1. “Depression and Chronic Pain” Agrability National Conference November 18, 2004 Crowne Plaza Hotel Springfield, IL David Weis, LCPC, Chestnut Health Systems Employee Assistance And Workplace Services, ADM National Account Manager Services, ADM National Account Manager

2. About Chestnut Health Systems Not-for-profit behavioral healthcare provider started in 1973 Headquartered in Bloomington, IL about 650 employees JCAHO accredited since 1983 One of the first addiction treatment centers in the country to be accredited

3. About Chestnut Health Systems Diverse array of services: -addiction treatment -community mental health services -prevention and school based programs -applied research & evaluation -domestic and international employee assistance services

4. Facts about depression Affects about 10% of the U.S. population with nearly three out of four in the workplace (Gemignani, 2001) Prevalence among school age children and adolescents is 4.6% (Wagner, 2003) Millions do not seek treatment due to inadequate benefits and the stigma associated with depression (U.S. Surgeon General, 2000) Effective pharmacotherapy combined with psychotherapy has been shown to reduce healthcare costs and the rate of suicide attempts (Ballenger, 1999) Average disability length as well as disability relapse are greater for depression than most comparison medical groups (Conti and Burton, 1994)

5. Types of depression: Unipolar Bipolar Dysthymia Seasonal Affective Disorder (SAD)

6. Symptoms of depression: DSM- IV Criteria Occurring over a two week period Helplessness/hopelessness Anhedonia Poor concentration Sleep disturbance (initiating and/or maintaining sleep) Suicidal ideations Appetite disturbance (typically weight loss, but in a small subgroup, weight gain).

7. Symptoms of depression Depressed mood Tearfulness Irritability Low energy level Guilt

8. Pain perception “Is it all in my head?” Emotional aspects of pain Biology of pain perception Cultural factors

9. Models of pain Peripheral vs. Central Disease vs. illness-behavior Reductionistic vs. systems Biomedical vs. Biopsychosocial Medical vs. Self-Management

10. Assessment of chronic pain and depression Patient Health Questionnaire (PHQ) Zung Depression Inventory (ZDI) Beck Depression Inventory (BDI)

11. Assessment of chronic pain and depression Standardized Instruments Pain Patient Profile (P-3) P-3 is a test that helps screen for the presence of depression, anxiety, and somatization—the factors most frequently associated with chronic pain.

12. Assessment of chronic pain and depression Overview: administration to individuals 17-76, reading level is 8 th grade and it takes 12-15 minutes to complete, 44 groups of statements with 3 statement per group Has validity scale to assess for random response and/or symptom magnification Report includes; results summary, clinical interpretation, pain patient profile and treatment recommendations. Cost is approximately $11/report with appropriate testing software

13. Million Behavioral Health Inventory (MBHI) Overview; administration to individuals 18 year and older, reading level is 8 th grade, 150 questions and takes approximately 20 minutes to complete Report includes basic coping styles, psychosomatic correlates, and psychogenic attitudes such as stress level, premorbid pessimism and future despair. Also includes a section on prognostic indicators such as pain treatment responsitivity and emotional vulnerability Cost is approximately $27/report with software Assessment of chronic pain depression

14. Minnesota Multiphasic Personality Inventory (MMPI-2) Consist of 567 true/false questions Internal reliability/validity scales Takes approximately 90 minutes to complete Most widely recognized instrument use in forensic evaluations Report includes; diagnosis, critical items, addiction potential and treatment receptivity Assessment of chronic pain and depression

15. Clinical interview (Biopsychosocial factors) Substance abuse evaluation (prescription and/or illicit) Suicide assessment Case management Assessment of chronic pain and depression

16. Psychological management of chronic pain: Locus of control (internal vs. external) Stress Management Assertiveness Training Exercise

17. Psychological management of chronic pain: The role of attention focus and complaint Treatment personnel The faith factor Accessing support systems Lifestyle changes

18. Psychological management of chronic pain: Medication use (indications/contraindications) Cognitive-behavioral approaches Family systems approaches Case Management

19. Barriers to treatment: Inadequate assessment/missed diagnoses Co-morbid conditions (such as diabetes, stroke, cancer etc) Substance abuse Lack of available resources Poor continuity of care Inappropriate medication dosing/titrating Lack of behavioral health treatment providers in rural areas

20. Intervention considerations for Agrability Selection of an appropriate screening tool to be utilized by Agrability field workers Development of a database of resource and referral options Development and implementation of a training program for workers involved in assessment of farmers with disabilities. A resource manual would be included Administration of a technical support line where Agrability workers could receive expert consultation on screening and referral issues