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The Impact of Co-existing Chronic Pain and Mental Health QUERI Conditions: QUERI Implementation Seminar Series

The Impact of Co-existing Chronic Pain and Mental Health QUERI Conditions: QUERI Implementation Seminar Series. Matthew J. Bair, MD, MS Research Scientist, Roudebush VA Center of Excellence on Implementing Evidence Based Practice and Regenstrief Institute, Inc

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The Impact of Co-existing Chronic Pain and Mental Health QUERI Conditions: QUERI Implementation Seminar Series

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  1. The Impact of Co-existing Chronic Pain and Mental Health QUERI Conditions:QUERI Implementation Seminar Series Matthew J. Bair, MD, MS Research Scientist, Roudebush VA Center of Excellence on Implementing Evidence Based Practice and Regenstrief Institute, Inc Assistant Professor of Medicine, IU School of Medicine, Indianapolis June 28, 2007

  2. OUTLINE • The “Pain Problem” • The “Depression Problem” • Pain and Depression Dyad • SCAMP Study • Baseline Analyses • Questions and Answers

  3. Objectives • To discuss the impact of co-existing chronic pain and depression/anxiety • To introduce a model to assess and treat both chronic pain and depression (anxiety) concurrently

  4. ManagingPAINin Primary Care: Issues and Challenges Brief Visits Complicated Patients Clinical Reminders Minimal Resources JCAHO & VHA Mandate to Manage pain Policies Guidelines Expectations

  5. PAIN CRISES • Pain accounts for 20% of all clinic visits • Analgesics = 12% of all prescriptions (# 2) • $100 billion dollars/yr in health care costs • Excessive surgery (e.g., back pain) • Leading cause of work loss & disability • Leading reason for alternative medicine

  6. Consequences of Under-treatment of Chronic Pain • Physiologic (CV, GI, immune) • Psychological (depression, anxiety) • Diminished quality of Life • Impairment of activities • Large impact on working age adults • Absenteeism, unemployment, and under-employment

  7. VETERAN STORIES • “Doc, I hurt all day- 24/7” • “Nothing works for my pain” • “I can’t do anything because of my pain so I stay in bed all day” • “I can’t deal with this (pain)…it’s depressing” • “On a scale of 0 to 10 my pain is a 20! If I don’t get some relief fast I will blow my head off!”

  8. Prevalence of chronic non-cancer pain in Primary Care • 44% (VA); 25 %(university, PCC) (Reid et al,2002 ) • 48% VA Primary Care - Palo Alto VA (Clark, JD, 2002) • 71 % VA Primary Care – Western New York (Crosby et al 2006)

  9. Pain: 5thVital Sign in Primary Care and Association with Depression • 301 primary care Veteran patients • Mean age = 60; 91% men; 85% white • Depression in 28% (PHQ-9 ≥ 10) • Pain in 76% • Mild 21% (score of 1-3) • Moderate 31% (score of 4-6) • Severe 22% (score of 7-10) Bair MJ, Williams LS, Kroenke K. J Gen Intern Med 2004;19 (Supplement 1):123.

  10. Pain Severity as Correlate of Depression Bair MJ, Williams LS, Kroenke K. J Gen Intern Med 2004;19 (Supplement 1):123.

  11. Ischemic heart disease Major Depression Traffic accidents Cerebrovascular disease COPD Global Burden of Disease Year 2020 Murray and Lopez, 1996

  12. Depressed Patients Usually Present with Physical Symptoms 69% Presented ONLY With Physical Symptoms Other N = 1146 patients with major depression 1. Simon GE, et al. N. Engl J Med. 1999;341(18):1329-1335.

  13. Unrecognized and Untreated Depression • Interferes with treatment and rehab • May increase pain intensity and disability • Decrease pain threshold and tolerance • Magnification of medical symptoms • Less successful treatment outcomes

  14. RECIPROCAL RELATIONSHIP Pain Depression

  15. Depression and Negative Pain Outcomes • Depression is associated with • ↑ pain complaints and intensity • ↑ disability • ↑ functional limitations • ↑ utilization (office visits, hospitalizations) • ↑ costs • ↑ risk of nonrecovery Bair MJ, et al. Arch Intern Med. 2003;163(20):2433-2445.

