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A Narrative Review of the Assessment of Depression in Chronic Pain
Abstract
Objectives:
This narrative review sought to explore the main critical issues in the assessment of depression in chronic pain and to identify self-report tools that can be reliably used for measuring it.
Design:
Narrative review of the literature.
Methods:
Articles were obtained through a search of three databases and a hand search of the references of full-text papers. Key results within the retrieved articles were summarized and integrated to address the review objectives.
Results:
Criterion contamination, different ways to define and evaluate pain and depression across studies, variability in chronic pain samples and settings, pitfalls of diagnostic systems and self-reports, and reluctance to address (or difficulty of recognizing) depression in patients and healthcare providers emerged as main critical issues. The Beck Depression Inventory seems to be the more accurate tool to evaluate depression in chronic pain patients, while other instruments such as the Patient Health Questionnaire could be recommended for a rapid screening.
Conclusions:
Assessment of depression comorbidity in chronic pain represents a challenge in both research and clinical practice; the choice and use of tests, as well as the score interpretation, require clinical reasoning.
Nursing practice implications:
Nurses play an important role in screening for depression. Cognitive contents of depression should be carefully evaluated since somatic symptoms may be confusing in the chronic pain context. Some self-reports may be useful for rapid screening. It is also advisable to consider other relevant patient information in evaluating depression.
... Chronic pain also hinders daily functioning and social participation, as one study found that 40% of individuals with chronic pain had difficulty walking, and 34% had difficulty socializing [7,8]. Moreover, chronic pain is linked to depression, anxiety, and lower quality of life (QOL) [9][10][11]. In general, chronic pain is one of the most common health challenges globally, with significant direct or indirect adverse consequences for patients, their families, and society [5,12,13]. ...
Objectives
To assess the efficacy of acceptance and commitment therapy (ACT) for patients with chronic pain.
Materials and methods
The research conducted a systematic search of the Cochrane Library, Web of Science, PubMed, EMBASE, PsycINFO, and Cumulative Index of Nursing and Allied Health Literature (CINAHL) databases following the PRISMA guidelines. The retrieval time limit was from the establishment of the database to October 2023. A meta-analysis was carried out for the randomized controlled trials (RCTs) that meet the inclusion and exclusion criteria by using RevMan 5.3.
Results
Twenty-one RCTs were included. At post-treatment, a significant medium effect size (ES) was found in measuring pain interference, functional impairment, pain acceptance, psychological inflexibility, and depression; Pain intensity, anxiety, and quality of life (QOL) had a small ES. At three months post-treatment, a large ES was found in measuring functional impairment, and a medium ES was found in the other indicators.
Conclusion
The researchers provided evidence for the effectiveness of ACT as an intervention for patients with chronic pain, which can be applied by clinicians or nurses in practice. Future research should explore the applicability of ACT to different pain conditions and modalities.
Implications for nursing
Post-treatment data highlight the efficacy of ACT in moderating pain-related outcomes. Clinical nurses are encouraged to incorporate ACT into routine patient education and interventions, including promoting pain acceptance, promoting mindfulness practices, and using cognitive stress reduction techniques. Standardized follow-up after an ACT intervention for patients with chronic pain is critical, including regular assessment, feedback, and realignment of treatment strategies. Overall, ACT became an important tool for nurses to improve the lives of patients with chronic pain.
... In this research, when in the presence of anxiety and depression, patients with CP presented, comparatively, worse quality of sleep than those patients who did not present these psychiatric disorders. Pain is associated with somatic symptoms very similar to those found in depression, with inadequate sleep being one of the most common overlapping factors 36 . The presence of emotional suffering, depression and/ or anxiety in people with CP represents a challenge in the evaluation of sleep alterations, as the symptoms can be the result of the pain itself or of drugs prescribed to control pain 37 . ...
