We know that depression may increase patients’ vulnerability to pain, and the co-existence of pain and depression has previously been a subject here on the Picture of Pain blog, and is the subject of our latest scientific publication.

The new study is a primary care study from Rochester, New York. By assessing the inflammatory marker IL-6 the researchers found how inflammatory activity were linked to depression, pain and chronic medical morbidity, and the findings are important.

Patients with elevated depressive symptoms had IL-6 associated with greater pain reports and with chronic medical morbidity. However in contrast those relationships were not found among patients without clinical significant depressive symptoms. This suggests that depressive symptom alone or in combination with chronic disease burden, may have increased vulnerability to pain and increased inflammation. Furthermore seemed depression severity and pain severity to be associated without relation to medical morbidity.

Recent evidence suggests that depression treatment may reduce systematic inflammation. It is also possible that by reducing inflammation, depression treatment might serve as a pathway to reducing pain associated with chronic medical morbidities.

We have in a recent published study found, that 58% of primary care patients meeting criteria for depression come with a pain problem. Not making a comprehensive assessment of pain and its impact including mood and depression, and designing treatment according to findings, bear the risk of missing the co-existence. Thereby the patient may not be provided with optimal treatment, and even not reduce accompanying inflammation and associated health concerns.

Reference:

Poleshuck, E.L., Talbot, N.L., Moynihan, J.A., Chapman, B.P. & Heffner, K.L., 2013, Depressive Symptoms, Pain, Chronic Medical Morbidity, and Interleukin-6 among Primary Care Patients, Pain Medicine.

Kristiansen, K., Lyngholm-Kjaerby, P. & Moe, C., 2012, DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression, International Journal of Family Medicine, 2012, pp. 1-8.

Kim Kristiansen, M.D. (2013). Pain and Depression Linked to the Immune System Picture of Pain Blog

http://www.sciencedirect.com/science/article/pii/S0304395913001887

Traditionally healthcare professionals are educated to identify a disease or other health problem, and then treat it if possible. The modern and informed patient are often presenting more complex chronic – and thereby not curable – conditions, which in it self is a challenge. Presented with patients with these symptoms and syndromes health professionals might find their authority and self-image challenged, since the symptoms and complaints presented by the patients do not fit into to the normal biomedical frame for understanding and treating medical conditions. Further more does these symptoms and complaints not always fit to well into the traditional understanding of scientific and evidence based disease management, which is a deep and integrated part of our pride for what healthcare professionals do and how we work.

As healthcare becomes more specialized multiple specialists will often be looking only at “their part” of the patient’s problems, and often it is the primary care physician who must try to connect the dots.

Taking a look across the 20 great TEDMED challenges makes it obvious that a changed approach to modern healthcare are shared by many of them. Changes in attitude are not necessarily the easiest part of anything, but since these 20 areas in healthcare are crucial, facilitating the needed changes across the challenges are an important part of bringing them forward. It is goodbye to the well known healthcare-centered care and hello to active patients, shared decision making, and an on-going process towards defined goals together.

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We also hear what the other part is not saying.

So why not chose to actively and engaged communicate and make decisions in healthcare whether you are the patient or the clinician.

Communication is not optional so see this interesting TEDMED discussion about medical communication

Click here to view the video on YouTube.

According to our new study published in International Journal of Family Medicine, where we looked at 715 persons coming to primary care, 66% of the men and 54% of the women (58% in total) who met the criteria for depression came to primary care due to a pain problem.

Research has demonstrated pain and depression has a strong negative impact on each other, and that simultaneous treating both can have enhanced effect on outcome, function and quality of life, and simultaneous treatment of pain and depression also reduces the risk of misuse of opioids.

Depression together with pain is associated with considerable functional impairment and decreased quality of life, increased health care utilization, and difficult clinician-patient relationships. Irish researches have found that 5% of chronic pain patients account for 26% of costs due to pain,. This was the patients  who experienced the highest pain intensity and the patients with a combination of chronic pain and depression. At the same time we know, that these patients are those with the lowest quality of life, so finding and treating these patients have both human and economical importance.

Pain, sleep problems and depression share neurological pathways and are often coexisting. Take a look at the graph showing data from the same study. On the horizontal axis is score on sleep problems at DoloTest (0-100, 100 being worst possible). This line is divided into 5 segments along the sleep VAS line. The blue columns are showing the relative frequency of patients meeting criteria for depression within each segment; the line is showing the average pain intensity in each sleep-problem segment. Data from average primary care that demonstrates a close co-existence in accordance with our knowledge from neuropsychological research.

