Paul E. Stang

Chronic spinal pain and physical-mental comorbidity in the United States: Results from the national comorbidity survey replication

This paper investigates comorbidity between chronic back and neck pain and other physical and mental disorders in the US population, and assesses the contributions of chronic spinal pain and comorbid conditions to role disability. A probability sample of US adults (n=5692) was interviewed. Chronic spinal pain, other chronic pain conditions and selected chronic physical conditions were ascertained by self‐report. Mood, anxiety and substance use disorders were ascertained with the Composite International Diagnostic Interview (CIDI). Role disability was assessed with questions about days out of role and with impaired role functioning. The 1 year prevalence of chronic spinal pain was 19.0%. The vast majority (87.1%) of people with chronic spinal pain reported at least one other comorbid condition, including other chronic pain conditions (68.6%), chronic physical conditions (55.3%), and mental disorders (35.0%). Anxiety disorders showed as strong an association with chronic spinal pain as did mood disorders. Common conditions not significantly comorbid with chronic spinal pain were diabetes, heart disease, cancer, and drug abuse. Chronic spinal pain was significantly associated with role disability after controlling for demographic variables and for comorbidities. However, comorbid conditions explained about one‐third of the gross association of chronic spinal pain with role disability. We conclude that chronic spinal pain is highly comorbid with other pain conditions, chronic diseases, and mental disorders, and that comorbidity plays a significant role in role disability associated with chronic spinal pain. The societal burdens of chronic spinal pain need to be understood and managed within the context of comorbid conditions.

Lifetime co-morbidities between social phobia and mood disorders in the US National Comorbidity Survey.

BACKGROUND General population data were used to study co-morbidities between lifetime social phobia and mood disorders. METHODS Data come from the US National Comorbidity Survey (NCS). RESULTS Strong associations exist between lifetime social phobia and major depressive disorder (odds ratio 2.9), dysthymia (2.7) and bipolar disorder (5.9). Odds ratios increase in magnitude with number of social fears. Reported age of onset is earlier for social phobia than mood disorders in the vast majority of co-morbid cases. Temporally-primary social phobia predicts subsequent onset of mood disorders, with population attributable risk proportions of 10-15%. Social phobia is also associated with severity and persistence of co-morbid mood disorders. CONCLUSIONS Social phobia is a commonly occurring, chronic and seriously impairing disorder that is seldom treated unless it occurs in conjunction with another co-morbid condition. The adverse consequences of social phobia include increased risk of onset, severity and course of subsequent mood disorders. Early outreach and treatment of primary social phobia might not only reduce the prevalence of this disorder itself, but also the subsequent onset of mood disorders.

Impact of Pain on Depression Treatment Response in Primary Care

Objective Pain commonly coexists with depression, but its impact on treatment outcomes has not been well studied. Therefore, we prospectively evaluated the impact of comorbid pain on depression treatment response and health-related quality of life. Methods We analyzed data from the ARTIST study, a randomized controlled trial with naturalistic follow-up conducted in 37 primary care clinics. Participants were 573 clinically depressed patients randomized to one of three selective serotonin reuptake inhibitor (SSRI) antidepressants: fluoxetine, paroxetine, or sertraline. Depression as assessed by the Symptom Checklist-20 (SCL-20) was the primary outcome. Secondary outcomes included pain and health-related quality of life. Results Pain was reported by more than two thirds of depressed patients at baseline, with the severity of pain mild in 25% of patients, moderate in 30%, and severe in 14%. After 3 months of antidepressant therapy, 24% of patients had a poor depression treatment response (ie, SCL-20 >1.3). Multivariate odds ratios for poor treatment response were 1.5 (95% confidence interval, 0.8–3.2) for mild pain, 2.0 (1.1–4.0) for moderate pain, and 4.1 (1.9–8.8) for severe pain compared with those without pain. Increasing pain severity also had an adverse impact on outcomes in multiple domains of health-related quality of life. Conclusions Pain is present in two thirds of depressed primary care patients begun on antidepressant therapy, and the severity of pain is a strong predictor of poor depression and health-related quality of life outcomes at 3 months. Better recognition, assessment, and treatment of comorbid pain may enhance outcomes of depression therapy.

