Randy S. Roth

Assessing depression among persons with chronic pain using the center for epidemiological studies-depression scale and the beck depression inventory: A comparative analysis

OBJECTIVE This study examined the ability of two self-report questionnaires, the Beck Depression Inventory (BDI) and the Center for Epidemiological Studies-Depression Scale (CES-D), to discriminate between chronic pain patients with and without major depression. Since previous research has suggested that medical conditions such as chronic pain can influence the endorsement of items that measure neurovegetative symptoms of depression, the accuracy of each of these questionnaires was also assessed eliminating these items. SUBJECTS These included 132 consecutive patients with chronic pain, 44 of whom were diagnosed as suffering from major depression according to DSM-IV criteria. METHODS Patients were administered a battery of questionnaires that included the CES-D and BDI. They were also interviewed by a clinical psychologist to determine the presence or absence of major depression. RESULTS Both questionnaires were able to discriminate significantly between persons with and without major depression. Removal of the somatic items on each questionnaire did not improve their accuracy. Discriminant function analysis revealed an optimal cut-off score of 21 for the BDI, and 27 for the CES-D. Overall hit rates at these cut-offs for the two questionnaires were comparable, while the CES-D had somewhat better sensitivity (81.8% vs. 68.2%). Conversely, the BDI had slightly better specificity (78.4% vs. 72.7%). CONCLUSION The results suggest that both questionnaires have good predictive validity among chronic pain patients, and decisions regarding the use of one questionnaire rather than the other may depend upon the goals of the user and the setting within which the questionnaire is used.

Prospective analysis of psychosocial outcomes in breast reconstruction: one-year postoperative results from the Michigan Breast Reconstruction Outcome Study.

In the past decade, changing attitudes toward breast reconstruction among both patients and providers have led a growing number of women to seek breast reconstruction after mastectomy. Although investigators have documented the psychological, social, emotional, and functional benefits of breast reconstruction, little research has evaluated the effects of procedure choice on these outcomes. The current study prospectively evaluated and compared psychosocial outcomes for three common options for mastectomy reconstruction: tissue expander/implant, pedicle TRAM, and free TRAM techniques. In a prospective cohort design, patients undergoing postmastectomy reconstruction for the first time with expander/implant, pedicle TRAM, or free TRAM procedures were recruited from 12 centers and 23 plastic surgeons in the United States and Canada. Before reconstruction and at 1 year after reconstruction, patients were evaluated by a battery of questionnaires consisting of both generic and condition-specific surveys. Outcomes assessed included emotional well-being, vitality, general mental health, social functioning, functional well-being, social well-being, and body image. Baseline (preoperative) scores and the change in scores (the difference between postoperative and preoperative scores) were compared across procedure types using t tests and analysis of covariance. Preoperative and 1-year postoperative surveys were obtained from 273 patients. Procedure type was reported in 250 patients, of whom 56 received implant reconstructions, 128 pedicle TRAM flaps, and 66 free TRAM flaps. A total of 161 immediate and 89 delayed reconstructions were performed. Among women receiving immediate reconstruction, significant improvements were observed in all psychosocial variables except body image. However, no significant effects of procedure type on these changes over time existed. Similarly, delayed reconstruction patients had significant increases in emotional well-being, vitality, general mental health, functional well-being, and body image. Although the choice of reconstructive technique did not significantly impact most of these outcomes, significant differences existed among procedure types for three psychosocial subscales. Patients undergoing delayed expander/implant reconstructions reported greater improvements in vitality and social well-being relative to women receiving delayed TRAM procedures. By contrast, delayed TRAM patients noted significantly greater gains in body image compared with women choosing delayed expander-implant reconstruction. The authors conclude that both immediate and delayed breast reconstructions provide substantial psychosocial benefits for mastectomy patients. Although the choice of reconstructive procedure does not seem to significantly affect improvements in psychosocial status with immediate reconstruction, our data suggest that procedure type does have a significant effect on gains in vitality and body image for women undergoing delayed reconstruction.

