Guido Magni

Chronic musculoskeletal pain and depressive symptoms in the national health and nutrition examination I. Epidemiologic follow-up study

&NA; We report here follow‐up data on subjects who were examined in two surveys conducted by the United States Center for Health Statistics at an interval of 8 years. The first survey was the 1st National Health and Nutrition Examination Survey (NHANES‐1), and the second conducted 8 years later was the National Health and Nutrition Epidemiologic Follow‐up Study (NHEFS). From an original sample of 3023 subjects, 153 were known to be deceased, leaving a potential sample of 2870 cases, of whom 2341 were ultimately examined in the NHEFS. The definition of pain used in the NHANES‐1 survey identified 15% of the subjects as suffering from persistent pain. Using a different pain definition, in the NHEFS, the frequency of subjects with chronic pain was 32.8%. Applying this second definition, the percentage of subjects with chronic pain in the NHANES‐1 had risen from 15 to 20.2. Some subjects (32.5%) who originally had chronic pain were free from pain at the time of follow‐up; 59% of the subjects with chronic pain on follow‐up did not have it initially. As found originally in the NHANES‐1, the group with chronic pain at the NHEFS comprised significantly more females, older people, and people with lower income. On logistic regression analysis the strongest relationship found at the NHEFS between the variables examined was between chronic pain and depression. Using a cut‐off point of ⩾ 20 on the Center for Epidemiologic Studies Depression scale (CESD), 16.4% of the subjects with chronic pain were depressed compared with 5.7% among those with no chronic pain (corrected odds ratio 3.26, confidence intervals 2.4–4.43).

Chronic musculoskeletal pain and depressive symptoms in the general population. An analysis of the 1st National Health and Nutrition Examination Survey data

&NA; Chronic pain and depression frequently occur together. A selection bias afflicts all hospital clinic and family practice populations in which this relationship has been examined. We report here some of the results from civilian populations outside institutions, examined in the United States in national surveys. The findings are based upon the recollection of individuals with respect to the period of 12 months prior to interview and upon the occurrence of depression in the previous week as indicated by the answers to the Depression Scale of the Centre for Epidemiologic Studies (CES‐D). They indicate that 14.4% of the United States population between the ages of 25–74 suffer from definite chronic pain related to the joints and musculoskeletal system. Another 7.4% have some pain of uncertain duration. Eighty‐three percent of the definite pain group received treatment. Chronic pain subjects scored significantly higher than normals on the CES‐D (10.68 ± S.E.M. 0.76 vs. 8.05 ± 0.23, P < 0.01) with subjects with pain of uncertain duration scoring similar to the definite chronic pain population (11.13 ± 0.76). Using a high cut‐off score for depression, 18% of the population with chronic pain were found to have depression. This is in contrast to 8% of the population who did not have chronic pain.

Depressive and distress symptoms as predictors of low back pain, neck-shoulder pain, and other musculoskeletal morbidity: a 10-year follow-up of metal industry employees

&NA; Six‐hundred‐seven employees in 3 metal industry plants were studied for depressive and distress symptoms, musculoskeletal symptoms, and findings in the musculo‐skeletal system made by a physiotherapist. Measurements were made 3 times at 5‐year intervals. The mean distress and depressive symptom scores of the first 2 examinations predicted the change in several musculo‐skeletal symptom measures during the second 5‐year period, when the effects of age and occupational class were accounted for in multiple regression analysis. They also predicted the development in clinical musculoskeletal findings in men. The proportions of variance explained by the depressive and distress symptoms were modest in magnitude. Analogous analyses were made with reference to the reverse temporal sequence: musculoskeletal disorders were considered as predating the development in depressive and distress symptoms. The musculoskeletal symptom scores were associated with the change in the stress symptoms in men, as did the clinical findings in the neck‐shoulder and low back regions. None of the musculoskeletal morbidity scores predicted the change in the depressive symptoms in either sex. We conclude that depressive symptoms predict future musculoskeletal disorders, but not vice versa, whereas the association of stress symptoms and musculoskeletal disorders is reciprocal.

The use of antidepressants in the treatment of chronic pain. A review of the current evidence.

SummaryIn the last 30 years antidepressant drugs have been used increasingly in the treatment of patients with chronic pain. This article reviews the results of some 40 placebo-controlled studies. It is difficult to make comparisons between the various studies because they often differ in terms of pain conditions, patient selection, antidepressant drug used, dosages, trial design, etc. However, in spite of this heterogeneity and other methodological problems it is clear that a wide range of pain conditions are responsive to antidepressant drug treatment, in particular: headache, migraine, facial pain, neurogenic pain, fibrositis, and probably arthritis and rheumatoid arthritis. More data need to be gathered in cancer pain, and in other conditions such as low back pain for which no, or very limited, effect has been shown.The beneficial effects of antidepressant drugs is in most cases of a mild to moderate degree, some time lag is necessary before it is completely manifest, and it tends to persist over time if drug treatment is continued in the long term. Strong evidence of efficacy is not evident for all the antidepressants, and there are probably significant differences in this respect between various drugs. The effect of a drug on pain does not seem necessarily to be related to its effect on mood.Further studies are needed to clarify this topic, and it will be necessary to examine specific pain conditions, compare different antidepressants, with reference to each other and to placebo, further investigate the role of drug plasma concentrations and control for the presence of concomitant psychiatric disturbances and for organic lesions responsible for the pain symptomatology.