... In this research, when in the presence of anxiety and depression, patients with CP presented, comparatively, worse quality of sleep than those patients who did not present these psychiatric disorders. Pain is associated with somatic symptoms very similar to those found in depression, with inadequate sleep being one of the most common overlapping factors 36 . The presence of emotional suffering, depression and/ or anxiety in people with CP represents a challenge in the evaluation of sleep alterations, as the symptoms can be the result of the pain itself or of drugs prescribed to control pain 37 . ...
BACKGROUND AND OBJECTIVES
Chronic pain and its relationship with sleep disturbance are common conditions with great influence on the individual’s quality of life. The simultaneous occurrence of these two entities results in greater suffering, reduced functionality and well-being. The objective of this research was to evaluate the influence of chronic pain on sleep and its impact on quality of life.
METHODS
This is an observational, cross-sectional, individual, uncontrolled study carried out at the Multidisciplinary Pain Center of the Clinical Hospital of the Federal University of Minas Gerais (Hospital das Clínicas da Universidade Federal de Minas Gerais - HC-UFMG). The patients answered a semi-structured, face-to-face interview via the pain center’s own computer system (avaliaDor®), using internet-connected mobile devices. Socioeconomic and pain data was collected, and then instruments were applied to assess pain intensity (Visual Numerical Scale - VNS), quality of life (Medical Outcomes Study 36 - Short Form Health Survey - SF-36), presence of psychiatric disturbances (Hospital Depression Anxiety Scale - HAD) and sleep (Mini Sleep Questionnaire - MSQ).
RESULTS
One hundred and three patients participated in the study. Seventy two percent were women, the median age was 55 years, and the patients were predominantly married, white and with a low level of schooling. Of the entire study population 74.76% presented “severe difficulty” in sleeping, while 22.33% had “good quality” sleep. Regarding pain intensity, patients in the moderate and severe pain groups had a higher percentage of “severe difficulty” in sleeping, when compared to patients with mild pain. About the presence of anxiety and depression, it was observed lower scores on: “restless sleep”, “tiredness for no apparent reason”, “wakes up with a headache”, “wakes up and goes back to sleep”, “wakes up tired in the morning”, and finally “wakes up and does not go back to sleep”. The general data from the SF-36 points to a low quality of life for the patients in the present study and, based on the multivariate analysis, the items “SF-36-Pain and SF-36-Vitalidade” were shown to be protective factors for the presence of sleep disturbances.
CONCLUSION
Sleep disorders in patients with chronic pain are common and show a worsening in quality of life. The frequency of this disturbance was higher in patients with anxiety and depression compared to patients without these psychiatric disorders. The early identification of sleep disturbances in individuals with chronic pain is necessary to improve well-being.
Keywords:
Chronic pain; Quality of life; Sleep
... Localization of the visceral-pain pathway partially superimposed on localization of PPD circuitry. Besides, serotonin and norepinephrine are involved in depression and the modulation of pain signals [19]. When delivered intrathecally, these neurotransmitters alleviate pain, suggesting that pain and depression may follow similar neurochemical pathways. ...
Background
Lack of motivation and behavioural abnormalities are the hallmarks of postpartum depression (PPD). Severe uterine contractions during labour are pain triggers for psychiatric disorders, including PPD in women during the puerperium. Creating biomarkers to monitor PPD may help in its early detection and treatment. It has been suggested that uterine contraction-induced labour pain plays a role in the emergence of this syndrome. Therefore, abnormal electroencephalography (EEG) patterns during the early stage of labour may provide useful information. Here, we propose that aberrant EEG patterns caused by uterine contraction pain may be predictive markers for PPD.
Methods
This study is a single-centre prospective cohort planned for 330 parturients for vaginal delivery in the maternity ward of Zhujiang Hospital from 2021 to 2023. At baseline, online or paper-based questionnaires, including the Edinburgh Postnatal Depression Scale (EPDS) and demographic data, will be collected at their final prenatal visit in the outpatient clinic. EEG, electrocardiography (ECG) and electrohysterography (EHG) signals will be monitored and recorded during the first stage of labour in the ward. Follow-up will be taken at the postpartum timepoints of day 3, day 42, and 3, 6 and 12 months, respectively. Power spectral density and functional connections will be quantified. The connections between PPD severity and EEG measurements as a function of time will be assessed using linear mixed-effects models. Maternal age, parity, and whether oxytocin is used during labour, all have an impact on the incidence of PPD, hence a stratified analysis will be carried out.
