37 - Podiatric Disorders and Depression

Question 1

What percent of primary care patients have clinical depression?

Answer 1

13% to 25% of patients in primary care have clinical depression

Question 2

What is the difference between depression and chronic pain?

Answer 2

“Does depression lead to an increased sensitivity to pain or does chronic pain lead to depression?”

Both - they tend to occur together

“The chicken and the egg” of depression and pain

Question 3

Describe patients with depression

Answer 3

• “People who have major depression are more than ***twice as likely to have chronic pain when compared to people who have no symptoms of depression”
• Chronic back pain is ***3-4 times more prevalent with depression than in the general population.

Question 4

What is more likely in patients with depression and chronic pain?

Answer 4

People with depression may be more likely to experience chronic pain and that depressed people with chronic pain may respond better to a class of drugs that treat both symptoms

In particular, the current drugs of choice for treating both pain and depression in the same patient are tricyclic antidepressants (amitriptyline, nortriptyline, Doxepin®)

KNOW THESE DRUGS ***

Question 5

What are the TCAs used to treat depression and chronic pain?

Answer 5

TCAs

• amitriptyline
• nortriptyline
• Doxepin

KNOW THESE

Question 6

What are characteristics of patients with chronic pain?

Answer 6

• Chronic pain causes a reduction in physical, psychological, and social well-being
• Depression is one of the most common problems experienced by patients with chronic pain

Question 7

How much of health care does chronic pain consume?

Answer 7

… chronic pain is “the biggest health problem” facing patients in the US today, affecting “100 million adult Americans, according to a 2011 report from the Institute of Medicine, part of the National Academy of Sciences.” Chronic pain, which may affect up to 40% of the population, “is the leading reason people go to doctors and it costs the nation upwards of $635 billion a year – more than cancer, heart disease and diabetes combined.”

** UP TO 40% **

Journal of Pain suggests that nearly 20 percent “of Americans do daily battle with crippling, chronic pain, a large new survey reveals, with the elderly and women struggling the most.”

** 20% **

Question 8

Describe pain in depressed and chronic pain patients

Answer 8

• Patients with depression and chronic pain relate more pain than those without depression.
• Patients with chronic pain have increased rates of suicidal ideation, suicide attempts, and successful suicide***

A “potent cocktail” leading to suicide

Question 9

Describe suicide statistics in terms of chronic pain

Answer 9

• 52% of patients who attempted suicide had somatic pain, 21% were on daily analgesics for pain

Question 10

What is the impact of chronic pain?

Answer 10

• If pain decreases mobility or participation in social activities, depression is significantly increased
• Consider this point when recommending extended treatments or surgery that require immobilization

Question 11

Describe the differences in brain PET scans in depressed patients

Answer 11

PET scanning shows profound changes in brain activity in patients who report with depression vs. those without depression

This is DEPRESSION ***

Question 12

Describe the differences in glucose metabolism in the prefrontal cortex of patients with severe pain

Answer 12

Compared to patients with no pain, patients with moderate to severe pain had increased glucose metabolism bilaterally in the prefrontal cortex

This is PAIN ***

Question 13

Describe the white matter structural changes seen in chronic pain patients

Answer 13

• …the present results imply that brain white matter properties are indicators for predisposition to chronic back pain, pointing to the need for more extensive studies regarding white matter integrity in chronic pain and in chronification of pain.
• The myelin and axons are distorted compared with typical axons

This is PAIN ***

Question 14

Define fibromyalgia

Answer 14

• A pain disorder related to chronic fatigue syndrome in which patients have physiological malfunction in the interpretation of pain
• Cause is unknown
• Many health professionals do NOT recognize it as a disease

Question 15

What is the incidence of fibromyalgia?