Chronic abdominal pain and depression. Epidemiologie findings in the United States. Hispanic health and nutrition examination survey

&NA; We report data on abdominal pain and depression from a survey of Hispanic Americans by the United States National Center for Health Statistics. The point prevalence rates of chronic abdominal pain were 4.6% in Mexican Americans and 5.8% in Cuban Americans in a total of 4175 subjects. The rate was 8.3% among 1323 Puerto Ricans. In 53% the abdominal pain came in waves. Using the Depression scale of the Center for Epidemiologie Studies (CES‐D), 18.7% of Mexican and Cuban Americans with pain were found to be depressed to an extent likely to require intervention, and 40.8% of Puerto Ricans were so affected. The Diagnostic Interview Schedule (DIS) gave more conservative figures for major depression in terms of DSM‐III, viz., 6.8% for Mexican and Cuban Americans with chronic pain, and 12.6% for Puerto Ricans with chronic pain. Logistic regression analyses demonstrated links between depression and female sex, the single state, low education and income, and chronic abdominal pain. The most consistent relationships for depression were with chronic pain, female sex and the single state. The results confirm the strong relationships between chronic pain, mood and female gender, and other socio‐demographic variables.

Assessment of depression in an elderly medical population

Two self-rating depression scales, the Depression Factor Score derived from the SCL-90 and the Geriatric Depression Scale were administered to 220 medical geriatric in-patients, and two psychiatrists, after a clinical interview, made a diagnosis according to the DSM-III criteria for affective disorders. Eighteen patients were found to be affected by major depression, 49 by dysthymic disorder, 14 by atypical depression and 13 by an adjustment disorder with depressive mood. Women and single persons proved to be significantly more affected by depressive disturbances. The performance of both scales was good, so that they seem to be useful instruments aiding the non-specialist physician in a rapid screening procedure for the identification of depression in elderly patients with medical problems.

Antidepressants in the treatment of cancer pain. A survey in Italy

&NA; The authors sent a questionnaire to 79 Italian oncological centres to investigate the use of antidepressants in the treatment of cancer pain. Thirty‐five centres (44.3%) responded; twenty‐two of these used antidepressants. About 43% of the subjects treated for cancer‐related pain received antidepressants. The drug most frequently used was amitriptyline, followed by imipramine, clomipramine and trazodone. The dosages were relatively varied, in some cases under the minimum normally used in antidepressant therapy. Good or fair results were reported in 51% of the patients; the inclusion of all worthwhile responses raised the proportion with benefit to 98%. The majority of the centres stated that a depressive disorder or depressive symptoms were not a necessary precondition for the prescription of antidepressants. The occurrence of side‐effects seems to be higher in cancer patients than in depressed subjects; this may be partly related to the fact that in nearly all cases, antidepressants are used in association with other drugs, typically opiates and peripheral analgesics.

Depression in Geriatric and Adult Medical Inpatients.

The authors administered two scales for the evaluation of depression, the Zung SDS and the DFS (Depression Factor Score), derived from the SCL-90, to two groups of medical inpatients: One composed of adult subjects (N = 201) and the other of geriatric subjects (N = 178). The results confirm a high presence of depressive symptoms among patients with medical problems, particularly among geriatric subjects; the prevalence of depression was 20.39% for the adults and 42.13% for the elderly patients. High indices of correlation between the two scales were found for both populations. A multiple regression analysis indicated that the factors most predictive of depressive symptoms are female sex and the presence of somatic symptoms likely to lead to disability for elderly subjects and low social class and female sex for adults.

Pain as a symptom in elderly depressed patients

SummaryThe presence of pain as a symptom has been studied in a series of 51 depressed elderly inpatients and in a control group of 71 subjects. The frequency of patients with moderate to severe pain was significantly higher in the experimental group (72%) than in the controls (33.8%). Of the various categories diagnosed according to the DSM III° criteria, the highest scores for pain were gained by the subjects suffering from dysthymic disorder and atypical depression, while those obtained by the patients with major depression and adjustment disorder with depressive mood were lower. The difference does not seem to depend on the quantity of anxiety present.

Longitudinal evaluations of psychological distress in parents of children with malignancies.

ABSTRACT. The authors evaluated the psychological distress in 41 parents of children with acute lymphocytic leukaemia or with Hodgkins disease using the Symptom Distress Checklist (SCL‐90). The subjects were tested three times: within the first few days after the childs admission to hospital and 8 months and 20 months later. The experimental population was compared with a control group of 25 subjects matched for age, sex, marital status and social class. At the first evaluation the experimental group had higher mean scores than the controls for obsession, depression, anxiety and sleep disturbances. Seventy‐eight % of the subjects (65.8 % excluding the sleep disturbances (SIDi) subscale) scored moderate distress on at least one of the SCL‐90 subscales. The 8 month and 20 month follow‐ups confirmed the presence of high scores of psychological distress particularly in the sleep disturbances and depression subscales, with 78 % (58.4 % excluding SIDi) and 82.3 % (70 % excluding SIDi) of the subjects gaining scores of moderate distress in at least one of the subscales of the SCL‐90.