that remain after response to antidepressant treatment is achieved.
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Background: Pain is the most disabling characteristic of musculoskeletal disorders, and while exercise is promoted as an important treatment modality for chronic musculoskeletal conditions, the relative contribution of the specific effects of exercise training, placebo effects and non-specific effects such as natural history are not clear. The aim of this systematic review and meta-analysis was to determine the relative contribution of these factors to better understand the true effect of exercise training for reducing pain in chronic primary musculoskeletal pain conditions. Design: Systematic review with meta-analysis DATA SOURCES: MEDLINE, CINAHL, SPORTDiscus, EMBASE and CENTRAL from inception to February 2021. Reference lists of prior systematic reviews. Eligibility criteria: Randomised controlled trials of interventions that used exercise training compared to placebo, true control or usual care in adults with chronic primary musculoskeletal pain. The review was registered prospectively with PROSPERO (CRD42019141096). Results: We identified 79 eligible trials for quantitative analysis. Pairwise meta-analysis showed very low-quality evidence (GRADE criteria) that exercise training was not more effective than placebo (g [95% CI]: 0.94 [- 0.17, 2.06], P = 0.098, I2 = 92.4%, studies: n = 4). Exercise training was more effective than true, no intervention controls (g [95% CI]: 1.02 [0.67, 1.36], P < 0.001, I2 = 92.99%, studies: n = 42), usual-care controls (g [95% CI]: 0.65 [0.41, 0.89], P < 0.001, I2 = 84.82%, studies: n = 33), and when all controls combined (g [95% CI]: 0.86 [0.64, 1.07], P < 0.001, I2 = 91.37%, studies: n = 79). Conclusions: There is very low-quality evidence that exercise training is not more effective than non-exercise placebo treatments in chronic pain. Exercise training and the associated clinical encounter are more effective than true control or standard medical care for reductions in pain for adults with chronic musculoskeletal pain, with very low quality of evidence based on GRADE criteria.
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Objectives: To determine the association of somatic symptoms with Depressive disorder. Study Design: Descriptive cross sectional study. Study Setting and Duration: At department of medicine and allied OPD at Pir Syed Abdul Qadir Shah Jeelani Institute of Medical sciences, GAMBAT, Sindh, Pakistan, from 10th August 2019 to 31st January 2020. Methodology: The sample size of the study was 140. All the patients of both gender between ages of 18 to 60 years, having depressive disorder as per ICD-10 (International classification of diseases version-10) criteria as mild, moderate and severe were enrolled. Somatic symptoms were assessed through somatic symptoms scale-8. The collected data was analyzed by Statistical Packages for Social Sciences (SPSS) version 22.0. Results: Among 140 clients 131 (93.60%) were females with age range of 22 to 44 years. Among all majority were married, illiterate and were household by occupation. Amongst all mostly were having severe depressive disorder 62.9% followed by 34.3% moderate depression and 2.9% mild depression. The somatic symptoms as per somatic symptoms scale-8 were assessed in relation to depressive disorder and it was found that all the somatic symptoms were strongly associated with depressive disorder having p value less than 0.05. Conclusion: From this study it is to be concluded that somatic symptoms are strongly associated with depression, consequently putting an adverse impact on over all outcome of disorder. Keywords: Association, Depression, Somatic
Chapter
Anxiety is a common condition for which people have been found to self-medicate with cannabis. Anxiety is often comorbid with other conditions, including depression, sleep disorders and chronic pain. The pathomechanisms underpinning anxiety are complex. Animal and human research indicates that the endocannabinoid system is involved in our stress response and in anxiety. Evidence from preclinical studies has elucidated some of the potential mechanisms by which cannabidiol (CBD) is anxiolytic. Clinical research also supports the notion that CBD is anxiolytic, though the majority of studies have been studies of acute use rather than chronic use. There is evidence that tetrahydrocannabinol (THC) may have a bimodal effect, being anxiolytic in lower doses and anxiogenic in higher doses. The majority of studies of CBD and THC, in particular in animal studies, have utilised purified CBD or THC. Whole plant medicines that contain multiple phytocannabinoids, terpenes, polyphenols, flavonoids and other plant nutrients appear to act more potently, with different pharmacophysiologic relationships and reduced adverse effect profiles than purified isolates.