Comorbid Mental Disorders Account for the Role Impairment of Commonly Occurring Chronic Physical Disorders: Results From the National Comorbidity Survey

Specify the effects of four common chronic physical disorders on role impairment (sickness absence days plus work cut-back days), and their association with comorbid mental disorders.Describe the individual and joint effects of mental disorder and physical disorder on role impairment.Evaluate competing explanations of the apparent connection between mental comorbidity and role impairment. Most health and work productivity studies have focused on individual conditions without considering comorbidity. We illustrate the implication of this neglect by examining the effects of comorbid mental disorders on role impairment (number of sickness absence and work cut-back days in the past month) among people with chronic physical disorders. A nationally representative household survey of 5877 respondents assessed current mental and physical disorders and role impairments. Four physical disorders were sufficiently common to be studied: hypertension, arthritis, asthma, and ulcers. All 4 physical disorders were associated with significant role impairments in bivariate analyses. However, further analysis showed that these impairments were almost entirely confined to cases with comorbid mental disorders. Effectiveness trials in workplace samples are needed to evaluate the cost-effectiveness of treating comorbid mental disorders among workers with chronic physical disorders.

Using the World Health Organization Health and Work Performance Questionnaire (HPQ) to Evaluate the Indirect Workplace Costs of Illness

This report presents an overview of methodological issues in estimating the indirect workplace costs of illness from data obtained in employee surveys using the World Health Organization Health and Work Performance Questionnaire (HPQ). The HPQ is a brief self-report questionnaire that obtains three types of information: screening information about the prevalence and treatment of commonly occurring health problems; information about three types of workplace consequences (sickness absence, presenteeism, and critical incidents); and basic demographic information. The report considers two sets of methodological issues. The first set deals with measurement. The rationale for the HPQ approach to measurement is described in this section. In addition, data are presented regarding the accuracy of HPQ measures, documenting that the HPQ has excellent reliability, validity, and sensitivity to change. The second set of methodological issues deals with data analysis. A number of analysis problems are reviewed that arise in using self-report nonexperimental survey data to estimate the workplace costs of illness and the cost-effectiveness of treatment. Innovative data analysis strategies are described to address these problems.

Advancing the Science for Active Surveillance: Rationale and Design for the Observational Medical Outcomes Partnership

The U.S. Food and Drug Administration (FDA) Amendments Act of 2007 mandated that the FDA develop a system for using automated health care data to identify risks of marketed drugs and other medical products. The Observational Medical Outcomes Partnership is a public-private partnership among the FDA, academia, data owners, and the pharmaceutical industry that is responding to the need to advance the science of active medical product safety surveillance by using existing observational databases. The Observational Medical Outcomes Partnerships transparent, open innovation approach is designed to systematically and empirically study critical governance, data resource, and methodological issues and their interrelationships in establishing a viable national program of active drug safety surveillance by using observational data. This article describes the governance structure, data-access model, methods-testing approach, and technology development of this effort, as well as the work that has been initiated.

Sleep Problems, Comorbid Mental Disorders, and Role Functioning in the National Comorbidity Survey Replication

BACKGROUND Little is known about the population prevalence of sleep problems or whether the associations of sleep problems with role impairment are due to comorbid mental disorders. METHODS The associations of four 12-month sleep problems (difficulty initiating or maintaining sleep, early morning awakening, nonrestorative sleep) with role impairment were analyzed in the National Comorbidity Survey Replication controlling 12-month DSM-IV anxiety, mood, impulse-control, and substance disorders. The WHO Composite International Diagnostic Interview was used to assess sleep problems and DSM-IV disorders. The WHO Disability Schedule-II (WHO-DAS) was used to assess role impairment. RESULTS Prevalence estimates of the separate sleep problems were in the range 16.4-25.0%, with 36.3% reporting at least one of the four. Mean 12-month duration was 24.4 weeks. All four problems were significantly comorbid with all the 12-month DMS-IV disorders assessed in the survey (median OR: 3.4; 25(th)-75(th) percentile: 2.8-3.9) and significantly related to role impairment. Relationships with role impairment generally remained significant after controlling comorbid mental disorders. Nonrestorative sleep was more strongly and consistently related to role impairment than were the other sleep problems. CONCLUSIONS The four sleep problems considered here are of public health significance because of their high prevalence and significant associations with role impairment.