  16. Pain and Negative Depression Outcomes • PAIN ASSOCIATED WITH: •  depressive symptoms •  functional limitations •  unemployment rate • frequent use of opioid analgesics • frequent pain-related doctor visits • worse self-rated health Von Korff M. Grading the severity of chronic pain. Pain 1992; 50:133-149

  17. Severity of Pain is Associated with Poor Depression Outcome Baseline Pain Severity * *P<.05 vs patients with no baseline pain 4.1 N=573 Odds Ratio for Poor Depression Response** Relative to Patients Without Pain * 2.0 1.5 No effect relative to patients without pain at baseline (n=144) (n=170) (n=81) ARTIST=A Randomized Trial Investigating SSRI Treatment.**Poor depression treatment response defined as Symptom Checklist-20 >1.3. Pain severity was measured by the SF-36 pain severity item Bair MJ, et al. Psychosom Med. 2004;66(1):17-22.

  18. Nonsomatic depressive Sx Positive well-being Non-pain somatic Sx Pain somatic Sx What Symptoms are the Most Resistant? 1.4 N=573 1.2 Emotional 1.0 0.8 Improvement Treatment Effect Size 0.6 Physical 0.4 0.2 0 Baseline 1 Month 3 Months 6 Months 9 Months ARTIST=A Randomized Trial Investigating SSRI Treatment. Adapted from: Greco T, et al. J Gen Intern Med. 2004;19(8):813-818.

  19. Source: Residual Symptoms Predict Relapse Review: by SHARIE SIPOWICZ 4/8/2003 1:23:11 PM SL32 Rev: 2152 Jackie Strasser 4/10/03 76% 94%hadPhysicalSymptoms Reviewer Memo: % Relapse 25% Patients With ResidualDepressive Symptoms Patients With No ResidualDepressive Symptoms © 2006 NogginStorm Labs *Based on Item 13 (general somatic symptoms) of the HAM-D17. Paykel ES, et al. Psychol Med. 1995;25(6):1171-1180. Slide Modified: Memo:

  20. Integrated Model Physical Symptoms Psychological Symptoms PAIN is the most common physical symptom DEPRESSION most common psychological symptom

  21. Research Spectrum for Pain • Other Clinical • Epidemiology • Health services Translational YOU ARE HERE • Basic • Neurosciences • Genetics • Pharmacology • Imaging • Social • Qualitative • Behavioral • Sociological Clinical Trials

  22. Primary Care Pain and Depression Trial • Stepped Care for Affective disorders and Musculokeletal Pain study • Funded by National Institute of Mental Health-RO1 MH071268-01

  23. SCAMP STUDY TEAM • Kurt Kroenke, MD: Principal Investigator • Matt Bair, MD: Co-I (Medical Director) • Teresa Damush, PhD: Co-I ( Health psychology) • Jason Sutherland, PhD: Co-I (Biostatistics) • Shawn Hoke (Project Manager) • Carol Kempf, RN and Gloria Nicholas, RN • Monica Huffman and Celeste Nicholas • Jingwei Wu (Data analyst)

  24. Comorbidity of Pain and Depression Is Common • Reviews have demonstrated a strong association • 30-60% overlap • Coexisting musculoskeletal pain with depression is very common Bair MJ, et al. Arch Intern Med. 2003;163(20):2433-2445.