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Objective Lack of clarity regarding effective communication behaviors in chronic pain management is a barrier for implementing psychologically informed physical therapy approaches that rely on competent communication by physical therapist providers. This study aimed to conduct a systematic review and meta-synthesis to inform the development of a conceptual framework for preferred communication behaviors in pain rehabilitation. Methods Ten databases in the health and communication sciences were systematically searched for qualitative and mixed-method studies of interpersonal communication between physical therapists and adults with chronic pain. Two independent investigators extracted quotations with implicit and explicit references to communication and study characteristics following Standards for Reporting Qualitative Research and STROBE guidelines. Methodological quality for individual studies was assessed with CASP, and quality of evidence was evaluated with GRADE-CERQual. An inductive thematic synthesis was conducted by coding each quotation, developing descriptive themes, and then generating behaviorally distinct analytical themes. Results Eleven studies involving 346 participants were included. The specificity of operationalizing communication terms varied widely. Meta-synthesis identified 8 communication themes: (1) disclosure-facilitating, (2) rapport-building, (3) empathic, (4) collaborative, (5) professional accountability, (6) informative, (7) agenda-setting, and (8) meta-communication. Based on the quality of available evidence, confidence was moderate for 4 themes and low for 4 themes. Conclusion This study revealed limited operationalization of communication behaviors preferred by physical therapists in chronic pain rehabilitation. A conceptual framework based on 8 communication themes identified from the literature is proposed as a preliminary paradigm to guide future research.
Thesis
Mood disorders are frequently comorbid with chronic pain and the anterior cingulate cortex (ACC) appears to be an important region in this relationship. We aimed to investigate the molecular basis of this comorbidity, at both the whole structure and the cell type specific level. A genomic analysis of the ACC in a mouse model displaying chronic pain-induced anxiodepressive consequences evidenced an overexpression of the Mitogen Activated Protein Kinase (MAPK) Phosphatase 1 (MKP-1). An upregulated ACC MKP-1 was also observed in other models of depression, while decreasing its expression attenuates depressive-like behaviors, showing that MKP-1 is a key factor in the pathophysiology of depression. This was further validated by showing that acute ketamine administration normalizes the disrupted MAPK pathway, alongside producing a transient analgesic and a prolonged antidepressant effect. Finally, to address the role of different cell populations in this comorbidity, we have isolated GABAergic neurons from animals showing depressive- like behaviors, which will be used for genomic analysis in order to reveal important cell-type specific candidate genes.
Article
Introduction In many countries, there are waits for elective (planned) surgery. In these settings, processes for triaging patients are applied to determine how long patients wait for their surgery. There are very few instances that evaluate the effectiveness of surgical triage processes. Methods A sample of patients from four acute care hospitals in Vancouver, Canada, completed a number of patient-reported outcomes shortly after being registered on the surgical wait list. Patients’ diagnosis was used to triage and determine their expected wait for surgery. The associations between patient-reported outcomes with surgical triage were measured. Results The mean wait times for participants were similar across wait times categories. Participants whose expected waits for surgery were the longest reported successively lower levels of self-rated health (p < 0.01) and successively higher levels of pain (p < 0.01.) There was no difference in symptoms of anxiety among participants expected to wait the longest. Discussion The diagnosis-based system for prioritizing patients found higher levels of pain and lower health status among those expected to wait the longest for their surgery. Screening waiting patients for treatable mental health conditions should be implemented and the process of surgical triage could be redesigned to allow for a broader set of attributes of health to determine how long a patient waits for their elective surgery.
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Background: Delayed retirement initiative is taken as one of the proposed solutions to population aging. Rare research attention has been paid to determinants in decisions-making of late retirement. Method: This study applies data from CHARLS survey (2018) that traces the health status among older adults in China, and implements the stepwise multiple regression analysis adjusted with robust standard errors on individual level. Results: The difficulty in instrumental activities of daily living (IADLs) and chronic conditions could increase the intention of retirement-aged workers to withdraw from late career participation; and the overlay of both would interact to reinforce such intention. Besides, the employment-related social pension participation could further strengthen the jointly contributing effect of both on withdrawal from late career participation. Conclusion: The triple interaction mechanism in retirement-aged workers' decisions of late retirement needs considering in the policy formulation of delayed retirement initiative.
