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The Impact of Co-existing Chronic Pain and Mental Health QUERI Conditions:
QUERI Implementation Seminar Series
Matthew J. Bair, MD, MS
Research Scientist, Roudebush VA Center of Excellence on Implementing Evidence Based Practice and Regenstrief Institute, Inc
Assistant Professor of Medicine, IU School of Medicine, Indianapolis
June 28, 2007
OUTLINEThe “Pain Problem” The “Depression Problem” Pain and Depression Dyad SCAMP Study
Baseline Analyses
Questions and Answers
Objectives
To discuss the impact of co-existing chronic pain and depression/anxiety
To introduce a model to assess and treat both chronic pain and depression (anxiety) concurrently
Brief Visits
ComplicatedPatients
Clinical Reminders
Minimal Resources
JCAHO & VHAMandate toManage pain
PoliciesGuidelinesExpectations
Managing PAIN in Primary Care: Issues and Challenges
PAIN CRISES
Pain accounts for 20% of all clinic visits
Analgesics = 12% of all prescriptions (# 2)
$100 billion dollars/yr in health care costs
Excessive surgery (e.g., back pain)
Leading cause of work loss & disability
Leading reason for alternative medicine
Consequences of Under-treatment of Chronic Pain
Physiologic (CV, GI, immune)Psychological (depression, anxiety)Diminished quality of LifeImpairment of activitiesLarge impact on working age adults
Absenteeism, unemployment, and under-employment
VETERAN STORIES “Doc, I hurt all day- 24/7” “Nothing works for my pain” “I can’t do anything because of my pain so I
stay in bed all day” “I can’t deal with this (pain)…it’s depressing” “On a scale of 0 to 10 my pain is a 20! If I
don’t get some relief fast I will blow my head off!”
Prevalence of chronic non-cancer pain in Primary Care
44% (VA); 25 %(university, PCC)
(Reid et al,2002 )
48% VA Primary Care - Palo Alto VA
(Clark, JD, 2002)
• 71 % VA Primary Care – Western New York (Crosby et al 2006)
Pain: 5th Vital Sign in Primary Care and Association with Depression
301 primary care Veteran patientsMean age = 60; 91% men; 85% whiteDepression in 28% (PHQ-9 ≥ 10)Pain in 76%
Mild 21% (score of 1-3) Moderate 31% (score of 4-6) Severe 22% (score of 7-10)
Bair MJ, Williams LS, Kroenke K. J Gen Intern Med 2004;19 (Supplement 1):123.
Pain Severity as Correlate of Depression
Pain Severity Odds Ratio (95% CI) for Depression
MildMild 2.2 (1.1 - 4.4) 2.2 (1.1 - 4.4)
ModerateModerate 5.2 (2.2-12.5)5.2 (2.2-12.5)
SevereSevere 12.0 (4.1-34.4)12.0 (4.1-34.4)
Bair MJ, Williams LS, Kroenke K. J Gen Intern Med 2004;19 (Supplement 1):123.
Global Burden of Disease
1. Ischemic heart disease
2. Major Depression
3. Traffic accidents
4. Cerebrovascular disease
5. COPD
Year 2020
Murray and Lopez, 1996
Depressed Patients Usually Present with Physical Symptoms
69%PresentedONLY With Physical
Symptoms
Other
N = 1146 patients with major depression
1. Simon GE, et al. N. Engl J Med. 1999;341(18):1329-1335.
Unrecognized and Untreated Depression
Interferes with treatment and rehabMay increase pain intensity and
disabilityDecrease pain threshold and toleranceMagnification of medical symptomsLess successful treatment outcomes
Depression and Negative Pain Outcomes
Depression is associated with↑ pain complaints and intensity↑ disability↑ functional limitations↑ utilization (office visits, hospitalizations)↑ costs↑ risk of nonrecovery
Bair MJ, et al. Arch Intern Med. 2003;163(20):2433-2445.