The relationship between symptoms of post-traumatic stress disorder and pain, affective disturbance and disability among patients with accident and non-accident related pain

&NA; Recent studies have reported a high prevalence of symptoms of post‐traumatic stress disorder (PTSD) among individuals with chronic pain. Studies suggest that persons with pain and PTSD also display higher levels of affective disturbance. In the present study we examined self‐reports of pain, affective disturbance, and disability among pain patients with and without symptoms of PTSD. Patients without PTSD symptoms were further subdivided into persons whose pain was the result of an accident or insidious in onset. Thus, three groups were examined: (1) persons with accident related pain and high PTSD symptoms (Accident/High PTSD); (2) persons with no or few symptoms of PTSD whose pain was accident related (Accident/Low PTSD); and (3) patients whose pain was not accident related and did not have PTSD symptoms (No Accident). No Accident patients were older than persons with accident related injuries, and both accident related pain groups were more likely than No Accident patients to be involved in litigation or receiving compensation. Thus, these variables were controlled for in the statistical analyses. Self‐report of pain was also included as a covariate in the analyses examining group differences in affective disturbance and disability. Accident/High PTSD patients displayed higher levels of self‐reported pain compared to the other two groups. The Accident/High PTSD group also had the highest levels of affective disturbance. Both accident groups tended to report greater disability compared to patients whose pain was not accident related. These findings suggest that PTSD symptoms in chronic pain patients are associated with increased pain and affective distress. Accident related pain, even without the presence of PTSD symptoms, appears to be associated with greater disability. The results indicate that the identification and treatment of PTSD symptoms in refractory pain patients may be a critical albeit subtle factor in the effective management of suffering and disability in this population.

Negative Affect, Self-report of Depressive Symptoms, and Clinical Depression: Relation to the Experience of Chronic Pain

OBJECTIVE The goal of this study was to examine the relative importance of global affective distress, self-report of depressive symptoms, and presence or absence of major depression to the experience of chronic pain. SETTING A multidisciplinary pain program at a university medical center was the setting for this study. PATIENTS Subjects in this study were 211 consecutive patients with chronic pain. OUTCOME MEASURES Pain duration, compensation, and litigation status were controlled for in the statistical analyses, as each correlated significantly with at least one of the measures of affect. Global affective distress was assessed using the Global Severity Index (GSI) from the Brief Symptom Inventory. The Beck Depression Inventory and the Center for Epidemiological Studies Depression Scale were used as measures of self-report of depressive symptoms. Presence or absence of major depression was based on DSM-IV criteria. RESULTS AND CONCLUSIONS The GSI, Beck Depression Inventory, and Center for Epidemiological Studies Depression Scale were significantly correlated with each measure of the experience of pain, although clinical depression was only significantly related to self-reported disability and negative thoughts about pain. The self-report measures of depression maintained their relation to the dependent measures when the somatic items from the scales were removed, suggesting that the relations were not spuriously due to the influence of pain symptoms on the scales. When examining the unique contribution of each variable to the experience of pain (by simultaneously controlling for the other measures of affect), the GSI was uniquely related to the sensory and affective components of pain. Self-report of depressive symptoms was more highly related to a measure of the evaluative component of pain and uniquely related to self-reported disability and negative thoughts about pain. The results are discussed within the context of theoretical models of the relation between pain and affect, and suggestions for future research are presented.

Quality of life and affective distress in women seeking immediate versus delayed breast reconstruction after mastectomy for breast cancer

Background: This study compared the presurgical psychosocial and functional status of 238 women seeking breast reconstruction, either at the time of their mastectomy (immediate) (n = 151) or after prior mastectomy (delayed) (n = 87). Delayed subjects were further categorized in groups of time-since-mastectomy to examine the effects of time on postmastectomy psychosocial adjustment. Methods: Presurgical measures of quality of life, psychological distress, and somatic anxiety were obtained. Results: The results revealed relative impairment of quality of life and psychosocial functioning for immediate compared with delayed subjects. Immediate subjects reported greater disturbance in general mental health functioning, more severe impairment in emotional well being related to their cancer diagnosis, and higher levels of anxiety. Immediate subjects also reported a trend toward greater disturbance in work and daily activities, more frequent interference in social activities, and less vitality. Similarly, it was noted that the immediate group reported greater impairment in physical and functional well being related to their cancer adjustment. On psychological assessment, immediate subjects were more likely to report higher levels of affective distress, depressive symptoms, and obsessive-compulsive traits. For the delayed group, no statistically significant differences in the dependent measures were obtained when comparing subjects at 1 year, 2 years, and more than 2 years after mastectomy. Conclusions: Women seeking immediate reconstruction at the time of mastectomy show a relatively higher incidence of psychosocial impairment and functional disability. Women who undergo mastectomy demonstrate early restoration of psychosocial health within the first year after surgery. Patient preoperative psychosocial distress may have important implications for clinical decision-making and surgical outcome for women seeking combined mastectomy and breast reconstruction.

