Depression Flashcards
Types of depression encountered in chronic pain patients, prevalence
Major depression: at least two weeks of depressed mood (sadness, hoplessness…) or loss of interest in most activities.
• At least four of the following symptoms must be present: weight loss, insomnia/hypersomnia, psychomotor retardation/agitation, feelings of guilt, feelings of worthlessness, diminished concentration, recurrent thoughts of death.
Dysthymia (300.4): mild, long-lasting depression (at least 2 years)
• At least two of the symptoms must be present: increased/decreased appetite, insomnia/hypersomnia, fatigue, low self-esteem, poor concentration, feelings of hopelessness
Chronic pain patients show about 2-3 times more frequent depression than general medical population
56% of of the chronic pain population have some form of depression (Fishbein et al. 1986)
Why depression matters
Depression contributes to disability (irrespective of the presence of chronic pain) (Schonfeld 1997)
Depression predicts health costs due to utilisation of the health system in pain patients
(Engel et al. 1996) analysed data from 1059 back patients, and computed multivariate regression between total costs and various independent variables including depressive symptomatology.
• Total health care costs were predicted by the presence of depression symptoms in the first month of the initial primary care visit.
Depression increases mortality by increasing ideations suicide and contributing to suicide attempts
Experimental pain in patients with
major depressive disorder
While depression and severity of pain stand in significant positive relationship, data on experimental pain are not so conclusive (e.g. Weiss et al. 2011)
Example: Dworkin et al. (1995) analyse the discriminability and response bias for painful and innocuous heat stimuli in patients with major depression.
• Major depression patients showed both reduced discriminability and increases response bias (more stoical) than healthy controls in thermal pain.
Depressed people show higher pain thresholds for skin stimuli but a lower threshold for muscle pain than healthy people (Bar et al., Pain, 2005; Bar et al., Eur J. Pain, 2006)
Links between pain and depression
Bar et al., 2007.
Stronger pain-related activations in depressed than healthy people
Thalamus, and ventro- and dorsolateral prefrontal cortex showed stronger activations during painful heat stimulation in MDD than in healthy subjects.
Is depression a consequence of chronic pain? Or, does acute pain change to chronic pain due to depression?
Brown ( 1990) applied structural causal modelling to analyse the possible causal links between reports of depression and pain intensity in 243 rheumatoid arthritis patients. Patients were sent questionnaires in 6 waves in 6-month intervals. The structural causal modelling indicated that the pain-to-depression relationship was appropriate to explain pain-depression relationships in the long run.
Feldman et al. (1999) asked 109 CRPS patients to complete daily diaries of pain, mood and social support during 28 consecutive days. The time-lagged cross-correlation analysis showed that the strongest relationship was between pain causing depressed, anxious and angry mood (pain-to-depression). However, the reversed relationship (depression contributing to pain) was also significant. A good example of bi-directionality.
Sleep
Sufficient data shows impaired sleep in chronic pain patients in terms of insomnia, delayed onset of sleep, night awaking, daytime sleepiness (Meltzer et al, 2005)
Sleep disturbances may lead to painful states:
Moldofsky et al. (1975) analysed sleep EEG in 10 fibromyalgia syndrome patients. 7 out of 10 patients showed abnormal alpha-delta sleep pattern.
In six healthy subjects, the abnormal sleep pattern was induced by auditory stimulation. Disturbed sleep was followed by musculoskeletal pain.
Kundermann et al. (2004)
Sleep disturbance in normal subjects induce a hyperalgesic state. Healthy subjects, two nights of sleep deprivation and two nights of normal sleep. Quantitative sensory testing was applied to measure the sleep deprivation effects on pain and innocuous thermal processing. Sleep deprivation decreased the cold and heat pain thresholds, but did not change the warm/cold thresholds
Haack and Mullington (2005)
Long-lasting sleep reduction increases pain symptoms and decreases the optimisitic views in healthy subjects. analysed day-to-day changes in psychological state during 12 days of reduced sleep (4 hours) in comparison to controls undergoing normal sleep (8 hours).
Sleep reduction induced progressive decreases in optimism-sociability, and increases of pain (back, stomach, muscle).
Sleep, pain severity, and depression vs. disability
Naughton et al. (2007) analysed data from 155 chronic pain patients using hierarchical regression analysis. Sleep quality (Pittsburgh Sleep Quality Index), depression (BDI), pain severity (numerical scales), and disability (Roland Morris Disability Questionnaire) were measured.
Depression and pain severity were significant mediators in the association between sleep quality and disability
Affleck et al. (1996) analysed sleep quality, pain intensity and attention to pain using portable computer questionnaires delivered automatically over 30 days in 50 fibromyalgia patients.
A night of poor sleep was followed by a significantly more
painful day (sleep»_space; pain path)
A more painful day was followed by a night of poorer sleep (pain»_space; sleep path)
helplesness
Edwards et al. (2011)
Proposed a model linking depression and catastrophising.
