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January 2011



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First Published Wednesday, 27 May 2009

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Cindy Fox Aisen

Pain complaints account for more than 40 percent of all symptom-related outpatient visits, and depression is present in 10 percent to 15 percent of all patients who receive primary care.

Pain and depression frequently co-exist (30-50% co-occurrence), effect the treatment responsiveness of each, and have adverse effects on quality of life, disability, and health care costs.

Researchers from the Indiana University School of Medicine and the Regenstrief Institute report in the May 27 issue of the Journal of the American Medical Association (JAMA) that a strategy they developed of closely monitored antidepressant therapy coupled with pain self-management can produce substantial improvements in both depression and pain.

Treating depression these days is like treating high blood pressure. There are many effective drugs out there. To control high blood pressure, the physician closely monitors the patient to determine the most appropriate drug and the proper dosage. Often with depression treatment, the patient is prescribed one of the many effective antidepressants but is not closely followed to see if it’s the best choice and the proper dosage, which means the patient’s depression is not being effectively managed,” said the study’s principal investigator, Kurt Kroenke, MD, professor of medicine at the IU School of Medicine and a Regenstrief investigator.

There are more significant challenges in treating patients with persistent pain. Ironically research on effective pain treatment has lagged a couple of decades behind work on depression and the drug choices are not as good. More study on the basic science and clinical levels needs to be done on both pain and the link between pain and depression, which may share common biological pathways, to develop better options,” said Dr Kroenke, an Indiana University-Purdue University Indianapolis Chancellor’s Professor.

The 250 study participants had low back, hip, or knee pain for three months or longer and at least moderate depression severity. They were randomized into two groups. The control group of 127 received usual care from their internists for both depression and pain. The other 123 had 12 weeks of optimized antidepressant therapy (actively managed by a nurse care manager); followed by 6 sessions of a pain self-management program over 12 weeks (during each session, the nurse care manager introduces new strategies for patient self-management, assists the patient in choosing strategies, and supervises the patient as he/she practices the chosen strategy – this included muscle relaxation and deep breathing exercises as well as coping, distraction and other tactics.); and a 6-month continuation phase, in which symptoms were monitored and treatments reinforced, with a focus on preventing relapse.

Those whose depression medications were closely monitored and who were trained in pain self- management were two to three times more likely to have decreased depression (46 of 123 intervention patients [37.4 percent] vs. 21 of 127 usual care patients [16.5 percent]) than those in the control group and nearly 4 times as likely to experience complete remission (17.9 percent vs. 4.7 percent) at 12 months, corresponding to a much lower number of patients with major depression (40.7 percent vs. 68.5 percent). Pain severity and disability also lessened. These benefits continued for the six months after optimizing antidepressant therapy and pain self-management had been completed.

In terms of the trial’s primary outcome, the intervention group was significantly more likely to experience a composite response, defined as a reduction of 50 percent or greater in depression and a reduction of 30 percent or greater in pain. This difference in composite response rates was significant at both 6 months (23.6 percent for intervention patients vs. 7.9 percent for usual care patients) and 12 months (26.0 percent vs. 7.9 percent).

It is possible that pain improvement in our trial reflected a main effect of improved mood (i.e., an antidepressant effect on mood rather than an analgesic effect), and that as depression lifts, patients may experience pain as being less intense and less disabling. Conversely, it is also possible that the improvement in depression was mediated by an improvement in pain (i.e., as pain improves, patients feel less depressed) or that both depression and pain lessened as a result of treatment effects on a common pathway,” the researchers write.

We were pleased to see the patients whose antidepressants were closely monitored and who practiced self-management improved, but we think we can lessen pain and depression even more. In our next studies we plan to investigate cognitive behavior therapy as well as optimizing pain medications to see if even greater improvements in pain can be achieved. Because pain and depression are among the leading causes of decreased work productivity, a strategy that is effective for both should be attractive not only to patients and their physicians. Health insurers and the business community will be interested as well,” said Dr Kroenke, an internist who is a former president of the Society of General Internal Medicine.

The study was funded by the National Institute of Mental Health.

Kroenke K, Bair MJ, Damush TM, et al. Optimized Antidepressant Therapy and Pain Self-management in Primary Care Patients With Depression and Musculo-skeletal Pain. JAMA. 2009 May;301(20):2099-2110   [Full text]

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