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Depression symptoms are often found in patients suffering from chronic pain, a phenomenon that is yet to be understood mechanistically. Here, we systematically investigate the cellular mechanisms and circuits underlying the chronic-pain-induced depression behavior. We show that the development of chronic pain is accompanied by depressive-like behaviors in a mouse model of trigeminal neuralgia. In parallel, we observe increased activity of the dopaminergic (DA) neuron in the midbrain ventral tegmental area (VTA), and inhibition of this elevated VTA DA neuron activity reverses the behavioral manifestations of depression. Further studies establish a pathway of glutamatergic projections from the spinal trigeminal subnucleus caudalis (Sp5C) to the lateral parabrachial nucleus (LPBN) and then to the VTA. These glutamatergic projections form a direct circuit that controls the development of the depression-like behavior under the state of the chronic neuropathic pain.
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Context The Primary Care Evaluation of Mental Disorders (PRIME-MD) was developed as a screening instrument but its administration time has limited its clinical usefulness.Objective To determine if the self-administered PRIME-MD Patient Health Questionnaire (PHQ) has validity and utility for diagnosing mental disorders in primary care comparable to the original clinician-administered PRIME-MD.Design Criterion standard study undertaken between May 1997 and November 1998.Setting Eight primary care clinics in the United States.Participants Of a total of 3000 adult patients (selected by site-specific methods to avoid sampling bias) assessed by 62 primary care physicians (21 general internal medicine, 41 family practice), 585 patients had an interview with a mental health professional within 48 hours of completing the PHQ.Main Outcome Measures Patient Health Questionnaire diagnoses compared with independent diagnoses made by mental health professionals; functional status measures; disability days; health care use; and treatment/referral decisions.Results A total of 825 (28%) of the 3000 individuals and 170 (29%) of the 585 had a PHQ diagnosis. There was good agreement between PHQ diagnoses and those of independent mental health professionals (for the diagnosis of any 1 or more PHQ disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%), similar to the original PRIME-MD. Patients with PHQ diagnoses had more functional impairment, disability days, and health care use than did patients without PHQ diagnoses (for all group main effects, P<.001). The average time required of the physician to review the PHQ was far less than to administer the original PRIME-MD (<3 minutes for 85% vs 16% of the cases). Although 80% of the physicians reported that routine use of the PHQ would be useful, new management actions were initiated or planned for only 117 (32%) of the 363 patients with 1 or more PHQ diagnoses not previously recognized.Conclusion Our study suggests that the PHQ has diagnostic validity comparable to the original clinician-administered PRIME-MD, and is more efficient to use. Figures in this Article Mental disorders in primary care are common, disabling, costly, and treatable.1- 5 However, they are frequently unrecognized and therefore not treated.2- 6 Although there have been many screening instruments developed,7- 8 PRIME-MD (Primary Care Evaluation of Mental Disorders)5 was the first instrument designed for use in primary care that actually diagnoses specific disorders using diagnostic criteria from the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition9(DSM-III-R) and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition10(DSM-IV). PRIME-MD is a 2-stage system in which the patient first completes a 26-item self-administered questionnaire that screens for 5 of the most common groups of disorders in primary care: depressive, anxiety, alcohol, somatoform, and eating disorders. In the original study,5 the average amount of time spent by the physician to administer the clinician evaluation guide to patients who scored positively on the patient questionnaire was 8.4 minutes. However, this is still a considerable amount of time in the primary care setting, where most visits are 15 minutes or less.11 Therefore, although PRIME-MD has been widely used in clinical research,12- 28 its use in clinical settings has apparently been limited. This article describes the development, validation, and utility of a fully self-administered version of the original PRIME-MD, called the PRIME-MD Patient Health Questionnaire (henceforth referred to as the PHQ). DESCRIPTION OF PRIME-MD PHQ ABSTRACT | DESCRIPTION OF PRIME-MD PHQ | STUDY PURPOSE | METHODS | RESULTS | COMMENT | REFERENCES The 2 components of the original PRIME-MD, the patient questionnaire and the clinician