Answer 15

• Age and sex-adjusted prevalence is 6.4% vs. 1.1% identified in charts by physicians ***
• Patients, particularly men, are NOT given the diagnosis by a physician, but do have the disorder when surveyed in the community***

This is the DIFFERENCE between physicians diagnosing and patients believing they have fibromyalgia

Question 16

Describe the pain symptoms of patients with fibromyalgia

Answer 16

• Painful pressure applied to thumb of fibromyalgia patient and normal patient
• “Sensations become unpleasant at stimulus intensities that are significantly lower than those observed in healthy controls”

Question 17

Describe the gray matter volume of patients with fibromyalgia

Answer 17

• Gray matter volumes of pain-related brain areas are decreased in fibromyalgia
• Uncertain if there is a direct cause-effect relationship

Question 18

Describe fibromyalgia in terms of foot pain and complaints

Answer 18

It is NOT an inflammatory process

• No swelling, no redness, no heat
• By far and away, the most common “systemic” illness associated with heel pain
• A non-inflammatory disease of soft tissue (muscle, ligaments, tendon) so there is NO joint swelling detected

If the pain you see in your patient is far worse than you see in other patients with heel pain, consider a referral for fibromyalgia

This will allow you to lower expectations and reconsider invasive treatment (surgery)

Note: heel pain is NOT a diagnostic criteria for fibromyalgia, but when they get plantar fascial pain, it is much worse

Question 19

What is one of the most common systemic problems of patients with fibromyalgia?

Answer 19

Sleep - insomnia

Also, abdominal problems, but sleep problems are more common and prominent

Question 20

What are the most common tender points in patients with fibromyalgia?

Answer 20

• Neck
• Shoulders
• Butt
• Outer thighs
• Elbows
• Inner knees

Question 21

What are the main complaints of patients with fibromyalgia?

Answer 21

• Can’t fall asleep, or more commonly, have fitful, continuously interrupted sleep, often awakening feeling as if they didn’t sleep
• Migraine headaches common
• Depression
• Burning pain, swelling in extremities due to fluid retention
• Irritable bowel syndrome

This was emphasized ***

Question 22

A diagnosis of fibromyalgia should be considered when a patient relates…

Answer 22

• At least 7 areas of pain
• Chronic sleep problems
• Bowel disturbances
• Feelings of depression

NOT when the patient has swollen, tender joints

Question 23

What is complex regional pain syndrome (CRPS I)?

Answer 23

• It is a term describing a variety of painful conditions following injury which appears regionally having a distal predominance of abnormal findings***
• Exceeds in both magnitude and duration*** the expected clinical course of the inciting event
• May result in significant impairment of motor function***
• Shows variable progression*** over time

Eventually the extremity becomes non-functional because they don’t use it - disuse atrophy and joint stiffness

Question 24

Describe the pain of CRPS I

Answer 24

• CRPS I (RSD-reflex sympathetic dystrophy)
• Develops after initiating noxious event (usually, a minor injury like sprain or stress fracture)
• Spontaneous pain or allodynia/hyperalgesia occurs that extends far beyond the area of injury, and pain out of proportion to inciting event
• Sympathetic nerve dysfunction leading to edema, erythema, warmth or coldness to touch

Know SYMPATHETICS - feelings of hot and cold due to vasodilation/vasoconstriction patterns - eventually causes osteoporosis and fractures

Question 25

Define allodynia and hyperalgesia

Answer 25

Allodynia is the experience of pain from a non-painful stimulation of the skin, such as light touch

Hyperalgesia is abnormally heightened sensitivity to pain.

Question 26

Descirbe CRPS II or Causalgia

Answer 26

• Develops after direct nerve injury

- Also has sympathetic nerve dysfunction

Question 27

What is SMP (sympathetically maintained pain)?