Discussion
We expect EEG changes caused by painful uterine contractions in the first labour may predict early PPD. The results from this study may act as a predictor for the development of PPD which may enhance long-term quality of life for the parturient and her offspring.
Trial registration
Name of registry: EEG Changes of Uterine Contractions in the First Stage of Labor Predicting PPD. Trial registration number: NCT05217251; registration date on the ClinicalTrial.gov platform: March, 23/2022.
... The HAD has frequently been used in population studies and its psychometric properties have been studied in many populations [19]. The HAD was developed to identify symptoms of anxiety and depression in non-psychiatric patients and, to prevent criterion contamination, all somatic indicators were excluded [21], with the depression symptoms focused on anhedonia and a lack of positive affectivity [22]. It is divided into two sub-scales to assess anxiety and depression separately, each consisting of seven questions. ...
Aim of the study
Mental illnesses are common in patients with chronic pain, and this association may result in changes in functional status. This study assessed the functionality and quality of life of patients with chronic pain, anxiety, and depression.
Subject or material and methods
A total of 103 patients were interviewed at Federal University of Minas Gerais’ (UFMG) Hospital das Clínicas Pain Center, in 2020 and 2021. The presence of depression and anxiety symptoms, pain intensity, quality of life, and functionality was assessed. The cohort studied was stratified into groups suffering from mild, moderate, and intense pain in accordance with the visual numeric scale, and these patients then underwent descriptive and comparative analyses. Subsequently, a multivariate analysis was performed, followed by linear regression analysis to identify risk factors and variables that contributed to the pain being felt.
Results
In total, 16.5% of the patients were diagnosed with symptoms of anxiety, 13.59% with depression, and 34.95% presented symptoms of both anxiety and depression. The functionality assessment revealed severe incapacity, with the highest levels of incapacity present in those suffering from the most intense pain.
Discussion
Patients with symptoms of anxiety and depression presented a worse quality of life than those without these symptoms, with some aspects directly related to pain intensity.
Conclusions
Chronic pain, in the presence of symptoms of anxiety and depression, produces severe functional psychosocial incapacity and a low quality of life, which are directly related to pain intensity. Skin color, suicidal ideation, and psychosocial issues are associated with depression, anxiety, and chronic pain.
... Middle-aged and older adults who long-term exposure to HAP reported high levels of pain that caused the depression and ultimately increased the risk of disability. Prior research indicated that depression was seen as an adverse outcome of pain and had been shown to predict disability better than pain 47,75,76 . Those suffering from pain reported their prevalence of depression as high as 21%, 14% higher than the general population 77 . ...
Household air pollution (HAP) is suggested to increases people's risk of disability, but mediating mechanisms between HAP and disability remains under-investigated. The aim of this study was to investigate the underlying mechanisms between household air pollution and disability in middle-aged and older adults (i.e., older than 45 years) using a nationally representative prospective cohort. In total, 3754 middle-aged and older adults were selected from the China Health and Retirement Longitudinal Study. Correlation analysis and logistic regression analysis were employed to estimate the association between HAP, pain, depression and disability. Finally, three significant mediation pathways through which HAP directly impacts disability were found: (1) pain (B = 0.09, 95% CI 0.01, 0.02), accounting for 15.25% of the total effect; (2) depression (B = 0.07, 95% CI 0.004, 0.02), accounting for 11.86% of the total effect; (3) pain and depression (B = 0.04, 95% CI 0.003, 0.01), accounting for 6.78% of the total effect. The total mediating effect was 33.89%. This study clarified that HAP can indirectly affect disability through the respective and serial mediating roles of pain and depression. These findings potentially have important implications for national strategies concerning the widespread use of clean fuels by citizens.
