Teresa M. Damush

Optimized Antidepressant Therapy and Pain Self-management in Primary Care Patients With Depression and Musculoskeletal Pain A Randomized Controlled Trial

CONTEXT Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30% to 50% of the time and have adverse effects on quality of life, disability, and health care costs. OBJECTIVE To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression. DESIGN, SETTING, AND PATIENTS Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) conducted at 6 community-based clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score > or = 10). INTERVENTION Patients were randomly assigned to the intervention (n = 123) or to usual care (n = 127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3). MAIN OUTCOME MEASURES Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months. RESULTS At 12 months, 46 of the 123 intervention patients (37.4%) had a 50% or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5%) (relative risk [RR], 2.3; 95% confidence interval [CI], 1.5-3.2), corresponding to a much lower number of patients with major depression (50 [40.7%] vs 87 [68.5%], respectively; RR, 0.6 [95% CI, 0.4-0.8]). Also, a clinically significant (> or = 30%) reduction in pain was much more likely in intervention patients (51 intervention patients [41.5%] vs 22 usual care patients [17.3%]; RR, 2.4 [95% CI, 1.6-3.2]), as was global improvement in pain (58 [47.2%] vs 16 [12.6%], respectively; RR, 3.7 [95% CI, 2.3-6.1]). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients [26.0%] vs 10 usual care patients [7.9%]; RR, 3.3 [95% CI, 1.8-5.4]). CONCLUSION Optimized antidepressant therapy followed by a pain self-management program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00118430.

Association of Depression and Anxiety Alone and in Combination with Chronic Musculoskeletal Pain in Primary Care Patients

Objective: To assess the relationship between depression and anxiety comorbidity on pain intensity, pain-related disability, and health-related quality of life (HRQL). Methods: Analysis of baseline data from the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study. All patients (n = 500) had chronic pain (≥3-month duration) of the low back, hip, or knee. Patients with depression were oversampled for the clinical trial component of SCAMP and thus represented 50% of the study population. Patients were categorized according to pain comorbid with depression, anxiety, or both. We used analysis of variance and multivariate analysis of variance models to assess the relationships between independent and dependent variables. Results: Participants had a mean age of 59 years; they were 55% women, 56% White, and 40% Black. Fifty-four percent (n = 271) reported pain only, 20% (n = 98) had pain and depression, 3% (n = 15) had pain and anxiety, and 23% (n = 116) had pain, depression, and anxiety. Patients with pain and both depression and anxiety experienced the greatest pain severity (p < .0001) and pain-related disability (p < .0001). Psychiatric comorbidity was strongly associated with disability days in the past 3 months (p < .0001), with 18.1 days reported by patients with pain only, 32.2 days by those with pain and anxiety, 38.0 days by those with pain and depression, and 42.6 days in those with all three conditions. We found a similar pattern of poorer HRQL (p < .0001) in those with pain, depression, and anxiety. Conclusions: The added morbidity of depression and anxiety with chronic pain is strongly associated with more severe pain, greater disability, and poorer HRQL. ANOVA = analysis of variance; BPI = Brief Pain Inventory; GAD-7 = Generalized Anxiety Disorder 7-item scale; HRQL = health-related quality of life; ICD-9 = International Statistical Classification of Diseases and Related Health Problems, 9th Edition; IU = Indiana University; MANOVA = multivariate analysis of variance; MRI = magnetic resonance imaging; PA = pain and anxiety; PD = pain and depression; PDA = pain, depression, and anxiety; PHQ-9 = Patient Health Questionnaire-9; PO = pain only; SCAMP = stepped care for affective disorders and musculoskeletal pain; SCL-20 = Hopkins Symptom Checklist-20; SF-36 = Medical Outcomes Study Short Form-36; VA = Veterans Affairs.

Reciprocal Relationship Between Pain and Depression: A 12-Month Longitudinal Analysis in Primary Care

UNLABELLED Pain and depression are the most prevalent physical and psychological symptom-based disorders, respectively, and co-occur 30 to 50% of the time. However, their reciprocal relationship and potentially causative effects on one another have been inadequately studied. Longitudinal data analysis involving 500 primary care patients with persistent back, hip, or knee pain were enrolled in the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study. Half of the participants had comorbid depression and were randomized to a stepped care intervention (n = 123) or treatment as usual (n = 127). Another 250 nondepressed patients with similar pain were followed in a parallel cohort. Outcomes were assessed at baseline, 3, 6, and 12 months. Mixed effects model repeated measures (MMRM) multivariable analyses were conducted to determine if change in pain severity predicted subsequent depression severity, and vice versa. Change in pain was a strong predictor of subsequent depression severity (t-value = 6.63, P < .0001). Likewise, change in depression severity was an equally strong predictor of subsequent pain severity (t-value = 7.28, P < .0001). Results from the full cohort were similar in the clinical trial subgroup. In summary, pain and depression have strong and similar effects on one another when assessed longitudinally over 12 months. PERSPECTIVE This study strengthens the evidence for a bidirectional and potentially causative influence of pain and depression on one another. A change in severity of either symptom predicts subsequent severity of the other symptom. Thus, recognition and management of both conditions may be warranted, particularly when treatment focused on 1 condition is not leading to an optimal response.