Depression shares some cognitive and affective components with catastrophising, yet depression is still an independent factor of pain in chronic pain patients.
Helplessness appears to be the factor shared by both depression and pain catastrophising, and known to contribute to suicidal behaviour (Racine et al., 2013).
80 fibromyalgia patients, battery of self-report instruments such as BDI, Helplessness, Rheumatology Pain Attitudes (operationalised “Helplessness”), Multiphasic Pain Inventory – Interference subscale (operationalised “Loss”).
• The 2-factor model whereby helplessness and loss of activities contribute to depression
Suicide behavior in chronic pain patients
Chronic pain patients are clearly at increased risk of suicidal ideation, attempts and committed suicides, probably 2-3 times more than the general population (Hassett et al., 2014)
• 20% lifetime prevalence of suicidal ideation in chronic pain patients
• 5-14% prevalence of suicide attempts in chronic pain population
Fishbain et al.,, 2014,
• suicide ideations (think about death) – passive behaviour: prevalence 8-41% in chronic pain
• attempted suicide: prevalence 14-38%
• completed suicide- only 1 study; history of chronic pain confirmed as a factor
General risk factors of suicide in chronic pain patients:
Being a female is a risk factor of suicide behavior in general population
No evidence of prevalence of suicide behavior in females in chronic pain patients, based on a large number of studies (Racine, 2017)
Fishbain et al. (2009): patients receiving worker compensation compared to those who did not endorsed suicide behavior more and had 3-7x greater risk of suicide
Racine et al. (2014): chronic patients who were unemployed showed 6x more of suicide thoughts than those patients who were employed or studied
Not all studies confirmed effects of employment status on suicide behaviour (Racine, 2017): different syndromes, small cohorts.
(Smith et al., 2004)
Patients with family history of suicide attempts were at 7-8 times greater risk of SI or SP than patients with no such history
Patients who experienced abuse or domestic violence predicted SA
• In spite of small number of studies available, family history of suicide and personal history of abuse and violence appear to be important factors in the decision to commit suicide
Depression
Edwards et al. 2006
Analysed the contribution of many variables from self-report instruments obtained in 1512 chronic pain patients.
Depressive symptoms and pain catastrophizing predicted suicidal ideation
A number of other studies confirmed the role of depression in suicide behavior (Racine, 2017)
While depression needs to be viewed as a strong general predictor, there are also studies not showing any association, associations disappearing after factoring out covariates, e.g. pain severity
Suicide attemps more frequent in arthritis patients who drank alcohol or taking illicit drugs (Fuller-Thompson et al., 2016)
Smoking in chronic patients was related to an increased suicidal ideation behavior (Fishbain et al., 2009)
Results inconsistent but important because consumption habits can be modified
Pain-specific factors for suicide - duration, severity, frequency, comorbidity
Methodological problems: often too a small numbers of syndromes (3-4) are compared in one study, cohort sizes not large enough, different methods to measure suicide behaviour
Some consistency in migraine and back pain being associated with high risk of suicidal behavior (Fuller-Thompson et al., 2013)
Ilgen et al. (2013) analysed 4.8 million of patients records to determine associations between type of a non-cancer pain and suicide: back pain, migraine, psychogenic pain were the syndromes with the greatest risk of suicide.
Duration of chronic pain condition has not been confirmed (Racine, 2017)
Pain severity shown to correlate with deaths by suicide (e.g., Ilgen et al., 2010)
Number of chronic pain conditions (comorbidities) is a factor: Ilgen et al. (2008) - patients with 2-3 chronic pain conditions show 2-3-fold risk of a suicide attempt
Perceived health quality
Life quality measuring mental and physical health
Patients perceiving their mental health as bad = suicide thoughts more. Physical health not associated with suicidal behaviour (Racine (2017))
sleep impairments
• Sleep impairments are predictor of suicide behavior in general population
• Pain-related sleep-onset insomnia has been shown to correlate with Intensity of sleep thoughts (Smith et al., 2004)
• Pathways via which impaired sleep affects suicidal thoughts are not known –interaction with depression and pain severity possible.
pain catastrophising
Pain catastrophizing is an independent contributor to suicidal behavior (Edwards et al., 2006; Racine et al., 2013; Tang et al., 2016)
Out of three components of pain catastrophizing, two have been found to contribute to suicidal behavior:
o helplessness correlated with endorsement of suicidal behavior (Racine et al., 2013)
o
Psychological interventions to prevent suicide attempts in chronic pain patients
• Health care professionals need to be aware of an increased risk of suicide, and to know about the risk factors in chronic pain patients, and assess the risk in interviews with patients.
• questions: “Have you been feeling helpless?”
• actions: provide crisis contacts, check family support
• (Hassett et al., Curr. Pain Head. Rep., 2014,18:436)
• Acceptance and Commitment Therapy program (Hayes et al., 2006): thwarted effort to suppress the pain is the basis of suffering leading to a suicide attempt
o emphasis on value of life and positive life goals
o mindfullness-meditation components – acceptance of pain
