Treating pain with depression

Pain, the most common reason for adults to visit a primary care physician, and depression, the most frequent mental complaint requiring a doctor's appointment, occur together as often as half the time.

Researchers from the Indiana University School of Medicine and the Regenstrief Institute report in the May 27 issue of the Journal of the American Medical Association (JAMA) that a strategy they developed of closely monitored antidepressant therapy coupled with pain self-management can produce substantial improvements in both depression and pain.

"Treating depression these days is like treating high blood pressure. There are many effective drugs out there. To control high blood pressure, the physician closely monitors the patient to determine the most appropriate drug and the proper dosage. Often with depression treatment, the patient is prescribed one of the many effective antidepressants but is not closely followed to see if it's the best choice and the proper dosage, which means the patient's depression is not being effectively managed," said the study's principal investigator, Kurt Kroenke, M.D., professor of medicine at the IU School of Medicine and a Regenstrief investigator.

"There are more significant challenges in treating patients with persistent pain. Ironically research on effective pain treatment has lagged a couple of decades behind work on depression and the drug choices are not as good. More study on the basic science and clinical levels needs to be done on both pain and the link between pain and depression, which may share common biological pathways, to develop better options," said Dr. Kroenke, an Indiana University-Purdue University Indianapolis Chancellor's Professor.

The 250 individuals in the JAMA study had low back, hip, or knee pain for three months or longer and at least moderate depression. They were randomized into two groups. The control group of 127 received usual care from their internists for both depression and pain. The other 123 received careful monitoring of the medications prescribed for their depression plus 12 weeks of pain self-management training. This training included muscle relaxation and deep breathing exercises as well as coping, distraction and other tactics.

Those whose depression medications were closely monitored and who were trained in pain self- management were two to three times more likely to have decreased depression than those in the control group. Pain severity and disability also lessened. These benefits continued for the six months after optimizing antidepressant therapy and pain self-management had been completed.

"We were pleased to see the patients whose anti-depressants were closely monitored and who practiced self-management improved, but we think we can lessen pain and depression even more. In our next studies we plan to investigate cognitive behavioral therapy as well as optimizing pain medications to see if even greater improvements in pain can be achieved. Because pain and depression are among the leading causes of decreased work productivity, a strategy that is effective for both should be attractive not only to patients and their physicians. Health insurers and the business community will be interested as well," said Dr. Kroenke, an internist who is a former president of the Society of General Internal Medicine.