Pain and Negative Depression Outcomes
PAIN ASSOCIATED WITH: depressive symptoms functional limitations unemployment rate frequent use of opioid analgesics frequent pain-related doctor visits worse self-rated health
Von Korff M. Grading the severity of chronic pain. Pain 1992; 50:133-149
Bair MJ, et al. Psychosom Med. 2004;66(1):17-22.
0
1
2
3
4
5
Mild Moderate Severe
Severity of Pain is Associated with Poor Depression Outcome
N=573
Odd
s R
atio
for
Poo
r D
epre
ssio
n R
espo
nse*
* R
elat
ive
to P
atie
nts
With
out P
ain
*
*P<.05 vs patients with no baseline pain
1.5
4.1
ARTIST=A Randomized Trial Investigating SSRI Treatment.**Poor depression treatment response defined as Symptom Checklist-20 >1.3. Pain severity was measured by the SF-36 pain severity item
Baseline Pain Severity
2.0
*
(n=144) (n=170) (n=81)
No effect relative to patients without pain at baseline
What Symptoms are the Most Resistant?
Adapted from: Greco T, et al. J Gen Intern Med. 2004;19(8):813-818.
Impr
ovem
ent
Tre
atm
ent E
ffect
Siz
e
Em
otio
nal
Ph
ysical
ARTIST=A Randomized Trial Investigating SSRI Treatment.
Nonsomatic depressive Sx
Positive well-being
Non-pain somatic Sx
Pain somatic Sx
0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
Baseline 1 Month 3 Months 6 Months 9 Months
N=573
Residual Symptoms Predict Relapse
*Based on Item 13 (general somatic symptoms) of the HAM-D17.
Paykel ES, et al. Psychol Med. 1995;25(6):1171-1180.
0
20
40
60
80
100
% R
elap
se
Patients With ResidualDepressive Symptoms
Patients With No ResidualDepressive Symptoms
25%
76%
94%had
PhysicalSymptoms
© 2
006
Nog
ginS
torm
Lab
s
Integrated Model
Physical Physical SymptomsSymptoms
Psychological Psychological SymptomsSymptoms
PAIN is the most common physical symptom
DEPRESSION most common psychological symptom
Research Spectrum for Pain
Basic •Neurosciences•Genetics•Pharmacology•Imaging
Translational
Clinical Trials
Other Clinical•Epidemiology•Health services
Social•Qualitative•Behavioral•Sociological
YOU YOU ARE ARE
HEREHERE
Primary Care Pain and Depression Trial
SStepped CCare for AAffective disorders and MMusculokeletal
PPain studyFunded by National Institute
of Mental Health-RO1 MH071268-01
SCAMP STUDY TEAM
Kurt Kroenke, MD: Principal Investigator Matt Bair, MD: Co-I (Medical Director) Teresa Damush, PhD: Co-I ( Health psychology) Jason Sutherland, PhD: Co-I (Biostatistics) Shawn Hoke (Project Manager) Carol Kempf, RN and Gloria Nicholas, RN Monica Huffman and Celeste Nicholas Jingwei Wu (Data analyst)
Comorbidity of Pain and Depression Is Common
Reviews have demonstrated a strong association
30-60% overlapCoexisting musculoskeletal pain
with depression is very common
Bair MJ, et al. Arch Intern Med. 2003;163(20):2433-2445.
What is a Stepped-Care Intervention?
