Pain and its relation to depressive symptoms in frail older people living in the community: an observational study

The association of pain and depression represents an important health problem that is correlated with high rates of disability, morbidity, greater consumption of health care resources, and socioeconomic difficulties. Understanding the interaction between pain and depression is an important issue in light of the fact that physicians frequently fail to accurately assess and diagnose pain symptoms, and that elderly patients suffering from pain are particularly likely to receive inaccurate treatments. The aim of the present study was to describe the prevalence of pain and to investigate the association between pain and depressive symptoms in a representative sample of frail elderly people living in the community (n=5,372). The results show that more than 15% and 40% of elderly patients experienced pain less than daily and daily, respectively. The average score on the depression scale was significantly lower in patients without pain (2.5+/-2.5) than patients with less than daily and daily pain (3.2+/-2.5 and 3.6+/-2.5, respectively) (P<0.001). Without substantial differences between men and women, the rate of each depressive symptom was significantly and progressively higher among patients suffering less than daily and daily pain compared to those without pain. In conclusion, this study provides evidence from a large sample of frail elderly people that individuals suffering pain present an elevated risk to experience depressive symptoms. Treatment models that put together the assessment and the treatment of both pain and depression are indispensable for better outcomes.     

Clinical aspects of depression in chronic pain patients.

It has been widely recognized that an appreciable proportion of chronic pain patients have depressive disorders. Although numerous studies and several literature reviews have examined the relationship between chronic pain and depression, disorders of mood come in many forms, and little attention has been paid to the different types of depressive disorders found among patients with chronic pain. In this article, the different ways in which a chronic pain patient may manifest depression are discussed. Diagnostic criteria for major depression, dysthymia, and atypical depression are described, and the relevance of these disorders and of masked depression to chronic pain is discussed. The medical illnesses and medications that can cause symptoms of depressive disorders are also briefly described. Depressive disorders and their concomitants are an integral part of the experience of chronic pain and are important in developing an optimal treatment plan. For these reasons, they should be carefully evaluated in all patients with chronic pain.     

Perception for ischemic pain shows similarities in adjustment disorder and major depression.

We recently described an increase of pain thresholds and tolerances for thermal and electrical pain in patients suffering from adjustment disorder (AD). Furthermore, we presented evidence that pain perception in major depressive disorder (MDD) depends on pain modality, with thresholds for ischemic pain being decreased compared to increased thermal and electrical pain thresholds. Here, we investigated perception of experimentally induced ischemic pain in 15 patients suffering from AD (subtype with depressive symptoms) and controls matched for age and sex in order to examine whether a similar pattern of modality dependent pain perception can be established. Thresholds and tolerances were assessed on both sides of the body. We found a significant decrease of ischemic pain thresholds in AD patients as compared to controls. Analogue findings have been reported for pain perception in MDD, therefore suggesting similarities with regards to pain perception in both disorders. This adds weight to the assumption that depressive symptomatology might alter pain sensitivity in this subtype of AD since symptoms are milder, yet comparable to MDD.     

Cognitive behavioral therapy for depression in patients with heart failure: a critical review

Depression is a significant problem in patients with heart failure. Cognitive behavioral therapy (CBT) has been proposed as a potential non-pharmacological treatment for depression in patients with heart failure. The purpose of this review is to examine the evidence for the use of CBT in treating depression and depressive symptoms in patients with cardiovascular illness. In six of the ten studied reviewed, researchers found that CBT reduced depressive symptoms; however, the limitations of the studies prevent wide generalization of the results. There is insufficient evidence to support the use of CBT for the treatment of depressive symptoms in patients with cardiovascular illness at this time. Large randomized, controlled trials that demonstrate the efficacy of CBT are needed before nurses routinely refer patients with heart failure to CBT for the purpose of improving depression or depressive symptoms.     

Cytokines and depression: an analogic approach.

A growing body of evidence suggests that major depressive disorders may be accompanied by immune dysfunction and more particularly by an enhanced production of pro-inflammatory cytokines. The possible involvement of cytokines in depressive illness are based upon an analogic model. Pro-inflammatory cytokines are known to induce behavioral effects, and neuro-endocrine and immune activation similar to those observed in depression; these can be alleviated by antidepressant treatment. In this paper, we review research literature on the links between depressive illness and cytokine production and address further questions on this cytokine pathway. Further research is needed to see whether cytokines sustain specific depressive syndromes or whether cytokines induce depressive-like symptoms.     