evaluation guide, were combined into a single, 3-page questionnaire that can be entirely self-administered by the patient (it can also be read to the patient, if necessary). The clinician scans the completed questionnaire, verifies positive responses, and applies diagnostic algorithms that are abbreviated at the bottom of each page. In this study, the data from the questionnaire were entered into a computer program that applied the diagnostic algorithms (written in SPSS 8.0 for Windows [SPSS Inc, Chicago, Ill]). The computer program does not include the diagnosis of somatoform disorder, because this diagnosis requires a clinical judgment regarding the adequacy of a biological explanation for physical symptoms that the patient has noted. A fourth page has been added to the PHQ that includes questions about menstruation, pregnancy and childbirth, and recent psychosocial stressors. This report covers only data from the diagnostic portion (first 3 pages) of the PHQ. Users of the PHQ have the choice of using the entire 4-page instrument, just the 3-page diagnostic portion, a 2-page version (Brief PHQ) that covers mood and panic disorders and the nondiagnostic information described above, or only the first page of the 2-page version (covering only mood and panic disorders) (Figure 1). Figure 1. First Page of Primary Care Evaluation of Mental Disorders Brief Patient Health QuestionnaireGrahic Jump Location+View Large | Save Figure | Download Slide (.ppt) | View in Article ContextCopyright held by Pfizer Inc, but may be photocopied ad libitum. For office coding, see the end of the article. The original PRIME-MD assessed 18 current mental disorders. By grouping several specific mood, anxiety, and somatoform categories into larger rubrics, the PHQ greatly simplifies the differential diagnosis by assessing only 8 disorders. Like the original PRIME-MD, these disorders are divided into threshold disorders (corresponding to specific DSM-IV diagnoses, such as major depressive disorder, panic disorder, other anxiety disorder, and bulimia nervosa) and subthreshold disorders (in which the criteria for disorders encompass fewer symptoms than are required for any specific DSM-IV diagnoses: other depressive disorder, probable alcohol abuse or dependence, and somatoform and binge eating disorders). One important modification was made in the response categories for depressive and somatoform symptoms that, in the original PRIME-MD, were dichotomous (yes/no). In the PHQ, response categories are expanded. Patients indicate for each of the 9 depressive symptoms whether, during the previous 2 weeks, the symptom has bothered them "not at all," "several days," "more than half the days," or "nearly every day." This change allows the PHQ to be not only a diagnostic instrument but also to yield a measure of depression severity that can be of aid in initial treatment decisions as well as in monitoring outcomes over time. Patients indicate for each of the 13 physical symptoms whether, during the previous month, they have been "not bothered," "bothered a little," or "bothered a lot" by the symptom. Because physical symptoms are so common in primary care, the original PRIME-MD dichotomous-response categories often led patients to endorse physical symptoms that were not clinically significant. An item was added to the end of the diagnostic portion of the PHQ asking the patient if he or she had checked off any problems on the questionnaire: "How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?" As with the original PRIME-MD, before making a final diagnosis, the clinician is expected to rule out physical causes of depression, anxiety and physical symptoms, and, in the case of depression, normal bereavement and history of a manic episode. STUDY PURPOSE ABSTRACT | DESCRIPTION OF PRIME-MD PHQ | STUDY PURPOSE | METHODS | RESULTS | COMMENT | REFERENCES Our major purpose was to test the validity and utility of the PHQ in a multisite sample of family practice and general internal medicine patients by answering the following questions: Are diagnoses made by the PHQ as accurate as diagnoses made by the original PRIME-MD, using independent diagnoses made by mental health professionals (MHPs) as the criterion standard?Are the frequencies of mental disorders found by the PHQ comparable to those obtained in other primary care studies?Is the construct validity of the PHQ comparable to the original PRIME-MD in terms of functional impairment and health care use?Is the PHQ as effective as the original PRIME-MD in increasing the recognition of mental disorders in primary care patients?How valuable do primary care physicians find the diagnostic information in the PHQ?How comfortable are patients in answering the questions on the PHQ, and how often do they believe that their answers will be helpful to their physicians in understanding and treating their problems?