  25. What is a Stepped-Care Intervention? • Starting with lower intensity, less costly treatments (Step 1) • “Stepping up” to more intensive, costly, or complex treatments • In patients that are “poor responders” • Low Back Pain (Von Korff), PGW Syndrome (Engel)

  26. SCAMP DESIGN PAIN (back or hip/knee) (n = 250) (n = 250) DEPRESSED NONDEPRESSED randomized Stepped Care Usual Care Outcome Assessment at 1, 3, 6, and 12 months

  27. HYPOTHESESDepression/pain care management will, compared to usual care: Primary Hypothesis • Reduce pain and/or depression severity Secondary Hypotheses • Improve health-related quality of life (HRQL), including work and social functioning • Improve pain beliefs/behaviors • Be cost-effective in terms of QALYs

  28. STUDY SITES • Roudebush VAMC medicine clinics • University primary care clinics

  29. Clinical Trial Inclusion • Pain located in low back, hip or knee • Persistent pain for > 3 months • Brief Pain Inventory score of  5 (moderate pain severity) • Moderate depression (PHQ-9  10)

  30. Exclusion Criteria • Non-English speaking • Moderately severe cognitive impairment • Bipolar disorder or schizophrenia • Current disability claim being adjudicated for pain • Tried to cut down on drugs or alcohol in the past year • Currently pregnant or planning to become pregnant • Anticipated life expectancy ≤ 12 months

  31. Cohort Inclusion • Had to have a PHQ-9 depression score < 8 • Identical inclusion/exclusion criteria to participants in trial • To elucidate frequency & predictors of incident depression in patients with musculoskeletal pain

  32. Step 1 -- Pharmacotherapy

  33. Antidepressant Selection • Venlafaxine • Fluoxetine • Sertraline • Citalopram • Buproprion • Mirtazepine • Nortriptyline

  34. Step 2 – Pain Self-Management

  35. Pain Self-Management Program (example components) • Education – pain; vocabulary; red flags; • Identifying /modifying fears and beliefs • Goal-setting and problem-solving • Exercise – strengthening; aerobic; etc. • Relaxation; deep-breathing; • Handling pain flare-ups • Working with clinicians and employers

  36. DETAILS OF TREATMENT • All aspects of intervention delivered by nurse case manager • Weekly case management meetings • Regular contacts with participants to monitor depression/pain, response to treatment, introduction of self-management strategies

  37. SCAMP CONCEPTUAL MODEL COVARIATES Pain Self-management Anti-depressant • Demographics • Other Psych. • -- Anxiety • -- Stressors • Pain • -- Coping • -- Beliefs − − Depression severity Pain severity + + • Impaired Function/QoL • Increased Health Costs

  38. MEASURES • Brief Pain Inventory • SCL-20 depression scale • HRQL: -- generic (SF-36) -- pain-specific (Roland) • Other pain (coping, beliefs, self-mgmt) • Other psych (anxiety, somatization) • Health care utilization (costs)

  39. BASELINE DATA

  40. Baseline Characteristics SCAMP Participants

  41. Response of pain and depression in SCAMP Trial during Phase 1 (optimized antidepressant therapy) and Phase 2 (pain self-management) End of Phase 2 End of Phase 1 Depression (PHQ-9) Pain (BPI) (n=86) (n=79) (n=54) (n=53) (n=45)

  42. Impact of Depression and Anxiety Alone and in Combination among Primary Care Patients with Chronic Musculoskeletal Pain Baseline data analysis

  43. BACKGROUND • Individually, depression and anxiety are strongly associated with chronic pain. • Little is known how psychiatric comorbidity affects patients with pain.

  44. Symptom Triangle of Reciprocating Adverse Effects Pain – – – Depression Anxiety

  45. STUDY OBJECTIVE • Among patients w/ chronic pain: • Individual and combined impact of depression and/or anxiety • Pain intensity • Pain interference • Disability days • Health-related quality of life (HRQL)

  46. METHODS • Baseline analysis of SCAMP data • 4 cohorts identified • Pain only • Pain and Anxiety • Pain and Depression • Pain, Anxiety, and Depression

  47. ANALYSES • ANOVA models to compare baseline differences four groups • pain intensity/interference • Disability days • HRQL

  48. ANALYSES • MANOVA to model pain severity and pain interference concurrently • Interaction testing • Covariates: • Sociodemographics, medical comorbidity, study site, and pain location

  49. RESULTS

  50. Patients with concomitant pain, depression, and anxiety had more severe pain BPI Interference BPI Severity Pain Score Pain Only Pain & Anxiety Pain & Depression Pain, Anxiety, & Depression

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