Chronic medical conditions and work performance in the health and work performance questionnaire calibration surveys.

Associations between chronic conditions and work performance (absenteeism, presenteeism, and critical incidents) were studied in reservation agents, customer service representatives, executives, and railroad engineers. Conditions and work performance were assessed with the World Health Organization’s Health and Work Performance Questionnaire. Analysis of covariance was used to estimate associations. More work performance was lost from presenteeism than absenteeism. However, chronic conditions more consistently had negative impacts on absenteeism than presenteeism. Conditions with significant effects included arthritis, asthma, chronic obstructive pulmonary disease–emphysema, depression, and chronic headaches. Arthritis had the largest aggregate effect on absenteeism–presenteeism. Only depression affected both absenteeism–presenteeism and critical incidents. Some chronic conditions have substantial workplace effects. Disease management programs for these conditions might have a positive return on investment (ROI). Health and productivity tracking surveys are needed to evaluate ROI and provide quality assurance.

Costs of care for irritable bowel syndrome Patients in a health maintenance organization

Abstract OBJECTIVES: The aims of this study were: 1) to determine the total costs of care and costs related to lower GI–related problems for patients who received a diagnosis of irritable bowel syndrome (IBS), and 2) to compare them to age- and sex-matched population controls and patients treated for inflammatory bowel disease (IBD) or gastroesophageal reflux disease (GERD). METHODS: Use and cost data were obtained through the computerized information systems of a large staff-model health maintenance organization on three groups of patients diagnosed in 1994 or 1995 with IBS, IBD, or GERD; and an age- and sex-matched control group of patients without any of these listed diagnoses. The IBS patient group was compared to the three comparison groups on components of total and IBS-related costs. RESULTS: Total costs of care for IBS patients were 49% higher than population controls during the year starting with the visit at which IBS patients were identified. In the index year, every component of total costs except inpatient care was significantly higher for IBS patients than for population controls. The costs of care for lower GI problems were significantly higher for patients with IBS than for population controls across a range of services. However, only 33% of the difference in total costs of care between IBS patients and population controls was due to lower GI–related services in the index year. In the subsequent years, lower GI–related services accounted for 18% and 20% of the total cost difference between IBS patients and population controls. The total costs of care as well as the components of costs of care were generally higher for IBD patients than for IBS patients, but were comparable for GERD and IBS patients. CONCLUSIONS: Patients with IBS show sustained increases in health care costs relative to population controls for both lower GI services and care unrelated to lower GI problems. However, the majority of the excess in health care costs resulted from medical care not directly related to lower GI problems.

Angioedema Incidence in US Veterans Initiating Angiotensin-Converting Enzyme Inhibitors

Angioedema is a rare but potentially serious complication of angiotensin-converting enzyme inhibitor (ACE) use. We conducted a study to estimate incidence of ACE-related angioedema and explore its determinants in a large racially diverse patient population. We used linked medical and pharmacy records to identify all patients in the US Veterans Affairs Health Care System from April 1999 through December 2000 who received first prescriptions for antihypertensive medications. We studied 195 192 ACE initiators and 399 889 patients initiating other antihypertensive medications (OAH). New angioedema was identified by diagnosis codes using methods validated in a national sample of 869 angioedema cases with confirmation for over 95% of cases. Overall, 0.20% of ACE initiators developed angioedema while on the medication and the incidence rate was 1.97 (1.77 to 2.18) cases per 1000 person years. This compares with a rate of 0.51 (0.43 to 0.59) in OAH initiators and the adjusted relative risk estimate was 3.56 (2.82 to 4.44). Fifty five percent of cases occurred within 90 days of first ACE use but risk remained elevated with prolonged use, even beyond 1 year. We estimate that 58.3% of angioedema in patients starting antihypertensives was related to ACE. We also found that angioedema rates were nearly 4-fold higher in blacks, 50% higher in women, and 12% lower in those with diabetes. This study provides a reliable estimate of angioedema incidence associated with ACE use in a diverse nontrial patient population, confirming that the incidence is low, but finding substantial variation by race, sex, and diabetes status.