Marital functioning, chronic pain, and psychological distress

This study examined whether marital functioning variables related uniquely to psychological distress and diagnoses of depressive disorder independent of pain severity and physical disability. Participants were 110 chronic musculoskeletal pain patients. Hierarchical regression results showed that marital variables (i.e. marital satisfaction, negative spouse responses to pain) contributed significantly to depressive and anxiety symptoms over and above the effects of pain severity and physical disability. In contrast, marital variables were not significantly related to diagnoses of depressive disorder (i.e. major depression, dysthymia, or both) after controlling for pain variables. In multivariate analyses, physical disability and marital satisfaction were uniquely related to depressive symptoms whereas physical disability, pain severity, and negative spouse responses to pain were uniquely related to anxiety symptoms. Only physical disability was uniquely related to major depression. The results suggest that models of psychological distress in chronic pain patients might be enhanced by attributing greater importance to interpersonal functioning and increasing attention to anxiety.     

Nurse-led pain management program: Effect on self-efficacy, pain intensity, pain-related disability, and depressive symptoms in chronic pain patients

Nurses routinely use a variety of nonpharmacologic and patient education interventions designed to reduce pain and promote independence. Research on group programs that combine these nursing strategies in a systematic approach provides evidence that chronic pain patients can realize an enhanced confidence in their ability to manage pain (improved self-efficacy) in addition to reductions in pain, emotional distress, and disability. The purpose of this study was to investigate the effect of participating in a nurse-led cognitive-behavioral treatment (CBT) pain management program on self-efficacy, pain intensity, pain-related disability, and depressive symptoms among patients with chronic pain. Pre- and postprogram data from 154 participants were examined to identify changes in pain intensity, self-efficacy, disability, and depressive symptoms. Mean differences, effect sizes, and 95% confidence intervals were computed for the study variables and paired t-tests were done to determine if changes were significant. Z-scores were then calculated. Pearson product moment correlations were examined to test the association between changes in self-efficacy and changes in the other variables of interest. Patients in this study reported significant improvements in all scores postprogram. Self-efficacy, pain-intensity, pain-related disability, and symptoms of depression can be changed through participation in a nurse-led outpatient CBT program. In concert with results from other research on CBT pain programs this study provides further evidence that reduction in suffering and improved sense of well-being is possible even for people who have experienced pain for many years.     

An Update on Repetitive Transcranial Magnetic Stimulation for the Treatment of Co-morbid Pain and Depressive Symptoms

Purpose

Review recent meta-analyses and clinical trials investigating the therapeutic use of repetitive transcranial magnetic stimulation (rTMS) for concurrent pain and depressive symptoms.

Recent Findings

Recent meta-analyses have included both pain and depression outcomes in fibromyalgia and chronic pain. Randomized controlled trials have also been conducted in post-herpetic neuralgia, trauma-related headache, and neuropathic pain with attention to both pain and depressive symptoms. In general, studies have demonstrated reduction in pain in patients with fibromyalgia as an add-on treatment, post-herpetic neuralgia, trauma-related headache, and neuropathic pain. There are variable findings for reduction in depressive symptoms in patients with co-morbid pain disorders. Theta burst stimulation (TBS) is a novel rTMS protocol that has recently been investigated in patients with depression and some smaller trials in patients with co-morbid pain disorders. These emerging treatment options may have similar or greater therapeutic potency and may be delivered with greater efficiency.

Summary

There is evidence to support the use of rTMS for its analgesic effects in various pain syndromes. The variable results between trials for treatment of concurrent depressive symptoms may be due to heterogeneity in treatment protocols including parameters such as site of stimulation (primary motor cortex versus dorsolateral prefrontal cortex) and restrictions in the patient population which usually exclude primary psychiatric diagnoses. Future trials should work to standardize these protocols, investigate novel protocols like TBS, and continue to include standardized assessment of concurrent psychiatric outcomes such as depression and anxiety.

