Depression predicts disability in long-term chronic pain patients

PURPOSE: Investigators have examined factors that predict treatment outcome and disability status in chronic pain patients, including psychopathology and personality characteristics with equivocal results. The purpose of this study was to evaluate the usefulness of personality characteristics, depression, and personality disorders in predicting disability status in pain patients with long-term follow-up. The setting was a rehabilitation hospital in Southern Sweden. METHOD: Subjects were 184 pain patients (mean age = 43.4 (10.8) years; 72.8% female) who had no more than 365 sick leave days (Mean sick leave days = 132.7 (128.2)) prior to the baseline personality and psychiatric evaluation. The baseline evaluation consisted of a psychiatric interview that included the administration of the Structured Clinical Interview for DSM-IV Screen Questionnaire (SCID-II), the Montgomery-Asberg Depression Rating Scale (MADRS), and the Karolinska Scales of Personality (KSP). Disability status was assessed by insurance record review a minimum of two-and-a-half years after baseline evaluation. RESULTS: Multivariate logistic regression suggests that age (OR = 1.09, 95% CI = 1.02-1.18; p = 0.013), number of sick leave days prior to evaluation (OR= 1.01, 95% CI= 1.01-1.02; p = 0.018), and baseline diagnosis of depression significantly predicted subsequent disability status (OR = 7.04, 95% CI = 1.15-42.93; p = 0.034). Baseline personality traits and the diagnosis of a personality disorder were not useful predictors of disability status in our sample. CONCLUSIONS: These data suggest that depression, but not personality disorders characteristics, was an important disability predictor in chronic pain patients with extended follow-up.     

Depression predicts disability in long-term chronic pain patients

Purpose : Investigators have examined factors that predict treatment outcome and disability status in chronic pain patients, including psychopathology and personality characteristics with equivocal results. The purpose of this study was to evaluate the usefulness of personality characteristics, depression, and personality disorders in predicting disability status in pain patients with long-term follow-up. The setting was a rehabilitation hospital in Southern Sweden. Method : Subjects were 184 pain patients (mean age=43.4 (10.8) years; 72.8% female) who had no more than 365 sick leave days (Mean sick leave days=132.7 (128.2)) prior to the baseline personality and psychiatric evaluation. The baseline evaluation consisted of a psychiatric interview that included the administration of the Structured Clinical Interview for DSM-IV Screen Questionnaire (SCID-II), the Montgomery-Åsberg Depression Rating Scale (MADRS), and the Karolinska Scales of Personality (KSP). Disability status was assessed by insurance record review a minimum of two-and-a-half years after baseline evaluation. Results : Multivariate logistic regression suggests that age (OR=1.09, 95% CI=1.02-1.18; p =0.013), number of sick leave days prior to evaluation (OR=1.01, 95% CI=1.01-1.02; p =0.018), and baseline diagnosis of depression significantly predicted subsequent disability status (OR=7.04, 95% CI=1.15-42.93; p =0.034). Baseline personality traits and the diagnosis of a personality disorder were not useful predictors of disability status in our sample. Conclusions : These data suggest that depression, but not personality disorders characteristics, was an important disability predictor in chronic pain patients with extended follow-up.     

Adolescent self-perception: associations with chronic musculoskeletal pain and functional disability.

Associations among pain, functional disability, and self-perceived competence were examined in a retrospective record review of the initial clinical evaluations of 115 adolescents (ages 13 to 18 years) with chronic musculoskeletal pain not associated with a specific organic cause. Adolescents self-reported on pain intensity, functional disability, and 9 developmentally relevant domains of self-perceived competence, using the Self-Perception Profile for Adolescents (Harter, 1988). Results confirmed a relation between usual pain intensity and functional disability (r = 0.47, P < .001). A series of multiple regression analyses revealed that adolescents' perceptions of global self-worth significantly moderated the relation between pain and disability. These findings extend our understanding of the relations among self-perception, chronic pain, and disability to include adolescents with chronic musculoskeletal pain syndromes and have future research and therapeutic implications. PERSPECTIVE: Adolescents with chronic pain syndromes can face significant challenges in accomplishing developmental goals with respect to the pain and disability they experience. Perceptions of self-worth appear to play an important role in understanding the relation between pain and functional disability among adolescents with chronic pain.     

Predictive factors of chronic pediatric pain and disability: a Delphi poll.

