1. Pain and Depression in Older Adults Stephen Thielke Seattle GRECC

2. Disclosures My research is supported in part by a Geriatric Health Outcomes Research Award from the American Geriatric Society Foundation for Health in Aging No other disclosures or conflicts of interest

3. Overview Depression Pain 1.Overlap of depression and pain in aging 2.Similarities and differences 3.Depression through the lens of pain 4.Treatment recommendations

4. Depression and Aging Thielke, Aging and Mental Health, 2009

5. Depression and Aging Thielke, Aging and Mental Health, 2009 Incidence Persistence

6. Chronic Pain and Aging 2/3 of older adults report chronic pain [lasting 3 months or more] (Gagliese 1997) Of older adults with pain, 83% report that pain interferes with daily activities and negatively affects quality of life (Herr 2001) Most frequent pain types in those 65 or older are osteoarthritis of hip or knee (58%) and low back pain (35%) (CDC) Mean # of pain sites in older adults: 4.3

7. Chronic Pain and Aging Highest prevalence of chronic pain occurs at about age 65, after which there is a slight decline with advancing age, even beyond age 85 (Gibson & Helme 1995) Pain Intensity not associated with advancing age, but slightly greater intensity of low-level pain (Rustoen 2005)

8. Pain and Aging Many types of chronic pain disorders occur less commonly with advancing age: Headache Migraine Abdominal pain Chest pain Low back  Chronic pain is NOT a “natural part of getting older”

9. Depression is Common in Patients with Pain US Geriatric Population 5% Ambulatory Medical Patients 5-9% Medical Inpatients 15-20% Pain Clinics 10-100% (~50%) Pain is Common in Patients with Depression ~65%, regardless of treatment setting Bair et al, Arch Int Med 2003

10. Pain Is Strongly Associated with Depression ** ** p < 0.001 Thielke, HRS, 2008

11. Depression and Pain in Older Adults European 11-country study, Aged in Home Care (AdHOC) 3976 subjects, 65 years and older, receiving home care Pain: any daily pain over the last week, or pain behaviors Depression: MDS depression scale PainNo Pain Depression 19.5%11.3% No depression 80.5%18.7% Onder, J Clin Psy 2005 PainNo Pain Depression 71.9%18.1% No Depression 57.5%42.5%

12. Depression and Pain Patients with pain have 2-5 times increased depression incidence Greater risk of depression with: Multiple pain complaints Multiple episodes Severe pain Patients with pain and depression have greater: Pain complaints Pain intensity Chronicity Directionality?

13. Similarities and Differences Between Pain and Depression in Older Adults

14. Neuroimaging Studies Many, but not all, of the same brain areas that are stimulated by physical pain are also stimulated by: -Induced sadness -Social exclusion -Grief “There is that cliché of a broken heart, but my ribs ached from the pain in my heart. I had to go to the doctor because I thought I was having heart attacks.”

15. Psychological and Physical Pain “I have suffered from severe, recurrent depression for 40 years. The psychological pain that I felt during my depressed periods was horrible and more severe than my current physical pain associated with metastases in my bones from cancer.” “I woke up in the middle of the night to use the bathroom and forgot that my furniture had been re- arranged. I accidentally tripped over my cocktail table, breaking both of my legs. The pain that I experience from depression is so much worse than the pain associated with my breaking both of my legs.” Mee et al, J Psychiatric Res2006

16. Physical Pain During Depression

17. Sleep, Pain, and Depression 50-80% of patients with chronic pain have a significant sleep disturbance Sleep disturbance is one of the cardinal symptoms of depression Insomnia predicts depression onset Experimental disruption of slow-wave sleep increases pain sensitivity Sleep deprivation can temporarily relieve depressive symptoms

18. Pain Impairs Depression Treatment Response Thielke, et al. Am J Geriatric Psych. 2007. Baseline Pain Interference Category Increasing Pain % with Depression Response

