For patients who experience pain and depression, common co-existing conditions, an intervention that included individually tailored antidepressant therapy and a pain self-management program resulted in greater improvement in the symptoms of these conditions than patients who received usual care, according to a study in the May 27 issue of JAMA.
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 percent-50 percent co-occurrence), effect the treatment responsiveness of each, and have adverse effects on quality of life, disability, and health care costs, according to background information in the article.
Kurt Kroenke, M.D., of Indiana University School of Medicine and the Regenstrief Institute, Indianapolis, and colleagues conducted a study to determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and co-existing depression. The trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) included 250 patients who had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity. Patients were randomly assigned to the intervention (n = 123) or to usual care (n = 127). Depression was assessed with the 20-item Hopkins Symptom Checklist, and pain primarily with the Brief Pain Inventory.
The intervention consisted of 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); and a 6-month continuation phase, in which symptoms were monitored and treatments reinforced, with a focus on preventing relapse.
The researchers found that the intervention group had significantly better outcomes for depression. The intervention group was more than twice as likely to experience depression response (46 of 123 intervention patients [37.4 percent] vs. 21 of 127 usual care patients [16.5 percent]) 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).
Intervention patients were also much more likely than usual care patients to report overall improvement in their pain at 12 months (47.2 percent vs. 12.6 percent).
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 authors write.
“Because pain and depression are among the leading causes of decreased work productivity, an intervention that is effective for both conditions may further strengthen a business model. Also, an intervention that allows a care manager to cover several conditions rather than a single disorder may enhance its implementation and cost-effectiveness. Given the prevalence, morbidity, disability, and costs of the pain-depression dyad, the SCAMP trial results have important implications.”