Barriers and facilitators to exercise among stroke survivors

&NA; Physical activity after stroke may prevent disability and stroke recurrence; yet, physical impairments may inhibit post‐stroke exercise and subsequently limit recovery. The goal of this study was to elicit barriers to and facilitators of exercise after stroke. We conducted three focus groups and achieved content saturation from 13 stroke survivors—eight men and five women—85% of whom were African American and 15% White, with a mean age of 59 years. We coded and analyzed the transcripts from the focus groups for common themes. Participants across groups reported three barriers (physical impairments from stroke, lack of motivation, and environmental factors) and three facilitators (motivation, social support, and planned activities to fill empty schedule) to exercise after stroke. Exercise activity can provide a purpose and structure to a stroke survivors daily schedule, which may be interrupted after stroke. In addition, receiving social support from peers and providers, as well as offering stroke‐specific exercise programming, may enhance physical activity of stroke survivors including those with disabilities. We intend to incorporate these findings into a post‐stroke self‐management exercise program.

BARRIERS AND FACILITATORS TO CHRONIC PAIN SELF-MANAGEMENT: A QUALITATIVE STUDY OF PRIMARY CARE PATIENTS WITH COMORBID MUSCULOSKELETAL PAIN AND DEPRESSION

OBJECTIVE To identify barriers and facilitators to self-management of chronic musculoskeletal pain among patients with comorbid pain and depression. DESIGN A qualitative study using focus group methodology. SETTING Veteran Affairs (VA) and University primary care clinics. PATIENTS Recruited after participation in a clinical trial. INTERVENTION The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) trial tested an intervention of optimized antidepressant therapy combined with a pain self-management program versus usual care for primary care patients with comorbid chronic pain and depression. OUTCOME MEASURES Thematic content analysis from focus group data was used to identify patient-perceived barriers and facilitators to self-management of chronic musculoskeletal pain. RESULTS Patients (N = 18) were 27 to 84 years old (M = 54.8), 61% women, 72% white, and 22% black. Barriers to pain self-management included: 1) lack of support from friends and family; 2) limited resources (e.g., transportation, financial); 3) depression; 4) ineffectiveness of pain-relief strategies; 5) time constraints and other life priorities; 6) avoiding activity because of fear of pain exacerbation; 7) lack of tailoring strategies to meet personal needs; 8) not being able to maintain the use of strategies after study completion; 9) physical limitations; and 10) difficult patient-physician interactions. Facilitators to improve pain self-management included 1) encouragement from nurse care managers; 2) improving depression with treatment; 3) supportive family and friends; and 4) providing a menu of different self-management strategies to use. CONCLUSIONS Future research is needed to confirm these findings and to design interventions that capitalize on the facilitators identified while at the same time addressing the barriers to pain self-management.

Balance and Balance Self-Efficacy Are Associated With Activity and Participation After Stroke: A Cross-Sectional Study in People With Chronic Stroke

OBJECTIVES To (1) examine the relationships between multiple poststroke mobility variables (gait speed, walking capacity, balance, balance self-efficacy, and falls self-efficacy) and activity and participation; and (2) determine which poststroke mobility variables are independently associated with activity and participation. DESIGN This is the primary analysis of a prospective cross-sectional study completed to understand the impact of mobility on activity and participation in people with chronic stroke. SETTING University-based research laboratory, hospitals, and stroke support groups. PARTICIPANTS People (N=77) with stroke greater than 6 months ago were included in the study if they were referred to occupational or physical therapy for physical deficits as a result of the stroke, completed all stroke related inpatient rehabilitation, had residual functional disability, scored a ≥4 out of 6 on the short, 6-item Mini-Mental State Examination, and were between the ages of 50 and 85. INTERVENTIONS Not applicable, this is a cross-sectional data collection of 1 timepoint. MAIN OUTCOME MEASURES We measured activity and participation with the validated International Classification of Functioning, Disability and Health Measure of Participation and Activities. Other variables included gait speed (10-meter walk), walking capacity (6-minute walk), balance (Berg Balance Scale), balance self-efficacy (Activities Specific Balance Confidence Scale), and falls self-efficacy (Modified Falls Efficacy Scale). RESULTS Only balance self-efficacy was found to be independently associated with poststroke activity (β=-.430, P<.022, 95% confidence interval [CI], -.247 to -.021) and participation (β=-.439, P<.032, 95% CI, -.210 to -.010). CONCLUSIONS Among people with chronic stroke, balance self-efficacy, not physical aspects of gait, was independently associated with activity and participation. While gait training continues to be important, this study indicates a need to further evaluate and address the psychological factors of balance and falls self-efficacy to obtain the best stroke recovery.