The purpose of this study was to establish consensus on the factors that predict chronic pediatric pain and pain-related disability. A Delphi poll involving 2 rounds of data collection was used as a way to reach consensus among professionals with a specific interest in chronic pain in children and adolescents. Factors that had the greatest influence on long-term maintenance of pediatric pain included: Excessive use of heath care services; a tendency to somatize; and children's catastrophizing. Factors that had the greatest influence on long-term disability included: Children's self-concept as being disabled; a hesitance to perform exercise because of fear of a potential injury; and children's catastrophizing. These findings may help identify the specific items to be assessed in studies designed to predict which children are at risk to develop chronic pain and disability. If supported by further research, these results may ultimately help develop intervention programs that could prevent long-term pain in disability in children and adolescents. PERSPECTIVE: A Delphi poll was conducted to reach consensus among professionals with a specific interest in chronic pain among children and adolescents, regarding the factors associated with the development of chronic pediatric pain and disability. This study could serve as the basis for (1) prospective studies to validate the predictive utility of the variables; and (2) the design of secondary prevention programs.     

Depression and the chronic pain experience.

The present study examined the relationship between depression and a constellation of pain-related variables that describe the experience of chronic pain patients. Thirty-seven depressed and 32 non-depressed heterogeneous chronic pain patients were identified through structured interviews, use of standardized criteria and scores on the Beck Depression Inventory (BDI). The 2 groups were compared on demographic variables and scores on the Marlowe-Crowne Social Desirability scale (MC), as well as measures of disability and medication use, pain severity, interference due to pain and reported pain behaviors. The depressed group was found to be younger and to score lower on the MC than the non-depressed group. Multivariate analyses of covariance (MANCOVA), using age and MC as covariates, revealed that depressed chronic pain patients, relative to their non-depressed counterparts, reported greater pain intensity, greater interference due to pain and more pain behaviors. There were no group differences on the measures of disability and use of medications. The results provide further support for the importance of incorporating depression into clinical and theoretical formulations of chronic pain. Future use of structured interviews and standardized criteria for diagnosing depression may clarify some of the inconsistencies found in the literature.     

Functional assessment of pediatric pain patients: psychometric properties of the functional disability inventory

The Functional Disability Inventory (FDI; Walker LS, Greene JW. The functional disability inventory: measuring a neglected dimension of child health status. J Pediatr Psychol 1991;16:39-58) assesses activity limitations in children and adolescents with a variety of pediatric conditions. This study evaluated the psychometric properties of the FDI in pediatric pain patients. Participants included 596 patients with chronic abdominal pain, ages 8-17, and a subset of their parents (n = 151) who completed the FDI and measures of pain, limitations in school activities, and somatic and depressive symptoms at a clinic visit. Test-retest reliability was high at 2 weeks (child report, .74; parent-report, .64) and moderate at 3 months (child report, .48; parent report, .39). Internal consistency reliability was excellent, ranging from .86 to .91. Validity was supported by significant correlations of child- and parent-report FDI scores with measures of school-related disability, pain, and somatic symptoms. Study results add to a growing body of empirical literature supporting the reliability and validity of the FDI for functional assessment of pediatric patients with chronic pain.     

Depression, coping, and functional disability in juvenile primary fibromyalgia syndrome.

This study describes pain characteristics, coping, depression, and functional disability in children with juvenile primary fibromyalgia syndrome (JPFS) and compares them with a group of children with nonmalignant chronic back pain (CBP). Subjects were 18 female subjects (9 to 19 years of age) diagnosed with JPFS and 18 matched control subjects with CBP. Visual Analog Pain Rating Scales, the Pain Coping Questionnaire, the Children's Depression Inventory, and Functional Disability Inventory were administered. Results indicated that both JPFS and CBP groups reported significant disruption in functional abilities and school attendance as a result of chronic pain. Both groups reported mildly elevated symptoms of depression overall, but there was a subgroup of JPFS subjects who reported severe levels of depression. The JPFS group had suffered from pain for significantly longer than the CBP group before being referred for specialty care. However, pain duration was not significantly related to depression, functional disability, or pain coping efficacy. The levels of functional disability were similar in both groups, but the JPFS group reported somewhat more school absences. The longer time to receive specialty care and identification of a subgroup of depressed subjects at risk for long-term psychosocial consequences are of particular concern in JPFS.     

Psychiatric aspects of chronic pain and disability

Chronic pain is a major public health problem that inflicts not only tremendous personal suffering but also huge economic loss to individuals and society. This article discusses the psychiatric aspects of chronic pain and disability. Topics covered include chronic pain and psychiatric illness (eg. somatization disorder, conversion disorder, hypochondriasis, and so on), the interrelationship between pain and depression, and psychodynamics and psychotherapy.     

