Supported in part by Arkansas Blue Cross and Blue Shield and the Office of the Arkansas Drug Director and in partnership with the Arkansas Academy of Family Physicians (AAFP), the Arkansas Medical Society (AMS), the Arkansas State Medical Board (ASMB), the Arkansas Department of Health (ADH) and its Division of Substance Misuse and Injury Prevention (Prescription Drug Monitoring Program—PDMP) Continuing Education Credit: TEXT: 501-406-0076 Event ID: 25485-24581

AR-IMPACT Team Members Michael Cucciare, PhD Johnathan Goree, MD Corey Hayes, PharmD Teresa Hudson, PharmD, PhD Shona Ray-Griffith, MD Leah Tobey, PT, DPT Graduate Student: Andrea Melgar-Castillo

Flow of the Case Conferences General Information: 5 minutes Topic Presentation: 20 minutes Case Conference: 25 minutes Feedback and Thoughts on Future Sessions: 5 minutes

AR-IMPACT website: arimpact.uams.edu AR-IMPACT email address: AR-IMPACT@uams.edu Twitter: @ArkansasImpact Joining the Conference: Click to join: https://join.uams.edu/invited.sf?secret=YtVKQkHsoWTgJaguonymZw&id=415081971 Or call in: 1-844-885-1319, then enter 415081971

Faculty Disclosure of Financial Relationships: The planners of this RSS, Corey Hayes, Michael Cucciare, Johnathan Goree, Leah Tobey, Teresa Hudson, Marti Morrison and Cathy Buzbee have no financial relationships with commercial interests to disclose. A planner of this RSS, Shona Ray-Griffith, MD, has a financial relationship with a commercial interest to disclose: Neuronetics, Inc. – Contracted Research. The speaker of this RSS has no financial relationships with commercial interests to disclose. The accreditation compliance reviewers of this RSS, Karen Fleming and Courtney Bryant, have no financial relationships with commercial interests to disclose.

Continuing Education Accreditation: In support of improving patient care, University of Arkansas for Medical Sciences is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the healthcare team. Credit Designation: The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity. The University of Arkansas for Medical Sciences designates this live activity for a maximum of 1 ANCC contact hour. Nurses must attend the entire session in order to receive credit. This knowledge-based activity will provide pharmacists up to 1.0 contact hours or 0.1 CEU. ACPE# JA0000298-0000-18-040-L01-P AAFP Credit: Submit your AMA credit Pharmacists: Please email us your NABP number and month and day of birth

Other General Information CISCO IPhone App CISCO Meeting Information Please mute your microphone in CISCO Able to ask questions through CISCO Chat

Screening for Depression and Anxiety in Patients with Pain Michael A. Cucciare, PhD Psychologist, Women’s Mental Health Program University of Arkansas for Medical Sciences Text MICHAELCUCCI335 to 22333 join

Today’s Goals The reciprocal nature of depression, anxiety, and pain Screening tools for depression and anxiety in patients with pain Briefly describe care options for patients with depression and anxiety

What is depression and anxiety? Depression – pervasive low mood; loss of interest in usual activities; diminished ability to experience pleasure Anxiety – a physiological state characterized by cognitive, somatic, emotional, and behavioral components that contribute to fear and worry

Why talk about depression and anxiety in the context of pain? Costs of depression/anxiety in pain: Work and physical activities decrease Utilization of medical services increases Motivation and adherence are reduced Poorer quality of life And for the pain provider, make treating pain more challenging

How is depression related to pain? Depression can contribute to pain Patients with preexisting depression are more likely to develop pain (e.g., headache and chest pain) Research shows that depression can be a consequence of protracted pain Stress-diathesis model

How is anxiety related to pain? Is the second most common mental health condition (prevalence is twice that of the general population) Is associated with: Catastrophizing – dwelling on worst possible outcomes (associated with higher pain severity and disability in pain patients) Hypervigilance – increased attendance to pain/inability to distract Fear avoidance – avoidance of movement/activities out of fear of pain (counterproductive for physical rehabilitation)

https://www.polleverywhere.com/multiple_choice_polls/BgKkjSxJSdKi8Tq

Screening tools for depression Many screeners exist, but first a caveat: Some criteria for depression (fatigue, sleep problems, weight changes) can also be symptoms of pain leading to overestimating depression Patient Health Questionnaire (PHQ – 9) Patient Health Questionnaire (PHQ – 8) Depression Anxiety Stress Scale (DASS- 21)

Screening tools for anxiety Pain Anxiety Symptoms Scale Short Form 20 Generalized Anxiety Disorder -7

(PASS- 20 scores of greater than 30) Abrams, M. P. , Carleton, N (PASS- 20 scores of greater than 30) Abrams, M. P., Carleton, N., and Asmundson, G.J.G. (2007). An exploration of the psychometric properties of the PASS-20 with a nonclinical sample. The Journal of Pain, 8 (11), 879-886. GAD-7 total score for the seven items ranges from 0 to 21. Scores of 5, 10, and 15 represent cut points for mild, moderate, and severe anxiety, respectively. ... Using the threshold score of 10, the GAD-7 has a sensitivity of 89% and a specificity of 82% for generalized anxiety disorder

Treatment options Behavioral Cognitive Behavioral Therapy can help with depression and/or anxiety related to pain. It teaches patients: Psychoeducation Relaxation Training Distraction techniques Cognitive Restructuring Behavioral Activation Medication (SSRIs, SNRIs) Increasing exercise or activity

https://www.polleverywhere.com/multiple_choice_polls/eg5xk5erphdaus9

What to take away A reciprocal relationship exists between depression, anxiety, and pain Patients with pain and depression and/or anxiety have worse pain and functional outcomes than those without these conditions Brief screeners exist for use in busy primary care settings

Thank you! Questions/comments?

Questions about the Topic Continuing Education Credit: TEXT: 501-406-0076 Event ID: 25485-24581

Case Conference and Feedback Continuing Education Credit: TEXT: 501-406-0076 Event ID:25485-24581