Comparative Responsiveness of Pain Outcome Measures Among Primary Care Patients With Musculoskeletal Pain

Background:Comparative responsiveness data are needed to inform choices about pain outcome measures. Objectives:To compare responsiveness of pain intensity, pain-related function, and composite measures, using data from a randomized trial and observational study. Research Design:Analysis of responsiveness. Subjects:A total of 427 adults with persistent back, hip, or knee pain were recruited from primary care. Methods:Participants completed Brief Pain Inventory, Chronic Pain Grade (CPG), Roland disability, SF-36 bodily pain, and pain global rating of change measures. We used the global rating as the anchor for standardized response mean and receiver operating characteristic curve analyses. We used the distribution-based standard error of measurement to estimate minimally important change. To assess responsiveness to the trial intervention, we evaluated standardized effect size statistics stratified by trial arm. Results:All measures were responsive to global improvement and all had fair-to-good accuracy in discriminating between participants with and without improvement. SF bodily pain was less responsive than other measures in several analyses. The 3-item PEG was similarly responsive to full Brief Pain Inventory scales. CPG and SF bodily pain were less responsive to the trial intervention and did not perform well among participants with hip/knee pain. Agreement between anchor and distribution-based methods was modest. Conclusions:If a brief measure is desired, the 3-item PEG is more responsive than the SF bodily pain scale. CPG and SF bodily pain scales may be relatively poor choices for trial outcome assessment. Both anchor and distribution-based methods should be considered when determining clinically important change.

Supporting self-management for patients with complex medical needs: recommendations of a working group.

Increasing numbers of persons live with complex chronic medical needs and are at risk for poor health outcomes. These patients require unique self-management support, as they must manage many, often interacting, tasks. As part of a conference on Managing Complexity in Chronic Care sponsored by the Department of Veterans Affairs, a working group was convened to consider self-management issues specific to complex chronic care. In this paper, we assess gaps in current knowledge on self-management support relevant to this population, report on the recommendations of our working group, and discuss directions for future study. We conclude that this population requires specialized, multidimensional self-management support to achieve a range of patient-centred goals. New technologies and models of care delivery may provide opportunities to develop this support. Validation and quantification of these processes will require the development of performance measures that reflect the needs of this population, and research to prove effectiveness.

Poststroke Balance Improves With Yoga A Pilot Study

Background and Purpose— Balance impairment is common after stroke; modified yoga may be able to improve balance and other important poststroke variables. Scientific-evidence is needed to support such treatment interventions. The purpose of this study was to assess the impact of a yoga-based rehabilitation intervention on balance, balance self-efficacy, fear of falling (FoF), and quality of life after stroke. Methods— This was a prospective, randomized, pilot study of yoga-based rehabilitation for people with chronic stroke. All yoga sessions were taught by a registered yoga therapist, occurred twice per week for 8 weeks and included seated, standing, and floor postures with relaxation and meditation. Balance was assessed with the Berg Balance Scale, balance self-efficacy with the Activities-specific Balance Confidence Scale, FoF with a dichotomous yes/no question, and quality of life with the Stroke Specific Quality of Life scale. Results— There were no significant differences between wait-list control (n=10) and yoga (n=37) groups in baseline or follow-up scores. However, using within-group comparisons, yoga group data demonstrated significant improvement in balance (Berg Balance Scale, 41.3±11.7 vs 46.3±9.1; P<0.001) and FoF (51% vs 46% with FoF; P<0.001). Conclusions— A group yoga-based rehabilitation intervention for people with chronic stroke has potential in improving multiple poststroke variables. Group yoga may be complementary to rehabilitation, may be possible in medical-based and community-based settings, and may be cost-effective. Further testing of group yoga-based rehabilitation interventions is warranted. Clinical Trial Registration— URL: http://clinicaltrials.gov. Unique Identifier: NCT01109602.

The Impact of Poststroke Depression on Healthcare Use by Veterans With Acute Stroke

Background and Purpose— Poststroke depression (PSD) is common among stroke survivors, and it is associated with worse functional outcomes and increased poststroke mortality. Limited information is available about its impact on healthcare use. This study assessed the impact of PSD on healthcare use by veterans with acute stroke. Methods— In this retrospective, observational national study, 5825 veterans with acute stroke were identified from Veterans Affairs’ (VA) inpatient databases. To determine the patients’ comprehensive PSD and use status, VA and Medicare fee-for-service inpatient and outpatient as well as VA pharmacy data were used. PSD was established if a patient had an inpatient or outpatient depression diagnosis or if a patient received one of the antidepressants within the VA 12 months postindex stroke. Healthcare use referred to the number of hospital stays, outpatient visits, and cumulative length of inpatient stays under both VA and Medicare fee-for-service programs. Poisson regression was fitted to estimate the impact of PSD on use controlling for sociodemographic, clinical, and disease severity factors. Results— Forty-one percent of the sample had PSD. After adjusting for patient demographic and clinical factors, we found that the patients with stroke with PSD had significantly (P<0.0001) more hospitalizations, outpatient visits, and longer length of stays 12 months poststroke compared with these patients with stroke without PSD. Conclusions— Patients with PSD had greater 12-month poststroke healthcare use even when controlling for other demographic and clinical variables. Early detection and appropriate management of PSD for veterans with acute stroke may help reduce their poststroke healthcare use.