1. 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:
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2. Part 1: Depression in the Patient with Chronic Pain
Shona Ray-Griffith, MD
Assistant Professor
University of Arkansas for Medical Sciences

3. Disclosures I receive clinical trial support from Neuronetics.
I have received clinical trial support from Sage Therapeutics.
Neither will be discussed today.

4. Poll Everywhere
Text shonaraygrif105 to 22333

5. Objectives Define ‘depression’
Review literature exploring the association between depression and chronic pain

6. https://www. polleverywhere

7. What is depression? Depression is a symptom and not a diagnosis
Depression commonly refers to:
Major Depressive Disorder (MDD, unipolar depression)
Bipolar Disorder, current episode MDD (bipolar depression)
MDD is further defined as
Single or recurrent episode
Severity
Mild
Moderate
Severe
With or without psychosis

8. DSM-5 Diagnosis: MDD
5 or more of the following symptoms during the same 2 week period and represent a change from previous functioning:
Depressed mood
Anhedonia
Change in appetite or weight (5% in a month)
Insomnia or hypersomnia
Psychomotor agitation or retardation
Fatigue
Feelings of worthlessness or guilt
Poor concentration or indecisiveness
Suicidal ideation

9. https://www. polleverywhere

11. PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the following problems?
Little interest or pleasure in doing things
Feeling down, depressed, or hopeless
Trouble falling or staying asleep, or sleeping too much
Feeling tired or having little energy
Poor appetite or overeating
Feeling bad about yourself or that you are a failure or have let yourself or your family down
Trouble concentrating on things, such as reading the newspaper or watching television
Moving or speaking so slowly that other people could have noticed or the opposite being so fidgety or restless that you have been moving around a lot more than usual
Thoughts that you would be better off dead, or of hurting yourself

12. PHQ-9 0-3 Likert Scale Validated in chronic pain High sensitivity
If you checked off any problems, how difficult at all have these problems made it for you to do your work, take care of things at home, or get along with other people?
0-3 Likert Scale
Validated in chronic pain
High sensitivity
High specificity
Total Score
Depression Severity
1-4
Minimal depression
5-9
Mild depression
10-14
Moderate depression
15-19
Moderately severe depression
20-27
Severe depression

13. Other Screening Tools Beck Depression Inventory – II (BDI)
20 items
Hospital Anxiety and Depression Scale (HADS)
7 items
Both depression and anxiety measured

14. https://www. polleverywhere

16. Depression and Chronic Pain
MDD

17. Depression First
Pinheiro MB et al. “Symptoms of Depression and Risk of New Episodes of Low Back Pain: A Systematic Review and Meta-analysis” 2015
19 articles (reporting data from 16 studies)
N=28,326
Depressive symptoms increased the odds of developing a new case of LBP (OR 1.59, 95% CI , I2 = 59%)
Pooled OR for the most severe level of depression (OR 2.51, 95% CI , I2 = 36%) was higher than that for the lowest level (OR 1.51, 95% CI , I2 = 48%)

18. Depression First 65% of depressed patients report pain
Specifically, depressed patients complain of headache, abdominal pain, joint pain, and chest pain
Somatic symptoms are the primary presenting complaints of MDD in primary care
Increased rates of suicidal ideation, suicide attempts, and suicide completion
Unclear how treatment of MDD is impacted by comorbid pain

19. Chronic Pain First
Rayner L et al. “Depression in patients with chronic pain attending specialised pain treatment centre: prevalence and impact on health care costs” 2016
PHQ-9, N=1204
60.8% (CI ) met criteria for probable MDD
5.7% mild MDD; 21.3% moderate MDD; 33.8% severe MDD
15.2% reported suicidal thoughts
Patients with depression reported
Unable to work because of ill health
Of those in employment, they were more likely to have taken >21 days of sick leave/past year
Greater number of pain regions
Greater healthcare use and costs
Duration of pain and extent of relief from treatment did not differ

20. Chronic Pain First Chronic pain patients with MDD
52% in pain clinics or inpatient pain programs
38% in psychiatric clinics or psychiatric consultation
27% in primary care clinics
Multiple pain complaints increase the probability of MDD
Studies of more defined pain disorders (e.g., peripheral neuropathy) report lower MDD rates than studies of medically unexplained pain
Back pain and migraine headaches are specifically associated with MDD
Co-occurring MDD is better predictor of disability than pain severity

21. Chronic Pain First
Greater pain intensity, more pain persistence, and greater interference from pain
Pain often improves with improvement in depressive symptoms (another case of the chicken and the egg)
MDD is the most consistent and strongest predictor of suicidal ideation and behaviors in patients with chronic pain

22. Chronic Pain and MDD Comorbidity is associated with
Poorer treatment outcomes of both
Decreased recognition of MDD
Increased functional limitations
The association between depression and pain becomes stronger as the severity of either condition increases

23. Neurobiology Share common neural circuity
Depression and Pain follow the same descending pathway of the CNS
Serotonergic and noradrenergic pathways involve mood regulation and modulation of pain stimuli
If depleted (as in MDD), lost of modulation of pain occurs

24. MDD, Chronic Pain, and Opioids
Patient with MDD are more likely to be prescribed opioids and receive higher doses of opioids
Comorbidity is associated with more severe symptomatology
MDD is associated with vulnerability to opioid use disorder
Comorbidity may influence both patient's and provider’s perception of overall distress
Opioids may treat both physical and mental pain

25. MDD, Chronic Pain, and Opioids
Goesling J, et al. “Symptoms of depression are associated with opioid use regardless of pain severity and physical functioning among treatment-seeking patients with chronic pain” 2015
Outpatient tertiary pain clinic
N=2104
Opioid use was associated with higher depressive and anxiety symptoms (HADS), greater pain severity, worse physical functioning
Pts with depressive symptoms and opioid use reported higher median daily opioid dosage
For depressed patients, the predicted probabilities of opioid use remain constant across pain severity (opposite seen with nondepressed pts)
At a similar level of functioning, depressed patients had a higher probability of being on opioids

26. MDD, Chronic Pain, and Opioids
Mazereeuw G, Sullivan MD, Juurlink DN. “Depression in chronic pain: might opioids be responsible?” PAIN 2018
Activation of kappa receptor by opioids = dysphoria
Most currently used opioids are selective for mu receptor; however, chronic opioid use increases activity at kappa receptor
Opioids exhibit a dose-dependent association with depression
Prolonged opioid therapy is associated with depression
Opioids predispose to antidepressant failure
Opioid dose reduction may improve depressive symptoms

27. Part 2: Treatment of Depression in Patients with Chronic Pain
Coming March 20, 2019

28. Questions about the Topic
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29. Case Conference and Feedback
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