Sunday, October 21, 2012

Digesting the Moose Jaw adventure: Part VII Pain and depression

Older posts in this series:
Digesting the Moose Jaw adventure: Part I
Digesting the Moose Jaw adventure: Part II NERVES, baby
Digesting the Moose Jaw adventure: Part III Sensory testing for pain
Digesting the Moose Jaw adventure: Part IV Nature of Pain
Digesting the Moose Jaw adventure: Part V Mindfulness

Digesting the Moose Jaw adventure: Part VI Sensory testing 2

Dr. O. Afolabi is a UK-trained psychiatrist, originally from Nigeria, with no profile on google, who participated on the planning committee for the neuropathic pain conference, and who presented some compelling information related to pain and depression comorbidity: 

1. meds reduce pain severity by about 30-40%, in about 50% of patients, but don't usually touch the suffering
2. patients who seek treatment at chronic pain centers have had pain for a mean duration of 7 years
3. their mean age is 44 years
4. prevalence of depression in the general population: 18%. In primary care, 27%. In psychiatric clinics, 38%. In pain clinics, 52%. In orthopaedic or rheumatology clinics, 56%. (Bair 2003)
5. Looked at the other way, % of patients with mood or depressive disorders that have chronic pain is; no chronic pain, 34%; non-disabling chronic pain, 25%; disabling chronic pain, 41%. (Psychsom medicine 2006)
6. Incidence of depression in patients with non-disabling CP, 3 times higher than in those without non-disabling CP
7. In patients with disabling CP, incidence of depression was 5.4 times higher than in those without.
8. One in 5 Canadians have daily chronic pain to contend with (Schopflocher et al 2009; Gibson 2003) 

9. Economic burden of 1 out of 5 canadians with chronic pain is bigger than that of cancer, heart disease, HIV combined
10. One in 6 Canadians will experience depression at some point in their lives.
11. Direct pain care costs estimated to exceed $6B/year. Productivity costs related to job loss, sick days, estimated at $37B/year (Schopflocher 2008)
12. In Canada cost of depression estimated to exceed $25B
13.  Much greater economic cost with co-morbid depression and pain, lost work and access of health care - Suicide rate higher in this co-morbid situation
14. Biomedical, psychosocial and behavioural factors must all be assessed. Determine the patients' stressors, find out about their lives. What could they do before and what can't they do now? How does the spouse feel about the patient and the patient's situation? 
15.  Pain and depression share common neuro pathways, and share links in many other domains, such as genetic, cellular, structural, functional, neurotransmitter, and neuroendocrine. Link
16. Using PHQ9 - "you can find out in 5 minutes the extent of co-morbidity of depression and chronic pain." Scores will reveal the depression underlying the pain. Patient will tend to focus on the pain, not the depression, but test will show it. 

1. Bair MJ,  Robinson RL,  Katon W,  Kroenke K.; Depression and pain comorbidity: a literature review. Arch Intern Med. 2003 Nov 10;163(20):2433-45.

2. Lackner JM, Gudleski GD, Zack MM, Katz LA, Powell C, Krasner S, Holmes E, Dorscheimer K.; Measuring health-related quality of life in patients with irritable bowel syndrome: can less be more? Psychosom Med. 2006 Mar-Apr;68(2):312-20.

3. Marcus D; Chronic Pain: A Primary Care Guide to Practical Management (Current Clinical Practice) Humana Press; 2nd ed. 2009 edition (December 10, 2008)

4. Maletic V, Raison CL.; Neurobiology of depression, fibromyalgia and neuropathic pain. Front Biosci. 2009 Jun 1;14:5291-338. (Full text)

5.Clauw DJ, Chrousos GP. Chronic pain and fatigue syndromes: overlapping clinical and neuroendocrine features and potential pathogenic mechanisms. Neuroimmunomodulation. 1997 May-Jun;4(3):134-53.

6. Lisa C Campbell, Daniel J Clauw, Francis J Keefe; Persistent pain and depression: a biopsychosocial perspective. Biological Psychiatry Volume 54, Issue 3, 1 August 2003, Pages 399–409

7. A K P Jones, B Kulkarni and S W G Derbyshire; Pain mechanisms and their disorders Imaging in clinical neuroscience. British Medical Bulletin Volume 65, Issue 1 83-93.

8. Stahl S, Briley M. Understanding pain in depression. Hum Psychopharmacol. 2004 Oct;19 Suppl 1:S9-S13.

9. Arnow BA, Blasey CM, Lee J, Fireman B, Hunkeler EM, Dea R, Robinson R, Hayward C.; Relationships among depression, chronic pain, chronic disabling pain, and medical costs. Psychiatr Serv. 2009 Mar;60(3):344-50.

10. Yiannakoulias, N, Svenson LW, Schopflocher DP. (2009). An integrated framework for the geographic surveillance of chronic disease. International Journal of Health Geographics, 8:69 (open access)

11. Patten, SB, Schopflocher, D. (2009). Longitudinal epidemiology of major depression as assessed by the Brief Patient Health Questionnaire (PHQ-9). Comprehensive Psychiatry, 50, 26-33.

12. Lynch ME, Schopflocher D, Taenzer P, Sinclair, C. (2009). Research funding for pain in Canada. Pain Research and Management, 14(2), 113-115.

13. Rashiq S, Schopflocher D, Taenzer, P (Editors) (2008) Chronic Pain: A Health Policy Perspective, In Jonsson, E. (Series Editor) Health Care And Disease Management Series, John Wiley, ISBN: 978-3-527-32382-1.

* There were two more references under the topic of comorbidities, but they were impossible to read from a tiny 6-slide to a page, B&W photocopy, even under magnification, so they are missing from this list.  Also I couldn't find Gibson 2003, nor am I certain I could find the correct Schopflocher reference, so I brought all from 2009.

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