Differential changes in functional disability and pain intensity over the course of psychological treatment for children with chronic pain

Patients presenting for treatment of chronic pain often believe that pain reduction must be achieved before returning to normal functioning. However, treatment programs for chronic pain typically take a rehabilitative approach, emphasizing decreasing pain-related disability first with the expectation that pain reduction will follow. This information is routinely provided to patients, yet no studies have systematically examined the actual trajectories of pain and disability in a clinical care setting. In this study of youth with chronic pain (N = 94, 8 to 18 years), it was hypothesized that 1) functional disability and pain would decrease over the course of psychological treatment for chronic pain and 2) functional disability would decrease more quickly than pain intensity. Participants received cognitive behavioral therapy (CBT) for pain management (M = 5.6 sessions) plus standard medical care. The Functional Disability Inventory and a Numeric Rating Scale of average pain intensity were completed by the child at every CBT session. Hierarchical linear modeling was conducted to examine the longitudinal trajectories of disability and pain. Standardized estimates of the slopes of change were obtained to test differences in rates of change between pain and disability. Results showed an overall significant decline in functional disability over time. Although pain scores reduced slightly from pretreatment to posttreatment, the longitudinal decline over treatment was not statistically significant. As expected, the rate of change of disability was significantly more rapid than pain. Evidence for variability in treatment response was noted, suggesting the need for additional research into individual trajectories of change in pediatric pain treatment.     

Preventing iatrogenic disability from chronic pain

This article reviews the AMA guidelines for judging impairment that involves anatomic or physiologic deficits and should be evaluated objectively based upon current biomedical knowledge. Disability, in contrast, is a biopsychosocioeconomic phenomena based upon many nonmedical demands. Chronic pain syndrome is examined as a disabiling condition best conceptualized and treated with such a multisystems model, while the underlying impairment needs to be assessed and rated by a biomedical model.The wide range of "central processes" relevant to chronic pain are reviewed. It argues that patients should not be viewed as reaching MMI unless they have been treated at a comprehensive chronic pain rehabilitation program, or are unable or unwilling to do so. A balanced, direct yet compassionate approach is recommended in treating these patients: the source of pain and that it will not cause harm is carefully explained and a clear expecatation that the patient’s condition is not disabling and that he or she can return to work is conveyed.The need to change the compensation and disability systems so that they encourage early intervention with incentives toward rehabilitation and return to work is emphasized.     

Depression and chronic fatigue in the patient with chronic pain

Chronic benign pain is commonly associated with chronic fatigue and depression. Depression and chronic fatigue syndrome are also associated with each other and often include pain. Psychologic factors are prominent in these conditions, and they may share neurobiologic factors as well. Management requires separately addressing each component of patients' distress and usually includes physical rehabilitation, education, administration of nonhabituating medications and often counseling. Depression may be a favorable prognostic sign, as it suggests a treatable condition and provides incentive for recovery.     

Psychosocial risks for disability in children with chronic back pain.

Psychosocial factors related to disability in adults with chronic back pain have been well studied, but little is known about factors associated with functional impairment in pediatric patients with chronic back pain. The purpose of this study was to examine whether 2 potential risk factors-use of catastrophizing as a coping technique and presence of a familial pain history-were associated with disability in pediatric back pain patients. Participants were 65 patients (ages 8-18) with chronic back pain seen at a multidisciplinary pain clinic. Patients completed measures of pain (visual analog scales), disability (Functional Disability Inventory), and catastrophizing (Internalizing/Catastrophizing subscale of the Pain Coping Questionnaire). Parents provided demographic information and familial pain history. Patients reported that chronic back pain caused disruptions in their daily functioning and they missed, on average, 2.5 days of school every month. Catastrophizing and familial chronic pain history both were significantly associated with greater disability, with use of catastrophizing being the stronger predictor of disability. This study presents important findings on potential psychosocial risk factors of functional disability in children and adolescents with chronic back pain. Future research might clarify mechanisms by which such coping styles are developed and explore how familial communication about pain might influence a child's coping ability. PERSPECTIVE: Pediatric patients seeking treatment for chronic back pain often present with substantial functional impairment that is not well explained by disease variables or pain intensity. Two important psychosocial variables (catastrophizing and familial pain history) may provide a context for a better understanding of pain-related disability in children.     