Starting with lower intensity, less costly treatments (Step 1)
“Stepping up” to more intensive, costly, or complex treatments In patients that are “poor responders”
Low Back Pain (Von Korff), PGW Syndrome (Engel)
SCAMP DESIGN
PAIN (back or hip/knee)
Stepped Care Usual Care
NONDEPRESSEDDEPRESSED
randomized
(n = 250) (n = 250)
Outcome Assessment at 1, 3, 6, and 12 months
HYPOTHESES Depression/pain care management will, Depression/pain care management will,
compared to usual care:compared to usual care:
Primary Hypothesis Reduce pain and/or depression severity
Secondary Hypotheses Improve health-related quality of life (HRQL),
including work and social functioning Improve pain beliefs/behaviors Be cost-effective in terms of QALYs
Clinical Trial Inclusion Pain located in low back, hip or
kneePersistent pain for > 3 months Brief Pain Inventory score of 5
(moderate pain severity)Moderate depression (PHQ-9 10)
Exclusion Criteria Non-English speaking Moderately severe cognitive impairment Bipolar disorder or schizophrenia Current disability claim being adjudicated for pain Tried to cut down on drugs or alcohol in the past
year Currently pregnant or planning to become pregnantAnticipated life expectancy ≤ 12 months
Cohort InclusionHad to have a PHQ-9 depression
score < 8 Identical inclusion/exclusion criteria
to participants in trialTo elucidate frequency & predictors
of incident depression in patients with musculoskeletal pain
Step 1 -- Pharmacotherapy
WHENWHEN WHEREWHERE WHAT (Treatment Action)WHAT (Treatment Action)
BaselineBaseline Clinic Antidepressant startedAntidepressant started
1 wk1 wk Phone Check adherence & side effectsCheck adherence & side effects
3 wk3 wk Phone Adjust dose if neededAdjust dose if needed
6 wk6 wk Clinic Change antidepressant if neededChange antidepressant if needed
9 wk9 wk Phone Adjust dose if neededAdjust dose if needed
12 wk12 wk Clinic Decide if step 2 is warrantedDecide if step 2 is warranted
Step 2 – Pain Self-Management
WHENWHEN WHEREWHERE WHAT (Treatment Action)WHAT (Treatment Action)
12 wk12 wk Clinic PSMP – Session 1PSMP – Session 1
14 wk14 wk Phone PSMP – Session 2PSMP – Session 2
16 wk16 wk Clinic PSMP – Session 3PSMP – Session 3
18 wk18 wk Phone PSMP – Session 4PSMP – Session 4
20 wk20 wk Clinic PSMP – Session 5PSMP – Session 5
22 wk22 wk Phone PSMP – Session 6PSMP – Session 6
24 wk24 wk Clinic Close Phase 2. Phone q 3 mo.Close Phase 2. Phone q 3 mo.
Pain Self-Management Program (example components)
Education – pain; vocabulary; red flags;Education – pain; vocabulary; red flags; Identifying /modifying fears and beliefsIdentifying /modifying fears and beliefs Goal-setting and problem-solvingGoal-setting and problem-solving Exercise – strengthening; aerobic; etc.Exercise – strengthening; aerobic; etc. Relaxation; deep-breathing;Relaxation; deep-breathing; Handling pain flare-ups Handling pain flare-ups Working with clinicians and employersWorking with clinicians and employers
DETAILS OF TREATMENT
All aspects of intervention delivered by nurse case manager
Weekly case management meetingsRegular contacts with participants to
monitor depression/pain, response to treatment, introduction of self-management strategies
SCAMP CONCEPTUAL MODEL
Anti-depressant
Pain Self-management
Depression severity
Pain severity
• Impaired Function/QoL
• Increased Health Costs
• Demographics
• Other Psych.-- Anxiety-- Stressors
• Pain-- Coping-- Beliefs
COVARIATES
+
+
− −
MEASURESBrief Pain InventorySCL-20 depression scaleHRQL: -- generic (SF-36)
-- pain-specific (Roland)Other pain (coping, beliefs, self-mgmt)Other psych (anxiety, somatization)Health care utilization (costs)
Baseline Characteristic
Stepped Care
(N=123)
Usual Care
(N=127)
Non depressed
(N=250)
Mean (SD) age, yr 55.2 (12.6) 55.8 (11.0) 62.5 (14.1)
Women, n (%) 69 (56.1%) 63 (49.6%) 127 (50.8%)
Race, n (%)
White 75 (61.0%) 76 (59.8%) 140 (56.0%)
Black 42 (34.1%) 49 (38.6.7%) 100 (40.2%)
Married, n (%) 48 (39.0%) 44 (34.7%) 97 (38.8%)
Mean (SD) no. of medical diseases
2.7 (1.6) 2.6 (1.4) 2.6 (1.4)
Clinical site, n (%)
University clinics 73 (59.3%) 75 (59.1%) 152 (60.8%)
Veteran administration (VA)
50 (40.7%) 52 (40.9%) 99 (39.2%)
Baseline Characteristics SCAMP Participants
0
0.5
1
1.5
2
2.5
Baseline 12 wk 20 wk 32 wk 40 wk
Eff
ec
t S
ize
(n=86) (n=79) (n=54) (n=53) (n=45)
Depression (PHQ-9)
Pain (BPI)
Response of pain and depression in SCAMP Trial during Phase 1 (optimized antidepressant therapy) and Phase 2 (pain self-management)
End of Phase 1
End of Phase 2
Impact of Depression and Anxiety Alone and in Combination among Primary Care Patients
with Chronic Musculoskeletal Pain
Baseline data analysis
BACKGROUNDIndividually, depression and anxiety
are strongly associated with chronic pain.