... Beck Depression Scale, which was developed by Beck et al, is used to diagnose depression; it has been used both to measure its severity and to follow treatment-related changes. [8] On the scale consisting of 21 items, mood, pessimism, sense of failure, dissatisfaction, guilt, punishment, self-hatred, self-blame, desire to punish oneself, crying spells, irritability, social introversion drowsiness, indecisiveness, bodily image, impaired ability to work, sleep disorders, fatigue, fatigue, decreased appetite, weight loss, somatic complaints, and loss of sex drive. A high total score indicates an increase in the severity of depression. ...
The study aims to determine whether there is a relationship between fibromyalgia (FM) disease and depression, anxiety, anxiety sensitivity, fear-avoidance beliefs, and quality of life in female patients with a diagnosis of fibromyalgia. 37 female patients followed up with FM diagnosis in pain medicine clinic and a control group consisting of 37 healthy women were included in the study. Sociodemographic and Clinical Characteristics Data Form, Quality of Life Form, fear-avoidance beliefs questionnaire, Anxiety Sensitivity Index-3, Beck Anxiety Inventory, Beck Depression Inventory, and Visual Analogue Scale was applied to the participants. When the patients in the FM group were compared to the control group; Statistically lower scores in all Quality of Life Form subscales except emotional role difficulty and social functionality scores; statistically higher scores in both physical and work activity subscales in fear-avoidance beliefs questionnaire; statistically higher scores in cognitive symptoms subscale in Anxiety Sensitivity Index-3, Beck Anxiety Inventory, Beck Depression Inventory, and Visual Analogue Scale scores were found. In FM patients, it has been determined that anxiety, depression and perceived pain severity reduce social functionality and quality of life in areas such as mental health, physical function, and emotional role difficulties. It was determined that the functionality and quality of life of patients diagnosed with FM decreased in daily life. An important contribution of the study to the literature is that it shows that the behavior of avoiding activity due to pain-induced fear exacerbates the pain and even contributes to its chronicity. These results, which show the effects of anxiety, depression, anxiety sensitivity, and fear-avoidance behavior on the prognosis of the disease in FM patients, indicate that psychiatric evaluation and treatment in FM patients is an important factor that determines the functionality and quality of life.
... It has to be pointed out, however, that assessing depression in CP-affected subjects is complex and presents several critical aspects; furthermore, the prevalence of depression among pain sufferers may vary widely due to variability in the definition and assessment of depression across studies, as well as in samples and setting considered. 49 Regarding cancer, pain is the main symptom characterizing the pathology that affects in a persistent manner nearly 55% of all cancer patients, at least 66% of patients at an advanced stage of the disease, and 33-40% of individuals who survive from cancer. 50 The Ehis wave 3 (2019) shows that, among people with cancer, CP involved 56.4% of respondents. ...
Background
Chronic pain (CP) prevalence estimates addressing a wide phenotype are still quite fragmented and may vary widely due to the lack of standardized tools of investigation. There is an urgent need to update general population CP estimates.
Methods
For this purpose, the Brief Five-item Chronic Pain Questionnaire was developed through experts’ consultations for design and content validity assessment; literature analysis of measures used to investigate CP for general population surveys; understandability evaluation through a survey on a convenience sample of affected and non-affected individuals; reliability assessment by means of two double-wave online surveys carried out by the Italian Twin Registry; criterion and construct validity assessment through the third wave of the 2019 European Health Interview Survey (Ehis).
Results
Key dimensions were defined to describe CP main aspects from a public health perspective. Literature analysis showed that validated questionnaires were rarely used to address important public health CP aspects. Understandability of the measure was good. Test-retest analyses showed adequate reliability of the measure: k values were at least “moderate” with highest values regarding CP “occurrence” and “intensity”. Correlations of CP with well-known comorbidities (cancer, depression), and specific traits (age, education) as well as of CP and its intensity with “physical pain occurrence and intensity” detected in the Ehis 2019, confirmed, respectively, a good construct and criterion validity. Construct validity was also evaluated through the correlation between “perceived treatment effectiveness” and “interference of pain in daily life activities” as recorded in the Ehis 2019.