Cognitive distortion and disability in chronic low back pain

Numerous authors have suggested that cognitions play an important role in the development, maintenance, and treatment of chronic low back pain (CLBP). However, little evidence exists to support the association between cognitive variables and the CLBP problem. The present study examined the relationship of cognitive distortion, as measured by the Cognitive Error Questionnaire, to disability, as measured by the Sickness Impact Profile, in a sample of 138 CLBP patients. As predicted, cognitive distortion was consistently related to several aspects of disability. The cognitive variables accounted for variance in disability beyond that accounted for by severity of pain, number of pain treatments, and depression. Also as predicted, cognitive distortion concerning low back pain situations was more closely correlated with disability than was distortion concerning general, nonpain situations. Overgeneralization was the specific cognitive error most closely and consistently correlated with disability. The results are interpreted as consistent with a cognitive-behavioral model of CLBP.The authors would like to thank Holly Waldron, Dennis Turk, and several anonymous reviewers for their comments on an earlier version of this paper.     

Gender moderates the association between depression and disability in chronic pain patients.

Pain-related anxiety and depression are important correlates of disability amongst chronic pain patients. Furthermore, women may differ in their experience of pain, anxiety and depression when compared to men. The aim of the current study was to determine the relative contribution of anxiety and depression on disability in male and female chronic pain patients. The sample consisted of 260 patients (101 males, 159 females) referred to the Pain Management Unit at the Royal National Hospital for Rheumatic Diseases in Bath, UK. As part of an initial assessment, all patients completed measures of depression, pain-related anxiety and disability. As predicted, both anxiety and depression were found to be significant positive predictors of pain, number of medications used and disability. Although gender did not significantly predict disability, it did moderate the relationship between depression and disability, in that when depression was high, women report greater disability than men. Gender was also found to moderate the relationship between depression and number of medications used, in that a positive association was found for men, but not women. However, gender did not significantly moderate the relationship between anxiety and disability. Together these results not only suggest that gender is an important moderator of the relationship between emotional responses and disability, but that such associations may be related more to depression than anxiety.     

Effect of compensation on emotional state and disability in chronic back pain.

The adversarial nature of some compensation systems could be a major source of psychological stress. To investigate this, we measured emotional state, pain and disability in 19 compensation recipients and in 18 others who had settled their claim for lower back pain. All subjects were unemployed, and sex distribution was similar in both groups. Compensation recipients showed more signs of emotional distress, had greater difficulty coping with pain, and reported that pain disrupted various aspects of their life to a greater degree than subjects who had settled their claim. However, even after settlement, there was clear evidence of emotional distress. The promise of a financial windfall on settlement of a claim could discourage workers from resuming employment after injury. Unfortunately, this course of action increases the risk of pain becoming chronic and of unemployment and financial hardship continuing after settlement. To prevent this potentially disastrous situation, the compensation system should encourage workers to resume some type of employment as soon as possible after injury.     

One-year trend in pain and disability relief recall in acute and chronic ambulatory low back pain patients.

Clinicians use patients' recall of pain and disability relief as indicators of therapeutic effectiveness. Recall can change over time, however, and is influenced by factors other than true relief, including current health status. We have determined the trend in the relative contribution of current pain/disability and actual relief (current-baseline score) to relief recall over the course of 1 year. Self-referred patients (n=1182) seeking treatment from primary-care medical doctors and chiropractors in community-based clinics were asked to record present pain and disability, as well as perceived relief at five follow-up time points from 2 weeks to 12 months after initial consultation for acute and chronic low back pain (LBP). Multiple regression analysis was performed at each time point and over the five follow-up time points. We found a clear logarithmic time trend of increasing dependence of pain relief recall on present pain (P<0.0001) and a concomitant pattern of decreasing dependence on actual pain relief (P<0.0001). The patterns are fairly consistent for acute and chronic patients. The principal independent predictor of perceived pain/disability relief appears to be present pain/disability with actual relief playing a smaller role at all time points (P<0.0001) except for disability relief recall at 2 weeks (P=0.103). The findings are robust in LBP sufferers. Complaint characteristics including LBP chronicity, sciatica, LBP history, and comorbidity; psychosocial variables including stress, depression, and well being; sociodemographics; and treating provider type are not important independent predictors of pain and disability relief recall in ambulatory LBP patients. Perceived relief is too weakly related to present pain and disability to be accurate enough for use as a clinical assessment tool for individual patients. Physicians may need to use objective relief data to give the patient a realistic idea of actual improvement.     

Psychologic evaluation in the management of chronic pain and disability

This article attempts to provide a practical template for the psychologic assessment of chronic pain and disability. Topics discussed include differential diagnosis, goals of psychosocial assessment, psychologic constructs, personality issues, pain-drawing ratings, and multidimensional assessment instruments. Other factors affecting psychologic assessment, such as litigation, perception of disability, pain behavior, and cultural factors are also discussed.