Knowledge of and Agreement with Chronic Pain Diagnosis: Relation to Affective Distress, Pain Beliefs and Coping, Pain Intensity, and Disability

Many authors report that a high percentage of patients with chronic pain have no or insufficient underlying physical pathology to explain their pain. Even when patients do have an identified diagnosis, many patients profess to have little understanding of the source of their pain or fear that they may suffer from more severe pathology. This may be particularly true for patients with chronic musculoskeletal pain given the lack of “objective” findings for soft tissue pain complaints. In the present study, we examined whether chronic neck and back pain patients were able to identify the physiologic source of their pain, and based on their responses patients were placed in one of three groups: (1) patients who did not know the cause of their pain; (2) patients who did know the cause and agreed with their clinical diagnosis; and (3) patients who identified a cause for their pain that was different from their clinical diagnosis. The sample was comprised primarily of individuals with musculoskeletal pain problems (70%) referred to an outpatient chronic pain rehabilitation program. Each patient completed a pretreatment test battery, and group differences were examined on responses to the McGill Pain Questionnaire, Survey of Pain Attitudes, Brief Symptom Inventory, Coping Strategies Questionnaire, and Pain Disability Index. Upon initial evaluation, 47.2%(n = 85) of patients indicated that they did not know what was causing their pain. Of patients who articulated a cause for their pain, 20%(n = 36) attributed it to factors that did not agree with their diagnosis. Only 32.8%(n = 59) of persons in the entire sample were able to accurately identify the cause of their pain. Patients who disagreed with their clinical diagnosis were more likely to be diagnosed with musculoskeletal pain and reported the highest levels of pain(F(2,169) = 3.41, p > .05) as well as the greatest levels of affective distress(F(2,169) = 3.54, p > .05). Patients who were unsure of or disagreed with their diagnosis tended to report a greater belief in pain being a signal of harm(F(2,169) = 11.5, p > .001) and described themselves as more disabled(F(2,169) = 8.43, p > .001). In addition, both the “unsure” and “disagree” groups tended to use maladaptive pain strategies more frequently, and persons unsure of their diagnosis had the lowest levels of perceived control over pain. A hierarchical regression analysis examining a cognitive/behavioral model of pain disability indicated that lack of knowledge of pain etiology, a belief that pain is a signal of harm, catastrophizing and affective distress all significantly predicted increased disability, while pain intensity did not. The data suggests that lack of knowledge about the origin of pain is associated with maladaptive cognitions in relation to pain (i.e., fear of harming oneself and catastrophizing) and increased emotional distress which in turn are related to heightened disability due to pain. These data argue that educating patients regarding their diagnosis and the origin of their pain, thereby dispelling dysfunctional pain beliefs, may be an important component of pain treatment, particularly among patients with chronic musculoskeletal pain.

Educational achievement and chronic pain disability: Mediating role of pain-related cognitions

ObjectiveThis study examined the relation between level of educational achievement (LOE) and the clinical morbidity associated with chronic pain. SettingA multidisciplinary pain rehabilitation program located within a university hospital. PatientsTwo hundred ninety-nine consecutive patients with chronic spinal pain, average age 39.6 years (SD = 10.7) and with an average duration of pain of 41.9 months (SD = 51.6). Outcome MeasuresAge, duration of pain, sex, and compensation and litigation status were controlled for in the statistical analysis because each was found to be significantly associated with LOE. Pain intensity was assessed by the McGill Pain Questionnaire. Affective distress was assessed by the Global Severity Index from the Brief Symptom Inventory. Severity of depressive symptoms was derived from scores from the Center for Epidemiological Studies—Depression Scale. Pain beliefs and pain coping strategies were assessed by the Survey of Pain Attitudes and the Coping Strategies Questionnaire, respectively. Finally, self-report of pain-related disability was assessed by the Pain Disability Index. Results and ConclusionsAfter controlling for relevant covariates, LOE was unrelated to pain intensity, severity of depressive symptoms, or affective distress, but was inversely related to self-reported disability. Persons with lower LOEs possessed a greater belief that pain is a “signal of harm,” unrelated to emotional experience, disabling and uncontrollable. They also endorsed more passive and maladaptive coping strategies, including a tendency to catastrophize about their pain. Path analysis indicated that, after controlling for the influence of both the belief that pain is a “signal of harm” and catastrophizing on the association between LOE and disability, this relation loses statistical significance. These results suggest that pain-related cognitions mediate the relation between LOE and pain disability and that persons with lower LOEs are more likely to develop maladaptive pain beliefs and coping strategies.

