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24 Feb 2017
Judith Turner, Depression and Anxiety in Chronic Pain

Depression or anxiety is common among patients with chronic pain, which is why these individuals should be screened for the said mental health disorders, said Dr Judith Turner, University of Washington (UW) professor of psychiatry and behavioral sciences and rehabilitation medicine, during the 7th Association of South-East Asian Pain Societies Congress held in Yangon, Myanmar.

“Chronic pain frequently coexists with other medical and mental health disorders, most commonly depression and anxiety, which further complicate an already complex situation,” Turner said. “Patients with chronic pain may not adhere to recommended treatment or may not improve; this is more likely with patients who are depressed.”

The UW professor stressed that should patients have both pain and depression or anxiety, clinicians must treat both conditions to optimize outcomes.

A number of effective medication and behavioural options for the treatment of depression and anxiety are available, and these are helpful for both pain and depression/anxiety, she said. These include antidepressant medication, cognitive behavioural therapy and exercise.

Patients with chronic pain who also have depression or anxiety should be referred immediately to a mental health expert when the clinician is “stuck, first-line treatments aren’t working, depression is severe, suicidal ideation is present or medical issues complicate psychopharmacologic treatment,” Turner said.

The application of collaborative care, which involves a nurse care manager, regular monitoring, evidence-based treatment and psychiatric consultation, also improves anxiety and depression outcomes.

“Identifying and treating depression in patients with mild persistent pain might help prevent development of chronic disabling pain and excessive healthcare utilization,” Turner said.

Where to start?
When dealing with patients with both chronic pain and depression, communication is a good place to start. According to Turner, it is very common for patients with chronic pain to feel down, and this is understandable since pain can have a negative impact on almost every aspect of a person’s life.

She reiterated the importance of treating both pain and depression to improve the patient’s condition. Additionally, the same treatments (medication, exercise, psychotherapy, therapies for sleep disorders) can improve pain, depression, sleep and function.

Once communication has been established, clinicians should ask patients regarding their preference for medication vs psychotherapy. Turner recommends this approach because “matching preference to treatment increases chances of entering treatment and better outcomes.”

Once patient preference is known, specific goals for treatment must be identified, and follow-up visit in about 2 weeks should then be scheduled.

“It is helpful to talk with patients about the vicious cycle of chronic pain and problems with mood, sleep, activity participation and energy. Intervening at any part of the cycle can have benefits for all other parts,” Turner said.

Furthermore, clinicians should inform their patients about what to expect as treatment may take some weeks to take effect (2 to 8 weeks for medication and 2 to 12 weeks for psychotherapy). Patients should know as well that they must adhere to treatment long enough for it to work. Clinicians could then adjust treatment based on response. Finally, it is important to tell patients that setbacks may occur.

“Regular follow-up and monitoring using validated tools, and adjustment of treatment based on response, are important to achieving treatment goals and minimizing relapses,” Turner said.

Bidirectional relationship
A 2006 study found that chronic pain increases the risk of depression and vice versa.

Compared with primary care patients without chronic pain, those with nondisabling chronic pain had three times the odds of major depression, while those with disabling chronic pain had more than five times the odds of major depression. On the other hand, among primary care patients with depression, 66 percent had chronic pain (25 and 41 percent had nondisabling and disabling chronic pain, respectively) vs 10 percent in patients without chronic depression. [Psychosom Med 2006;68:262-268]

Like depression, there is a bidirectional relationship between anxiety and chronic pain—the presence of either increases risk for the other, according to Turner, adding that common anxiety disorders include generalized anxiety disorder, panic disorder, agoraphobia and post-traumatic stress disorder (PTSD).

Across chronic pain conditions, the prevalence of generalized anxiety disorder (GAD) is estimated at 1 to 10 percent, panic disorder at 1 to 28 percent and PTSD at 1 to 23 percent. [Hooten, Mayo Clin Proc, 91, 2016]

Apart from screening for depression (eg, PHQ-9) and anxiety (eg, GAD-7) in patients with chronic pain, Turner recommends a chronic care model since both pain and depression/anxiety tend to recur over time.

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