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Managing Pain When Accompanied by Depression

May 31, 2010 by  

Up to 70% of people experiencing chronic pain also experience clinical depression.

Having chronic pain can wear us down. It is not just the experience of pain that is so hard but the losses that occur because of the pain. These losses can include job, hobbies, social life and/or income. Perhaps even greater, are the loss of sense of self and purpose. All of this can contribute to depression.

Unfortunately, in most cases, the pain and depression are treated separately resulting in minimal improvement in either condition. Treating both at the same time, with an integrated treatment approach can result in significant improvement in both pain and depression.

Research reported in the May 27, 2009 issue of the Journal of the American Medical Association (JAMA) describes a strategy that can result in substantial improvements in both depression and pain and can be implemented in many medical centers.

The researchers used a combination of antidepressant medication along with a pain management class.  They used what is called Stepped Care, consisting of 12 weeks of optimized antidepressant therapy (step 1) followed by a 12-week pain management program (step 2), and a 6-month continuation phase that reinforced learning (step 3).

The study consisted of 250 individuals who had low back, hip or knee pain for 3 months or longer and were diagnosed with depression. The researchers split them into two groups. The control group, consisting of 127 patients, received usual care from their physician for both depression and pain. The other group of 123 received both the careful monitoring of the antidepressant medications prescribed, plus the 12-week pain self-management class. The patients in the self-management class learned muscle relaxation and deep breathing strategies, as well as pain coping skills such as distraction techniques. They also learned how to cope with pain fears and other negative emotions.

Here are the exciting results. Self-management pain classes, along with optimized antidepressant treatment, resulted in significant reduction in both depression and pain. Patients in this group also reported less disability.

A few key components were very helpful in getting these positive results:

1. The antidepressant medication was closely monitored and adjusted.

Too often physicians prescribe antidepressant medication and tell the patient to call if they are not feeling better. Many patients, if they are not feeling better, just stop taking the medication and do not call. Research has shown that many people with depression do not feel better on the first medication they try. In fact, during this study, of the 100 intervention patients whose antidepressant status was known at 12 months, 43% had switched to a different antidepressant or combination medication.

2. Pain management class started around the time the antidepressant medication was beginning to show results.

Many times when a patient with pain enters a pain management class her/his depression has not been adequately addressed. It is very difficult to be motivated to apply many of the pain management strategies if one is still significantly depressed. By reducing the depression, patients find the self-care strategies more effective.

3. Follow-up care was emphasized.

It is important not to assume patients will continue to utilize self-care strategies after treatment is finished. It is also important to continue to monitor the depression. Many patients may need adjustments to medication even months later.

*Kurt Kroenke, MD; Matthew J. Bair, MD, MS; Teresa M. Damush, PhD; Jingwei Wu, MS; Shawn Hoke, BA; Jason Sutherland, PhD; Wanzhu Tu, PhD.  Optimized Antidepressant Therapy and Pain Self-management in Primary Care Patients With Depression and Musculoskeletal Pain.  JAMA. 2009;301(20):2099-2110.

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