Presence of concomitant depression with chronic pain increases the risk of misuse of opioids, when defined as using opioids for stress or sleep and using more than prescribed.  Increasing depression score leads to an increasing risk of misuse of opioids. Alicia Grattan and colleagues present this in a paper in the a recent issue of Annals of Family Medicine. Even though opioids might reduce pain it might also be able to reduce the burden of pain by its cognitive- and calming effects, but where opioids can be part of treating pain, depression and anxiety or sleep problems should not be treated by this, but instead by relevant pharmaceutical or non-pharmaceutical treatment. If these patients are asked if they “feel better”, they might answer “yes”, this might be due to reduction in pain experience but might also be du to its calming effects. Or by both.

So when more than half or the patients meeting the criteria for depression comes to primary care clinics with a pain problem, there is a great risk for missing the depression and treating pain alone with potential serious problems.

Assessing pain alone is like measuring the length but not the waist circumference when buying a new pair of trousers: you are most likely to have trouble keeping the more significant parts covered.

References:

DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression, Kim Kristiansen, Pernille Lyngholm-Kjaerby, and Claus Moe

International Journal of Family Medicine. Volume 2012 (2012), Article ID 472505, doi:10.1155/2012/472505

Kristiansen K, Correlation between Sleep, Pain and Depression in Primary Care Patients using DoloTest®. Poster at WONCA EUROPE; Warsaw, Sept. 9. 2011

Grattan A, Sullivan MD, Saunders KW, Campbell CI, Von Korff MR. Depression and prescription opioid misuse among chronic opioid therapy recipients with no history of substance abuse. Ann Fam Med 2012, Jul;10(4):304-11.

Raftery, Miriam N, Padhraig Ryan, Charles Normand, Andrew W Murphy, Davida de la Harpe, and Brian E McGuire. “The Economic Cost of Chronic Noncancer Pain in Ireland: Results From the PRIME Study, Part 2.” The journal of pain : official journal of the American Pain Society 13, no. 2 (2012): doi:10.1016/j.jpain.2011.10.004.

Kim Kristiansen, M.D. (2013). Depressed Patients Seek Primary Care Due to Pain Picture of Pain Blog

Is this placebo? Might be at least to some degree, but it demonstrates a communication style respecting the patient’s autonomy can be a treatment of the patients pain in itself.

It will be interesting to see future and especially more long time studies in this field. However the knowledge from this study is ready to be used right away. Risk free.

Ref: Sarinopoulos, I., Hesson, A.M., Gordon, C., Lee, S.A., Wang, L., Dwamena, F. & Smith, R.C., 2013, Patient-centered interviewing is associated with decreased responses to painful stimuli: An initial fMRI study, Patient education and counseling, 90(2), pp. 220-5

Kim Kristiansen, M.D. (2013). Healthcare professionals AS pain treatment Picture of Pain Blog

DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression

Abstract

Background. Coexistence of pain and depression has significant impact on the patient’s quality of life and treatment outcome. DoloTest is a pain and HRQoL assessment tool developed to provide shared understanding between the clinician and the patient of the condition by a visual profile. Aim. To find the sensitivity and specificity of DoloTest as a screening tool for depression for patients in primary care. Methods. All patients coming to a primary care clinic were asked to fill in a DoloTest and a Major Depression Inventory. Results. 715 (68.5%) of 1044 patients entered the study. 34.4% came due to pain. 16.1% met depression criteria, and 26.8% of patients coming due to pain met criteria for depression. 65.6% of the men and 54.2% of the women meeting the criteria for depression came due to pain. Depressed patients had statistically significant higher scores on all DoloTest domains. Selecting the cutoff value for the domain “low spirits” to be “65″ (0-100) for depression gave a sensitivity of 78% (70-85%) and a specificity of 95% (93-96%) for meeting depression criteria. Conclusion. DoloTest can with a high sensitivity and specificity identify persons meeting criteria for depression and is an easy-to-use screening tool to identify patients with the coexistence of pain and depression.

Link to PubMed

Link to our paper on International Journal of Family Medicine

Link to Picture of Pain coverage

MERRY CHRISTMAS AND HAPPY NEW YEAR

Thanks to all Picture of Pain readers for your interest and support in 2012. We are are excited about the new year where we will launch a new tool, end some exciting projects and start new projects we are planing now.