Conclusion
The designed questionnaire is a brief self-administered measure, particularly suitable to detect persistent states of pain and related intensity in large-scale general population surveys by means of a first filtering item followed by four further items. It is, in fact, designed to detect CP possible underlying causes/triggers, drugs/treatments taking and frequency, and self-perceived effectiveness among CP sufferers. Further validation of the measure in different social and cultural contexts is desirable.
Despite the well-known impact of depression on patients with chronic pain and its association, few studies have evaluated its related factors in Physical Medicine and Rehabilitation settings. The objective of the present study was to assess the factors associated with depression in adult patients undergoing rehabilitation for chronic pain at Hospital Rebagliati (HNERM) in Peru. A cross-sectional analytical study was conducted between June and August 2023, involving 212 adult patients with chronic pain undergoing rehabilitation at HNERM. Data were collected through a survey, including sociodemographic information, pain characteristics, and depression assessment using the Patient Health Questionnaire-9 (PHQ-9). Statistical analysis included descriptive statistics and generalized linear models to identify factors associated with depression. Among 212 participants, 17.9% had a depression diagnosis based on the PHQ-9 (cutoff score: 10 points). Factors associated with a higher frequency of depression included a time since pain diagnosis of 3–6 months [adjusted prevalence ratios (aPR): 1.15, 95% confidence interval (CI): 1.04–1.27], severe pain (aPR: 1.17, 95% CI: 1.04–1.32), comorbidities (for 1: aPR: 1.21, 95% CI: 1.08–1.35; for 2: aPR: 1.17, 95% CI: 1.06–1.29; for ≥3: aPR: 1.27, 95% CI: 1.10–1.47), use of ≥2 medications for pain management (aPR: 1.27, 95% CI: 1.13–1.42), and receipt of psychological therapy (aPR: 1.26, 95% CI: 1.09–1.46). Nonpharmacological interventions did not show an association with an increased prevalence of depression. These findings underscore the significance of adopting a comprehensive approach to chronic pain management, including the screening, assessment, and treatment of associated depression.
Objectives:
Depression is prevalent among patients with chronic pain and may impact pain management. Accurate assessment is, however, complicated by overlapping symptoms. This study investigated how patients with high-impact chronic pain interpreted and responded to the Patient Health Questionnaire 9 (PHQ-9) to identify problematic items and causes hereof.
Methods:
Cognitive interviews using the Three-Step Test-Interview procedure were conducted during completion of the PHQ-9 in 33 patients with high-impact chronic pain referred to interdisciplinary treatment. Responses were analyzed using four coding categories: i) "congruent" (response consistent with intention); ii) "incongruent" (response not consistent intention); iii) "ambiguous" (response both congruent and incongruent or insufficient to evaluate congruency); and iv) "confused" (response with confused or misunderstood statements). Next, content of responses problematic items was analyzed to identify causes for non-congruency and encountered response difficulties were identified across all items.
Results:
Three items (item 2, 6, and 9) performed as intended (>97% congruent responses), while seven items (item 1, 3, 4, 5, 7, 8, and 10) were identified as problematic (<50% congruent responses). Problematic items had one or more issues: Responses were based on i) pain related issues or ii) other (non-pain) factors unrelated to depression, or item structure caused response difficulties due to wordings, reversion, or having two questions in one.
Discussion:
Problematic items limit the construct validity of the PHQ-9, leaving increased risk of inflated depression scores in high-impact chronic pain. Identified problems should guide future revisions to enhance validity and screening accuracy for the benefit of both research and clinical practice.