     

Depressive disorders in older medical inpatients

Symptoms of depression that are temporary or caused by physical illness can be difficult to differentiate from those that represent a depressive disorder. A diagnosis of depressive disorder depends on the underlying cause, and on the nature, severity and duration of symptoms. Management involves accurate diagnosis and treatment of medical illness, practical interventions to resolve concurrent family, social and economic stressors, and emotional support. Cognitive, behavioral and brief psychodynamic therapies may be helpful in selected cases. Antidepressants and electroconvulsive therapy have a role in the treatment of severe or persistent depression associated with suicidal behavior, marked psychomotor retardation, starvation or other life-threatening symptoms. Suicidal thoughts are frequent in older patients with concurrent major depression and chronic illness, and measures to ensure patient safety are a priority.     

Depression and Coping Behaviors Are Key Factors in Understanding Pain in Interstitial Cystitis/Bladder Pain Syndrome

Background: Interstitial Cystitis/Bladder Pain Syndrome (IC/BPS) is a urologic chronic pelvic pain syndrome with suboptimal treatment outcomes. Catastrophizing is an empirically supported risk factor for greater IC/BPS pain. Aims: In this study, a moderated multiple mediation model is tested in which several additional psychosocial risk factors (depression, illness and wellness-focused behavioral coping strategies) are proposed as mediators or moderators in the existing relationship between catastrophizing and IC/BPS pain. Design: The present questionnaire study employed a cross-sectional design. Settings and Participants: Female patients with an IC/BPS diagnosis (n = 341) were recruited at tertiary care sites. Methods: Participants completed questionnaires assessing pain, catastrophizing, behavioral coping strategies, and depressive symptoms. Aggregate factor scores were calculated following exploratory factor analyses. Results: It was found that patients with a greater tendency to catastrophize were more likely to engage in illness-focused coping strategies, which contributed to the reporting of greater sensory and affective pain. Furthermore, this mediating effect of illness-focused coping on affective pain was more likely to occur in those patients reporting greater depressive symptoms. Conclusions: Illness-focused behavioral coping is an important mechanism between maladaptive pain cognition and aspects of patient pain, with patients reporting greater depressive symptoms at increased risk for elevated pain. Patient management techniques, including screening for catastrophizing, coping, and depression, are recommended to enrich IC/BPS management.     

Pain perception in major depression depends on pain modality

One frequently described feature of depression is an increased vulnerability to pain complaints, and chronic pain is frequently accompanied by symptoms of depression. In contrast to this, a decreased sensitivity to experimental pain has been described in major depression. The physiological basis of this phenomenon is yet elusive. We investigated 30 patients suffering from a major depressive disorder and matched controls. Pain testing (threshold and tolerance) was performed on both sides of the body and included assessment of thermal, electrical and ischemic pain. While confirming hypoalgesia to heat and electrical pain in comparison to controls, we found hyperalgesia to ischemic muscle pain. Furthermore, thermal pain tolerance and electrical pain tolerance were significantly increased on the right hand side confirming previous results of a lateralized perception of pain in depression. Our main finding suggests that painful stimuli are processed differentially depending on the localization of pain induction in depression. This knowledge may enable us to understand and ultimately treat pain complaints more appropriately in depressed patients.     

Depression in the elderly. Characteristics and clinical management

Major depression and clinically significant depressive symptoms occur commonly in the community-dwelling, medically ill, and institutionalized elderly. Both major depression and depressive symptoms need thorough evaluation and treatment because of the significant morbidity and mortality associated with these syndromes. Depression may be difficult to diagnose, especially in the medically ill elderly, because of the masking of depressive symptoms by somatic complaints or the presumption that symptoms are attributable to concurrent medical illness. Therefore, the clinician must be alert to the possibility of depression in the elderly patient. Although no specific diagnostic test is available, rating scales can be useful in screening for depression in the elderly patient. It is necessary to rule out medical illness or medications as contributing factors to depression. Psychotherapy and psychopharmacology, alone or in combination, are effective treatments for most elderly patients with depression. ECT is a safe and effective treatment for major depression in this population. Depression in the elderly is potentially a chronic and relapsing illness with significant associated medical and social morbidity. Because of their frequent contact with the elderly, nurses play a particularly important role in the diagnosis and treatment of depression. They need to recognize typical and atypical symptoms of depression and must be familiar with the potential side effects of antidepressant treatment. Close monitoring for these potential side effects can minimize disability. By working as a team with physicians, psychologists, and others, nurses have a necessary role in the care of the elderly depressed patient.     