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Depression has been observed to accompany chronic pain. Yet, controversy remains regarding the extent and nature of the relationship between these 2 disorders. The authors analyze the literature regarding depression rates in chronic pain and other chronic medical populations and argue that depression appears to be highest among chronic pain patients. Drawing from cognitive-behavioral models of depression, the authors explore the unique psychological experiences of living with chronic pain that may account for the high prevalence of depression. A diathesis-stress framework is proposed to conceptualize the development of depression in chronic pain. Clinical and heuristic implications are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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This research develops and evaluates a simple method of grading the severity of chronic pain for use in general population surveys and studies of primary care pain patients. Measures of pain intensity, disability, persistence and recency of onset were tested for their ability to grade chronic pain severity in a longitudinal study of primary care back pain (n = 1213), headache (n = 779) and temporomandibular disorder pain (n = 397) patients. A Guttman scale analysis showed that pain intensity and disability measures formed a reliable hierarchical scale. Pain intensity measures appeared to scale the lower range of global severity while disability measures appeared to scale the upper range of global severity. Recency of onset and days in pain in the prior 6 months did not scale with pain intensity or disability. Using simple scoring rules, pain severity was graded into 4 hierarchical classes: Grade I, low disability--low intensity; Grade II, low disability--high intensity; Grade III, high disability--moderately limiting; and Grade IV, high disability--severely limiting. For each pain site, Chronic Pain Grade measured at baseline showed a highly statistically significant and monotonically increasing relationship with unemployment rate, pain-related functional limitations, depression, fair to poor self-rated health, frequent use of opioid analgesics, and frequent pain-related doctor visits both at baseline and at 1-year follow-up. Days in Pain was related to these variables, but not as strongly as Chronic Pain Grade. Recent onset cases (first onset within the prior 3 months) did not show differences in psychological and behavioral dysfunction when compared to persons with less recent onset. Using longitudinal data from a population-based study (n = 803), Chronic Pain Grade at baseline predicted the presence of pain in the prior 2 weeks. Chronic Pain Grade and pain-related functional limitations at 3-year follow-up. Grading chronic pain as a function of pain intensity and pain-related disability may be useful when a brief ordinal measure of global pain severity is required. Pain persistence, measured by days in pain in a fixed time period, provides useful additional information.
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The history, rationale, and development of the Structured Clinical Interview for DSM-III-R (SCID) is described. The SCID is a semistructured interview for making the major Axis I DSM-III-R diagnoses. It is administered by a clinician and includes an introductory overview followed by nine modules, seven of which represent the major axis I diagnostic classes. Because of its modular construction, it can be adapted for use in studies in which particular diagnoses are not of interest. Using a decision tree approach, the SCID guides the clinician in testing diagnostic hypotheses as the interview is conducted. The output of the SCID is a record of the presence or absence of each of the disorders being considered, for current episode (past month) and for lifetime occurrence.
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The National Comorbidity Survey is a nationally representative survey of the prevalences and correlates of DSM-III-R disorders in the US household population. Retrospective age-at-onset reports were used to study predictive relationships between lifetime panic and depression. Strong associations were found between the lifetime prevalences of panic and major depressive episodes (odds ratios: for panic attacks with depression, 6.2; for panic disorder with depression, 6.8). These associations were not significantly influenced by the inclusion or exclusion of respondents with mania. Temporally primary depression predicted a first onset of subsequent panic attacks but not of panic disorder. Temporally primary panic attacks, with or without panic disorder and whether or not the panic was persistent, predicted a first onset of subsequent major depression. The associations between panic attack and depression were attenuated in models that controlled for prior traumatic life experiences and histories of other DSM-III-R disorders. Lifetime panic-depression comorbidity characterizes most community respondents with panic disorder and a substantial few of those with major depression. The absence of a dose-response relationship suggests that primary panic attack is a marker, rather than a causal risk factor, of subsequent depression. Primary depression, in comparison, appears to be a genuine risk factor for secondary panic attacks. That primary depression predicts panic attacks but not panic disorder suggests that secondary panic is a severity marker of depression rather than a comorbid condition. These results are far from definitive because they are based on retrospective reports, lay-administered diagnostic interviews, and only 1 survey. However, they raise important questions that could lead to a fundamental rethinking of panic-depression comorbidity if they are replicated in future epidemiological and clinical studies.
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The nine-item Patient Health Questionnaire depression scale is a dual-purpose instrument that can establish provisional depressive disorder diagnoses as well as grade depression severity.