Introduction:
Chronic Pancreatitis (CP) is a fibroinflammatory condition with debilitating symptoms. Quality of life is severely affected in patients with CP and they are likely to suffer from mental health disorders, including depression. We conducted a systematic review and meta-analysis assessing the prevalence of depressive symptoms and depression in patients with CP.
Methods:
MEDLINE (OVID), PsycINFO, Cochrane Library, Embase, CINAHL Complete, Scopus and Web of Science were searched until July 2022 to identify manuscripts reporting the prevalence of depressive symptoms and depression (diagnosed clinically or with a validated scale without language restriction) in patients with Chronic Pancreatitis. The pooled prevalence was calculated using a random effects model. Heterogeneity was assessed by the inconsistency index (I2).
Results:
Among 3647 articles identified, 58 studies were identified for full text review, and ultimately nine studies were included. A total of 87,136 patients were included in the studies. Depression was diagnosed clinically or symptoms were identified using validated scales including Center for Epidemiological Studies 10-item Depression Scale (CESD), Beck Depression Inventory (BDI) and Hospital Anxiety and Depression Scale (HADS). The overall prevalence of depression in patients with chronic pancreatitis was 36.2% (95%CI: 18.8-55.7). In the stratified analysis, depression prevalence according to the clinical diagnosis, BDI and HADS was 30.10%, 48.17% and 36.61%, respectively.
Conclusion:
The high prevalence of depression among patients with CP deserves a call-to-action due to its medical implications and worsening quality of life. Our findings raise awareness of the importance of screening patients with CP for mental health disorders. Further well-designed studies are needed to further characterize these findings.
Background
Pain is the primary symptom of knee osteoarthritis (KOA), significantly associated with depressive symptoms. Whether the early pain intensity could distinguish different trajectories of depressive symptoms is not well understood among patients with KOA.
Aims
To identify heterogeneous depressive symptoms trajectories among patients with KOA, and investigate the association between depressive symptoms subgroups and pain intensity.
Design
Secondary analysis of a cohort sample.
Setting
Three waves of data from the China Health and Retirement Longitudinal Study was collected in 28 provinces across China.
Participants
702 patients with KOA aged ≥ 45 years completed the Center for Epidemiologic Studies Depression Scale biennially from 2011 to 2015.
Methods
Latent class growth analysis was performed to identify the optimal trajectory shape and number of classes. Multinomial logistic regression analysis was conducted to compare pain intensity across the trajectories.
Results
Four distinct trajectories were identified as follows: no depressive symptoms, highly stable, decreasing, and increasing. In multivariate analysis, compared with the “no depressive symptoms” class, patients in the “highly stable” class and “increasing” class were more likely to report moderate pain (p < 0.05) and severe pain (p < 0.05). In addition, there was no significant difference in pain intensity between “no depressive symptoms” class and “decreasing” class (p > 0.05).
Conclusions
These results suggest important heterogeneity in depressive symptom trajectories among patients with KOA. Pain intensity could predict different depressive symptom trajectories in patients with KOA. Efforts to improve the depressive symptoms in patients with KOA must incorporate strategies to address pain.
Recent research has highlighted a need for the psychometric evaluation of instruments targeting core domains of the pain experience in chronic pain populations. In this study, the measurement properties of SF-36, EQ-5D, and HADS were analyzed within the item response-theory framework based on data from 35,908 patients. To assess the structural validity of these instruments, the empirical representations of several conceptually substantiated latent structures were compared in a cross-validation procedure. The most structurally sound representations were selected from each questionnaire and their internal consistency reliability computed as a summary of their precision. Lastly, questionnaire scores were correlated to each other to evaluate their convergent and discriminant validity. Our results supported that SF-36 is an acceptable measure of two independent constructs of physical and mental health. In contrast, although the approach to summarize the HRQoL construct of EQ-5D as a unidimensional score was valid, its low reliability rendered practical model implementation of doubtful utility. Finally, rather than being separated into two subscales of anxiety and depression, HADS was a valid and reliable measure of overall emotional distress. In support of convergent and discriminant validity, correlations between questionnaires showed that theoretically similar traits were highly associated whereas unrelated traits were not. Our models can be applied to score SF-36 and HADS in chronic pain patients, but we recommend against using the EQ-5D model due to its low reliability. These results are useful for researchers and clinicians involved in chronic pain populations, as questionnaires’ properties determine their discriminating ability in patient status assessment.