Pain symptoms in depression: definition and clinical significance

This article presents the findings of a focused literature review and consensus meetings on the definition and clinical significance of painful symptoms in patients with depression. About 50% of depressed patients report pain, and many types of pain occur more frequently in people with depression than in those without. There is some evidence that pain in depressed patients is associated with a poor response to treatment. Pain and depression may share common pathways and may both respond to treatment with certain antidepressants. Doctors need to be alert to pain in depressed patients and be prepared to treat it.     

Chronische Rückenschmerzen im Zusammenhang mit belastenden Lebensereignissen

In a retrospective, controlled clinical study the life events of 35 patients suffering from chronic low back pain (LBP) and a matched sample of 23 patients with neurotic depression (ICD 300.4) were investigated. The pain patients formed two groups: 19 patients with definite organic diagnosis (IASP code 530.96) and 16 without (adequate) organic lesion (IASP code 510.99). Somatic diseases (other than LBP), injuries and operations, as well as psychic trauma (feelings of shame, narcissistic traumatisations and object losses) were defined and counted as documented in the patient's histories. Their distribution over the period between the 10th year before onset of LBP resp. depression and the 10th year after onset was calculated. As a result all patients have to cope with a maximum of stressful life events in the initial year of their disease. Those patients, who fell ill younger than 30 years old, are confronted with an increased number of stressful life events even during several years before the onset. In all groups significant more stress is experienced after illness onset compared with the time before onset. LBP patients without organic findings experience more narcissistic traumatisations than the other two groups in the initial year and later on. In contrast depressive patients suffer from more other diseases, injuries and have undergone more operations than pain patients throughout the whole time investigated. Object losses occur equally often in all groups, apart from the initial year, when depressive patients have to cope with even more losses than the others. These results are discussed considering the development of chronic pain syndromes, the influence of age and their consequences for models of illness. There is convincing evidence, that physical injury is neither a necessary nor a sufficient condition for the development of chronic pain and that chronic pain is in essence an emotional disease based on unresolved unconscious conflicts requiring psychotherapy.     

妇科门诊和住院患者更年期症状与抑郁的调查分析

目的 调查女性更年期症状与抑郁的影响因素,为促进健康提供依据.方法 采用改良更年期Kupperman评分量表和流行病学调查用抑郁自评量表(center for epidemiological studiesdepression,CES-D),对416例更年期女性进行调查,并对结果进行分析.结果 更年期综合征的发生率高达93.99％,抑郁发生率达49.52％.按时每天吃早餐、营养平衡的饮食、控制盐分摄入、定期锻炼身体及维持适当体质量,这5项健康生活因素是更年期综合征的主要影响因素.乳房疼痛、便秘、皮肤干燥、下腹部疼痛,这4项抑郁相关症状因素和更年期女性抑郁存在显著相关.更年期综合征和抑郁症状之间存在显著相关.结论 健康的生活方式是更年期症状的主要影响因素,更年期症状增加了抑郁症状的发生危险.     

The Relation of Post-Traumatic Stress Symptoms to Depression and Pain in Patients With Accident-Related Chronic Pain

Symptoms of post-traumatic stress disorder (PTSD) are a common comorbidity in patients with a history of accident-related chronic pain and depression. However, little is known regarding the influence of PTSD in contributing to the affective distress, pain experience, and disability associated with chronic pain in this population. This study used structural equation modeling to examine 3 models that assess these relations in a sample of chronic pain patients with accident-related pain. Subjects were assessed for pain experience, depressive symptoms, anxiety, PTSD symptoms, pain disability, and relevant demographic variables. Pearson correlations indicated that symptoms of depression were significantly related to more severe pain, disability, and PTSD symptoms. PTSD symptoms were significantly associated with higher disability. The model of best fit indicated that after controlling for the influence of anxiety on the dependent measures, PTSD symptoms have a direct influence on severity of depressive symptoms, whereas depressive symptoms have a direct influence on pain intensity and an indirect impact on pain intensity by way of their effect on disability. These data point to the importance of unresolved PTSD symptoms in contributing to the level of depression, pain, and disability exhibited by chronic pain patients and highlight the need to consider directed and primary treatment of PTSD in pain rehabilitation programs.PerspectiveThis study highlights the impact of symptoms of PTSD on levels of depression, disability, and pain in patients with pain secondary to physical injury. Our results suggest that pain rehabilitation programs provide directed interventions for PTSD symptoms among this population to improve pain treatment outcomes.