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Ed T B Ustun, N Sartorius Wiley for WHO, £50, pp 398 ISBN 0 471 95491 8 How do mental disorders in primary care vary in terms of frequency, nature, and treatment across the world? Mental Illness in General Health Care describes a prospective study, sponsored by the World Health Organisation, of cultural differences in mental disorders in primary care involving 15 centres in five continents. The topic should interest general practitioners, psychiatrists, and public health doctors. The book itself is clearly written and easy to follow. After …
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After a 4-wk baseline period during which daily ratings of headache activity were made and all participants took several psychological tests, 91 18–68 yr old patients with chronic headache (tension, migraine, and combined tension and migraine) were given a 10-session relaxation-training regimen. Ss who did not show substantial reductions in headache activity from the relaxation therapy were given a 12-session regimen of biofeedback (thermal biofeedback for vascular headaches and frontal EMG biofeedback for tension headaches). Relaxation therapy alone led to significant improvement for all groups, with a trend for the tension headache group to respond the most favorably. Biofeedback therapy led to further significant reduction in headache activity for all who received it, with a trend for combined migraine and tension headache patients to respond the most favorably. Multiple regression analyses revealed that approximately 32% of the variance in end-of-treatment headache diary scores could be predicted after relaxation and that 44% of the variance after biofeedback could be predicted using standard psychological tests. (34 ref) (PsycINFO Database Record (c) 2012 APA, all rights reserved)
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I define three separate and distinct types of non-random comorbidity: epidemiologic, clinical and familial. These might exist singly or in any combination for a pair of disorders. The focus is on their definition and the measurement and interpretation of the types of comorbidity of most common concern: epidemiologic comorbidity. I discuss certain sources of epidemiologic comorbidity such as shared risk factors, or diagnostic ‘fuzziness’, and I indicate the directions of research design and analyses to disclose such sources.
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Objective: This study was undertaken to determine the prevalence of mental disorders among obstetric-gynecologic patients and to assess the validity and utility of the PRIME-MD Patient Health Questionnaire (PHQ) in this population. Study design: A total of 3000 patients were assessed by 63 clinicians at seven obstetrics-gynecology outpatient care sites. The main outcome measures were PRIME-MD PHQ diagnoses, psychosocial stressors, independent diagnoses made by mental health professionals, functional status measures, disability days, health care use, and treatment or referral decisions. Results: Current mental disorders were fairly prevalent, present in 1 in 5 obstetric-gynecologic patients. Patients with PRIME-MD PHQ diagnoses had more functional impairment, disability days, health care use, and psychosocial stressors than did patients without PRIME-MD PHQ diagnoses (P <.005 for all measures). Although most clinicians judged the PRIME-MD PHQ to be useful in management decisions, the questionnaire diagnosis of mental disorder rarely led to therapeutic intervention. Conclusion: The PRIME-MD PHQ is a useful instrument for the assessment of mental disorders, functional impairment, and recent psychosocial stressors in the busy obstetrics-gynecology setting.
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Major depressive disorder has been recently found to be associated with high medical utilization and more functional impairment than most chronic medical illnesses. Major depression is a common illness among persons in the community, in ambulatory medical clinics, and in inpatient medical care. Studies have estimated that major depression occurs in 2%-4% of persons in the community, in 5%-10% of primary care patients, and 10%-14% of medical inpatients. In each setting there are two to three times as many persons with depressive symptoms that fall short of major depression criteria. Recent studies have found that in one-third to one-half of patients with major depression, the symptoms persist over a 6-month to one-year period. The majority of longitudinal studies have determined that severity of initial depressive symptoms and the presence of a comorbid medical illness were predictors of persistence of depression.
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Chronic pain is a problem of great public health importance that is frequently seen in the primary care setting. Pain chronicity shows a strong association with psychosocial factors. Assessment of these factors should be composed of two parts: (1) psychological factors and (2) psychiatric illness. Psychological factors include all those pain-associated alterations in the patient's environment that reinforce illness behavior. Psychiatric illness includes those syndromes that retard recovery from illness or injury, such as depression, anxiety, substance abuse, and dementia. Psychiatric and psychological interventions can be successfully introduced in the context of a comprehensive rehabilitation effort. Usually these interventions can be accomplished by the family physician in concert with a consultant psychiatrist or psychologist. In severely disabled or resistant patients, referral to a multidisciplinary pain clinic will be necessary.