Answer 27

• Pain maintained by sympathetic efferent innervation or by circulating catecholamines that is also out of proportion and not associated with any specific nerve
• Classic sympathetic changes to skin not seen ***

NO sympathetic changes in skin

Question 28

Describe the stages of CRPS I

Answer 28

CRPS I may be divided into stages to show progression of deformity, but much more often, the stages overlap and are not related to any time schedule

Question 29

What is the importance of early diagnosis in CRPS I

Answer 29

Early diagnosis based on heightened degree of vigilance offers best chance for recovery which among other things will involve aggressive physical therapy

Question 30

Describe therapy of patients with CRPS

Answer 30

• The pain is severe and causes the patient not to use the affected part, but immobility will only aid in advancing the disease
• Some investigators claim that depressed or anxious people are more prone to developing CRPS

Question 31

What can you see in a thermography image of a limb affected with CRPS I?

Answer 31

Decreased heat in CRPS
of left arm and hand (ice cold due to vasoconstriction)

Could also see a stage of vasodialiton where the limb is hot

Question 32

What will eventually happen in patients with CRPS I?

Answer 32

Bone changes

• Occur in the late phase of CRPS due to vasodilation
• Increased perfusion to bone due to loss of sympathetic tone

Question 33

What is your best option when you see a patient with CRPS

Answer 33

Ultimately, referring fibromyalgia patients to a rheumatologist and CRPS patients to a chronic pain center which includes psychiatric and psychological services are your best options

Question 34

What is the drug of choice for combined pain and depression?

Answer 34

Amitriptyline

Question 35

Describe the potential complications sen in the care of diabetic patients

Answer 35

The inability of many diabetics to take control over management of their disease and its complications is due to depression. It is not due to ignorance, to avoidance, or to anesthetic neuropathy.

DUE TO DEPRESSION ***

Question 36

Describe the connection between depression and diabetes

Answer 36

• Depression leads to poorer physical and mental functioning, so a person is less likely to follow a required diet or medication plan
• “…depressive symptoms can increase risk of diabetes and are related to higher levels of insulin resistance..” ***

It is now recommended that diabetic patients be screened for depression

Question 37

Describe the potential risks we see in depressed diabetics

Answer 37

People with diabetes and depression are more likely to develop diabetic complications than those without diabetes

Question 38

Describe the risk of depression in diabetics

Answer 38

“Compared with non-diabetic controls, type 2 diabetics have a 24% increased risk of depression” ***

Question 39

Describe a study of buproprion and type 2 diabetics

Answer 39

Buproprion administered to type 2 diabetics with comorbid depression not only improved mood, but “patients also lost weight, improved self-management of their diabetes, and improved their glucose control (A1C levels)”

**Weight loss and A1c improved **

Question 40

Describe the effect of exercise and cognitive behavioral therapy on diabetic patients

Answer 40

• 145 people with type 2 diabetes and depression: 12 weeks of cognitive behavioral therapy over the phone, followed by nine monthly booster sessions and participation in a walking program.
• 146 diabetes patients with depression received usual diabetes care only.
• At the end of the year, depression symptoms were in remission for…
  
  • -> 58 % in the intervention group (Also had lower BP, and better quality of life)
  • -> 39 % of those in the control group

Question 41

What is depression in diabetics a risk marker for?

Answer 41

…depression is a risk marker…for delayed healing and recurrence of foot ulcers in elderly type 2 diabetic patients.

Question 42

Are high blood sugars a cause of depression?

Answer 42

A study out of the Netherlands showed that depression increased in diabetics only when they were made aware of their illness compared to those who were not aware of their diabetes

So NO - it is the diagnosis more than the actual increased blood glucose

Question 43

In diabetic patients,

A. The risk of depression is

Answer 43

D. Depression is a risk factor for ulcer formation

Question 44

Describe the screening of depression in your office

Answer 44

• The USPSTF recommends use of questionnaires, such as the PHQ-9
• Score of 5, 10, 15, 20 represent mild, moderate, moderately severe, severe depression, respectively

Question 45

What to focus on…

Answer 45

Know fibromyalgia

Don’t memorize diagnostic criteria by rheumatology association, but be aware of the areas of discomfort as well as the systemic manifestations (sleep, headache, irritable bowl, swelling and pain of the extremities)