19. Depression Pain Treatment Overlap for Pain and Depression “Opium cure” for depression never worked ECT not effective for chronic pain Antidepressant response: -Depression response usually 6-8 weeks -Pain response usually 3-4 weeks Noradrenergic drugs have direct analgesic properties Pure serotonergic drugs have no direct effect on pain Doses for pain are roughly ½ of those for depression

20. Placebo Response Rates Brief Pain Inventory - Severity Depression trials show ~30% placebo response Only 48% of placebo-controlled trials of antidepressants showed superiority to placebo Khan & Bhat, J Clin Psy, 2008

21. Key Similarities and Differences Human suffering Sleep disturbance High placebo response Brain areas Human suffering Prevalence Neurotransmitters Medication effects Pain and depression often occur together “Psychic Pain” and “Physical Pain” are different  Pain and depression are a bad combination

22. Depression Through the Lens of Pain Why do we need physical pain? What would happen if we didn’t have pain? Why don’t people treat their pain? What does psychological pain do for us? Why don’t more people treat their depression?

23. Congenital Analgesia Depression = Guarding from Social Pain?

24. Most Patients Do Not Seek Out Treatment for Pain or for Depression

25. The Experience of Pain in Aging Belief that pain is “just a part of getting older” “Many [osteoarthritis patients] were unwilling to use medication. For these individuals, treating pain with medication was seen as masking rather than curing symptoms, and was seen as potentially harmful because of an increased risk of unwanted side effects.” Gignac, Hawker et al 2006

26. Evidence-Based Options for Treating Pain OTC analgesics Prescription analgesics Physical therapy Exercise Weight loss Acupuncture Massage Injections Joint replacement Supplements

27. “Taking”  Taking Effectively 19 older adults with osteoarthritis pain Qualitative interview 4/19 (21%) taking medications as prescribed or directed Others use lower doses than prescribed or less often than directed None using analgesics in advance of activities Sale, Gignac, Hawker 2006

28. Filling Percodan prescription and throwing the whole bottle away Filling higher-dose bottle with lower-dose pills Rationing pain medications to refill far less than allowed Not telling family members about using less than prescribed Adhering to pain medications differently than to other medications Sale, Gignac, Hawker 2006 Medication-Related Behaviors

29. Willingness to Undertake Risk in Pain Treatment Preference for topical treatments such as capsaicin over oral agents; pills preferred only if they were reported as being three times as effective as capsaicin All the patients switched their preferences when offered a safer but less effective treatment option 20% of older patients are unwilling to accept any additional risk for reductions in pain Many patients consider medications to be a treatment of last resort Fraenkel et al, 2004 Ross et al, 2001

30. Values and Perceived Need ThriftyWasteful CautiousRash StoicalHedonistic PatientHurried SelflessSelfish “I need to take something to feel better now.” “I don’t need to treat this. I’ll hold out.”

31. Responses to Pain May Explain Responses to Depression Depression as a form of “social pain”? Social comparison as the cause of depression in older adults? (Blazer 2008) Patients resist NEEDING a treatment for pain or depression Suffering the symptom often feels like the right thing to do Suffering the symptom often seems safer than risking something unknown just to placate it

32. TREATMENT RECOMMENDATIONS Ask about pain and about depression Ask about pain and depression treatments Work to understand effects of mental health on use of pain treatments Do not assume that one problem is causing the other Do not assume that addressing one problem will fix the other

33. TREATMENT RECOMMENDATIONS The realistic goal is to make the depression go away, but not to make the pain go away Consider antidepressants for pain and for depression, but do not expect them to fix the problem Placebo response is large in both depression and pain: use this to your advantage Understand patient’s sense of “as needed”

34. Be Careful with Opioid Analgesics Accidental deaths in US from prescription opioids exceed deaths from heroin & cocaine More deaths in Washington State last year from prescription opioids than from traffic fatalities!

35. Collaborative Care Interventions for Pain and Depression Improve Both IMPACT-DP, n = 13

36. Dobscha, S. K. et al. JAMA 2009;301:1242-1252. n = 401 Collaborative Care Interventions for Pain and Depression Improve Both