The Relation of Post-Traumatic Stress Symptoms to Depression and Pain in Patients With Accident-Related Chronic Pain

UNLABELLED Symptoms of post-traumatic stress disorder (PTSD) are a common comorbidity in patients with a history of accident-related chronic pain and depression. However, little is known regarding the influence of PTSD in contributing to the affective distress, pain experience, and disability associated with chronic pain in this population. This study used structural equation modeling to examine 3 models that assess these relations in a sample of chronic pain patients with accident-related pain. Subjects were assessed for pain experience, depressive symptoms, anxiety, PTSD symptoms, pain disability, and relevant demographic variables. Pearson correlations indicated that symptoms of depression were significantly related to more severe pain, disability, and PTSD symptoms. PTSD symptoms were significantly associated with higher disability. The model of best fit indicated that after controlling for the influence of anxiety on the dependent measures, PTSD symptoms have a direct influence on severity of depressive symptoms, whereas depressive symptoms have a direct influence on pain intensity and an indirect impact on pain intensity by way of their effect on disability. These data point to the importance of unresolved PTSD symptoms in contributing to the level of depression, pain, and disability exhibited by chronic pain patients and highlight the need to consider directed and primary treatment of PTSD in pain rehabilitation programs. PERSPECTIVE This study highlights the impact of symptoms of PTSD on levels of depression, disability, and pain in patients with pain secondary to physical injury. Our results suggest that pain rehabilitation programs provide directed interventions for PTSD symptoms among this population to improve pain treatment outcomes.

Assessing persistent pain and its relation to affective distress, depressive symptoms, and pain catastrophizing in patients with chronic wounds: a pilot study.

Roth RS, Lowery JC, Hamill JB: Assessing persistent pain and its relation to affective distress, depressive symptoms, and pain catastrophizing in patients with chronic wounds: A pilot study. Am J Phys Med Rehabil 2004;83:827–834. Objective:The purpose of this study was to examine pain experience among patients with chronic wounds, assess the utility of pain assessment scales for chronic wound-related pain, and determine the relation of wound-related pain to wound stage, affective distress, depressive symptoms, and pain catastrophizing. Design:In this cross-sectional study of patients with a mix of chronic wounds (n = 69) recruited for a study evaluating a telemedicine system for assessing chronic wounds, 19 men (12 with spinal cord injury) with wound-related pain were identified. Questionnaires included the Numerical Pain Rating Scale, McGill Pain Questionnaire, Brief Symptom Inventory, Center for Epidemiologic Studies Depression Scale, and the catastrophizing scale of the Coping Strategies Questionnaire. Results:The McGill Pain Questionnaire was more sensitive to pain experience than a single rating of pain intensity. Wound stage was positively related to severity of pain. Pain catastrophizing was positively related to pain intensity and higher levels of affective distress and depressive symptoms. Conclusions:Pain associated with chronic wounds is a significant clinical challenge for both patients and health practitioners.

Psychological Factors Predict Patient Satisfaction with Postmastectomy Breast Reconstruction

Background: This prospective study examined the contribution of psychological factors to the prediction of patient satisfaction with postmastectomy breast reconstruction surgery. Methods: Women presenting for breast reconstruction were administered presurgical psychological inventories. Measures of affective distress, depressive symptoms, anxiety, somatization, and somatic preoccupation were obtained from standardized inventories. At 1-year (n = 295) and 2-year (n = 205) follow-up, subjects completed ratings of their satisfaction with both the general and aesthetic results of surgery. Results: After controlling for sociodemographic variables and both surgical procedure type and timing, multiple linear regression analyses indicated that at 1-year follow-up preoperative measures of affective distress, depression, somatization, and somatic anxiety predicted less general satisfaction with surgical outcome, while presurgical levels of affective distress, depression, anxiety, somatization, and somatic anxiety predicted decreased aesthetic satisfaction. At 2-year follow-up, only preoperative affective distress retained a significant association with lowered general satisfaction with reconstructive surgery. In addition, at 2-year reassessment, aesthetic quality of surgical outcome was inversely related to all the presurgical psychological variables. Conclusions: Affective distress and somatic preoccupation negatively influence patient satisfaction with both aesthetic and general outcomes associated with postmastectomy breast reconstruction. Presurgical psychological screening and counseling of selected women who are being considered for breast reconstruction may be advisable to enhance patient satisfaction with reconstructive surgery.