Little is known how psychiatric comorbidity affects patients with pain.
STUDY OBJECTIVEAmong patients w/ chronic pain:Individual and combined impact of
depression and/or anxietyPain intensityPain interferenceDisability daysHealth-related quality of life (HRQL)
METHODSBaseline analysis of SCAMP data4 cohorts identified
Pain only Pain and Anxiety Pain and Depression Pain, Anxiety, and Depression
ANALYSESANOVA models to compare
baseline differences four groupspain intensity/interferenceDisability daysHRQL
ANALYSESMANOVA to model pain severity
and pain interference concurrentlyInteraction testingCovariates:
Sociodemographics, medical comorbidity, study site, and pain location
3
4
5
6
7
8
Pain Only
Pai
n S
core
Pain & Anxiety
Pain & Depression
Pain, Anxiety, & Depression
BPI Interference
BPI Severity
Patients with concomitant pain, depression, and anxiety had more severe pain
Psychiatric Comorbidity & Disability in 500 pts with musculoskeletal pain
Depression and/or Anxiety
%
Roland Disability Score
Disability Days past 3 mo
Pain only 54% 12.1 18
Pain & Anxiety 7% 15.5 33
Pain & Depression 15% 17.9 37
Pain, Anxiety, & Depression 25% 18.1 42
Bair, Damush, Wu, Sutherland, Kroenke (abstract at SGIM meeting, 2007)Bair, Damush, Wu, Sutherland, Kroenke (abstract at SGIM meeting, 2007)
20
40
60
80
Pain only
SF
-36
Sca
le
Pain & Anxiety
Pain & Depression
Pain, Anxiety, &
Depression
Social
Vitality
General
Pain
Poorer HRQL seen in those with pain and psychiatric comorbidity
MANOVA Model Predicting Pain Severity and Interference
Variables F Value P-value
Age 2.24 0.1075
Medical diseases 1.38 0.2525
Gender 0.49 0.6148
Education 3.80 0.0231
Employment 4.13 0.0026
Marital 0.04 0.9595
Pain location 1.82 0.1630
Clinic site 6.52 0.0016
Depression * Anxiety 5.88 0.0030
Study StrengthsLarge, multi-site primary care studyAnalytic plan that assessed
independent & combined effects of depression and anxiety on variety of pain outcomes
Use of validated measures with good psychometric properties
Study LimitationsCross-sectional dataSingle academic medical centerSelf-report measures for depression
and anxiety (rather than structured clinical interviews)
CONCLUSIONAmong primary care patients with
chronic musculoskeletal painWe found an independent and
additive associations between depression and/or anxiety ANDPain intensity/interferenceDisability daysHRQL
IMPLICATIONSPsychiatric comorbidity among
chronic pain patients is commonAssociated with poor clinical
outcomes as well as patient sufferingRepresents complex management
challenges for VA providers caring for these patients
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