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A prospective survey of patients seeking primary care for low back pain. Clinical and psychosocial data, available at presentation, were explored for predictors of outcome at 1 year. To determine the relative value of clinical and psychosocial variables for early identification of patients with a poor prognosis. Current treatment strategies for low back pain have failed to stem the rising levels of disability. Psychosocial factors have been shown to be important determinants of response to therapy in chronic patients, but the contribution from similar data in acute or subchronic patients has not been comprehensively investigated. Two hundred fifty-two patients with low back pain, presenting to primary care, underwent a structured clinical interview and completed a battery of psychosocial instruments. Follow-up was done by mail at 1 year; outcome was measured using a back pain disability questionnaire. Predictive relationships were sought between the data at presentation and disability at follow-up. Most patients showed improved disability and pain scores, although more than half had persisting symptoms. Eighteen percent showed significant psychological distress at presentation. Multiple regression analysis showed the level of persisting disability to depend principally on measures in the psychosocial domain; for acute cases outcome is also dependent on the absence or presence of a previous history of low back trouble. Discriminant models successfully allocated typically 76% of cases to recovered/not-recovered groups, largely on the basis of psychosocial factors evident at presentation. Early identification of psychosocial problems is important in understanding, and hopefully preventing, the progression to chronicity in low back trouble.
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The authors examined the effect of patients' style of clinical presentation on primary care physicians' recognition of depression and anxiety. The subjects were 685 patients attending family medicine clinics on self-initiated visits. They completed structured interviews assessing presenting complaints, self-report measures of symptoms and hypochondriacal worry, the Diagnostic Interview Schedule (DIS), and the Center for Epidemiologic Studies Depression Scale (CES-D). Physician recognition was determined by notation of any psychiatric condition in the medical chart over the ensuing 12 months. The authors identified three progressively more persistent forms of somatic presentations, labeled "initial," "facultative," and "true" somatization. Of 215 patients with CES-D scores of 16 or higher, 80% made somatized presentations; of 75 patients with DIS-diagnosed major depression or anxiety disorder, 76% made somatic presentations. Among patients with DIS major depression or anxiety disorder, somatization reduced physician recognition from 77%, for psychosocial presenters, to 22%, for true somatizers. The same pattern was found for patients with high CES-D scores. In logistic regression models education, seriousness of concurrent medical illness, hypochondriacal worry, and number of lifetime medically unexplained symptoms each increased the likelihood of recognition, while somatized presentations decreased the rate of recognition. While physician recognition of psychiatric distress in primary care varied widely with different criteria for recognition, the same pattern of reduction of recognition with increasing level of somatization was found for all criteria. In contrast, hypochondriacal worry and medically unexplained somatic symptoms increased the rate of recognition.
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Empirical results from epidemiological studies on pain-depression comorbidity in primary care and population samples have shown that: (a) pain is as strongly associated with anxiety as with depressive disorders; (b) characteristics that most strongly predict depression are diffuseness of pain and the extent to which pain interferes with activities; (c) certain psychological symptoms (low energy, disturbed sleep, worry) are prominent among pain patients, while others (guilt, loneliness) are not; (d) depression and pain dysfunction are evident early in the natural history of pain, but dysfunction and distress are often transient; and (e) among initially dysfunctional pain patients whose dysfunction is chronic, depression levels do not improve but neither do they increase over time with chronicity alone. These results seem consistent with these mechanisms of pain-depression comorbidity; (1) a trait of susceptibility to both dysphoric physical symptoms (including pain) and psychological symptoms (including depression), and a state of somatosensory amplification in which psychological distress amplifies dysphoric physical sensations (including pain); (2) psychological illness and behavioural dysfunction being interrelated features of a maladaptive response to pain evident early in the natural history of the condition, and often resolving during an early recovery phase; (3) pain constituting a significant physical and psychological stressor that may induce or exacerbate psychological distress. Thus, pain and psychological illness should be viewed as having reciprocal psychological and behavioural effects involving both processes of illness expression and adaption, as well as pain having specific effects on emotional state and behavioural function.