Thanks also to all users of DoloTest – indeed a growing number. Thank you for kind feed back (and please send more )

Be sure to like DoloTest on Facebook or follow DoloTest on Twitter to keep updated.

Best Wishes

Kim Kristiansen and the DoloTest-Team

Pain Chronicles, Melanie Thernstrom.

Melanie Thernstrom is a pain patient herself. Her mission is to share information about pain, information she would have liked to have had from the day her pain started. Findings from research regarding pain together with chapters about the history of pain, the attitude toward pain and persons with pain through history, and religious believes about pain. Through the book all this information is mixed with her personal story about pain, love, life and quality of life.

It seems to be a very difficult task to make all these pieces fit together to create a – well a picture of pain – but MT manages to make the puzzle fit together to create a journey trough humans lives with pain. The book presents a well-written mixture of knowledge, thoughts and feelings.

Overcoming Chronic Pain. Frances Cole

Dr. Frances Cole is a GP and cognitive behavioural therapist from Bradford in England. Together with three colleagues she has written this book. It is a very good book to patients with information about pain, treatments, and what the patient can do them selves to live better life with pain.

The Language of Pain. David Brio.

This is a special book. The author combines his knowledge as a physician with his own experience of illness and pain, and put it into a cultural context and references. A great insight into living with pain.

Stumbling on Happiness. Daniel Gilbert.

Well this book is not exactly about pain. I would rather say, that it is also about pain and whatever has influence on our quality of life and happiness. It is a wonderful book, well written and with a lot of humour. As the author states in the foreword is this book not a self-help book, but if you ever should have bought such a book and still felt miserable after you have read it, you can turn to this book and understand why. A must read.

I hope you will add your best reads in this field too

Thanks

Kim Kristiansen (2012). Best Reads About Chronic Pain and Positive Mental Health Creating a list of best reads about chronic pain and mental health

The paper is published in the International Journal of Family Medicine. We asked all patients coming to primary care to fill in a DoloTest, a depression test (Major Depression Inventory) and answer some questions; we call the study DoloTest General Practice Study or just GPS.

34,4% of the patients came due to a pain problem, and 16.1% of all patients met criteria for depression, making both conditions very frequent in primary care. But fact is, as often discussed here at the Picture of Pain Blog, that chronic pain and depression often are co-existing, and that both patients and care providers must be aware of both conditions to be able to provide the optimal treatment. In our study 65,6% of men and 54.2% of women who met criteria for depression came due to a pain problem, highlighting the importance for this awareness. They were not complaining of one or more complaints form the diagnostic criteria for depression, but complaining of the physical symptom “pain”. This means that patients with depression often present a physical symptom rather than one ore more psychological symptoms, making it easier to miss the important co-existence.

Turning the focus around to patients presenting a pain problem 22.8% of the men and 29.2% of the women met criteria for depression.

From DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression, Kim Kristiansen, Pernille Lyngholm-Kjaerby, and Claus Moe International Journal of Family Medicine. Volume 2012 (2012), Article ID 472505, doi:10.1155/2012/472505

These numbers are alarmingly high, and we know from many studies, that it is very important to be aware of this co-existence to provide the best possible treatment, and to achieve best possible improvement in quality of life. What more is, that a recent published study has also showed co-existence of depression and pain to be a major risk factor for opioid misuse both by using opioids for depression, stress and sleep problems instead of for pain alone, and by using more opioids than prescribed. The picture illustrates one of the figures from our paper showing DoloTest-Profiles for men and women with and without depression (MDD on the picture). With no problems towards the center and worst possible towards the periphery the overall burden and impact on quality of life is clear.

In our study we found that the scoring on the domain “To what extent do you experience low spirits” could be correlated to the risk of meeting the criteria for depression. Setting a cutoff score at “65” on the 0-100 scale allowed us to find 78% of persons with depression and eliminate 95% of persons without depression.

This demonstrates that DoloTest can be used to screen for depression besides providing an overview of quality of life.

In coming blog posts I will present and discuss more results from our study.

DoloTest in General Practice Study: Sensitivity and Specificity Screening for Depression, Kim Kristiansen, Pernille Lyngholm-Kjaerby, and Claus Moe

International Journal of Family Medicine. Volume 2012 (2012), Article ID 472505, doi:10.1155/2012/472505

Kim Kristiansen, M.D: (2012). Our New Study About Easy Screening for Co-existence of Pain and Depression Picture of Pain Blog