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General population data are presented on the prevalence and correlates of comorbidity between DSM-III-R major depressive disorder (MDD) and other DSM-III-R disorders. The data come from the US National Comorbidity Survey, a large general population survey of persons aged 15-54 years in the non-institutionalised civilian population. Diagnoses are based on a modified version of the Composite International Diagnostic Interview (CIDI). The analysis shows that most cases of lifetime MDD are secondary. In the sense that they occur in people with a prior history of another DSM-III-R disorder. Anxiety disorders are the most common primary disorders. The time-lagged effects of most primary disorders on the risk of subsequent MDD continue for many years without change in magnitude. Secondary MDD is, in general, more persistent and severe than pure or primary MDD. This has special public health significance because lifetime prevalence of secondary MDD has increased in recent cohorts, while the prevalence of pure and primary depression has remained unchanged.
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To determine the current status for the association of chronic pain and depression and to review the evidence for whether depression is an antecedent or consequence of chronic pain (CP). A computer and manual literature review yielded 191 studies that related to the pain-depression association. These reports were reviewed and sorted into seven categories relating to the topic of this paper. Eighty-three studies were then selected according to inclusion criteria and subjected to a structured review. Any medical treatment setting including pain treatment as inclusion criteria for selection of studies. Any patients with any type of chronic pain. The reviewed studies were consistent in indicating that there is a statistical relationship between chronic pain and depression. For the relationship between pain and depression, there was greater support for the consequence and scar hypotheses than the antecedent hypothesis. Depression is more common in chronic pain patients (CPPs) than in healthy controls as a consequence of the presence of CP. At pain onset, predisposition to depression (the scar hypothesis) may increase the likelihood for the development of depression in some CPPS. Because of difficulties in measuring depression in the presence of CP, the reviewed studies should be interpreted with caution.
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This paper presents the results of a detailed study of the pain epidemiology and health related quality of life (HRQL) in 150 chronic non-malignant pain patients consecutively referred to a Danish multidisciplinary pain center. Mean pain severity was 71.6 (SD = 18.5) on the VAS scale. Forty-two percent reported poor quality of sleep. HRQL was evaluated with the Medical Outcome Study-Short Form (SF-36), the Hospital Anxiety and Depression scale (HAD) and the Psychological General Well-Being Scale (PGWB). Compared with the normal population (NP) both SF-36 scores and PGWB scores were significantly reduced (P < 0.001) indicating that physical, psychological and social well-being were severely reduced. On the HAD scale 58% were found to have a depressive or anxiety disorder. Statistically significant but modest correlations were found between pain severity and HRQL. Psychological and social well-being was closely correlated. Sixty-three percent of the referred patients had neurogenic pain conditions. Of these, only 25% were treated with antidepressants or anticonvulsants at referral. Seventy-three percent were treated with opioids at referral. Mean opioid consumption was 64 mg of morphine per day (range 1-280 mg). Compared with the NP the chronic pain patients had used the health care system five times more often in the years prior to referral (P < 0.001). The study confirms the severe multidimensional impact of chronic pain and demonstrates that HRQL of chronic non-malignant pain patients is among the lowest observed for any medical condition.
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Current DSM-IV somatoform diagnoses may inadequately capture many somatizing patients in primary care. By using data from two studies (1,000 and 258 patients, respectively), the authors determined 1) the optimal threshold on a checklist of 15 physical symptoms to screen for a recently proposed somatoform diagnosis, multisomatoform disorder (MSD), and 2) the concordance between MSD and somatization disorder. The optimal threshold for pursuing a diagnosis of MSD was seven or more physical symptoms. The majority (88%) of the patients who met criteria for MSD had either full or abridged somatization disorder. MSD was intermediate between abridged and full somatization disorder in terms of its association with functional impairment, psychiatric comorbidity, family dysfunction, and health care utilization and charges.
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This paper presents the results of a detailed study of the pain epidemiology and health related quality of life (HRQL) in 150 chronic non-malignant pain patients referred to a Danish multidisciplinary pain centre. Mean pain intensity was 71.6 (SD 18.5) on the VAS scale. HRQL was evaluated using the questionnaires: SF-36, HAD and PGWB. Compared with the normal population (NP) both physical, psychological and social well-being was severely reduced, and 58% were found to have a depressive or anxiety disorder. Sixty-three percent of the patients had neurogenic pain conditions. Of these, only 25% were treated with antidepressants or anticonvulsants. At referral 73% were treated with opioids. Mean opioid consumption was 64 mg of morphine per day. Patients had used the health care system five times more often than the NP (p < 0.001). The study showed that HRQL of chronic non-malignant pain patients is among the lowest observed for any medical condition.