Objective
To test the validity and reliability of screening instruments for depression and anxiety in rheumatoid arthritis (RA).
Methods
Participants with RA completed the Patient Health Questionnaire (PHQ‐2 or PHQ‐9), the Patient Reported Outcomes Measurement Information System depression short form 8a and anxiety short form 8a, the Hospital Anxiety and Depression Scale anxiety score (HADS‐A) and depression score (HADS‐D), the Overall Anxiety Severity and Impairment Scale, the Generalized Anxiety Disorder 2‐ and 7‐item scales, and the Kessler‐6 scale. Clinical depression and anxiety disorders were confirmed using the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Axis I Disorders (SCID‐1) research version. We reported sensitivity, specificity, positive predictive value, and negative predictive value using SCID‐1 diagnoses as the criterion standard. Test–retest reliability was assessed with the intraclass correlation coefficient.
Results
Of 150 participants, 11.3% had SCID‐1–diagnosed depression, 7.3% had SCID‐1–diagnosed generalized anxiety disorder, and 19.3% had any SCID‐1–diagnosed anxiety disorder. For depression, sensitivity ranged from HADS‐D (cut point 11; 35%) to PHQ‐2 (88%) and PHQ‐9 (87%). Specificity ranged from PHQ‐9 (77%) and PHQ‐2 (84%) to HADS‐D (cut point 11; 94%). Positive predictive value ranged from 30% to 43%. Negative predictive value ranged from 92% to 98%. For generalized anxiety disorder, sensitivity ranged from HADS‐A (cut point 11; 45%) to HADS‐A (cut point 8; 91%). Specificity ranged from 81% to 89% for all measures except the HADS‐A (cut point 8; 63%). Intraclass correlation coefficient estimates ranging from 0.69 to 0.88 confirmed good test–retest reliability.
Conclusion
Depression screening instruments had good diagnostic performance; anxiety instruments were more variable. Identified depression and anxiety require clinical confirmation.
Chronic pain, one of the most common reasons adults seek medical care (1), has been linked to restrictions in mobility and daily activities (2,3), dependence on opioids (4), anxiety and depression (2), and poor perceived health or reduced quality of life (2,3). Population-based estimates of chronic pain among U.S. adults range from 11% to 40% (5), with considerable population subgroup variation. As a result, the 2016 National Pain Strategy called for more precise prevalence estimates of chronic pain and high-impact chronic pain (i.e., chronic pain that frequently limits life or work activities) to reliably establish the prevalence of chronic pain and aid in the development and implementation of population-wide pain interventions (5). National estimates of high-impact chronic pain can help differentiate persons with limitations in major life domains, including work, social, recreational, and self-care activities from those who maintain normal life activities despite chronic pain, providing a better understanding of the population in need of pain services. To estimate the prevalence of chronic pain and high-impact chronic pain in the United States, CDC analyzed 2016 National Health Interview Survey (NHIS) data. An estimated 20.4% (50.0 million) of U.S. adults had chronic pain and 8.0% of U.S. adults (19.6 million) had high-impact chronic pain, with higher prevalences of both chronic pain and high-impact chronic pain reported among women, older adults, previously but not currently employed adults, adults living in poverty, adults with public health insurance, and rural residents. These findings could be used to target pain management interventions.
Background
We aimed to investigate the prevalence of unrecognized depression in patients with chronic pain, but with no history of psychiatric diseases.
Methods
Patients with chronic pain who did not have a history of psychiatric disease were selected for this study. The Beck Depression Index (BDI) was used to evaluate depression. Participants' socio-demographic characteristics and pain-related characteristics were also recorded.
Results
The study included 94 consecutive patients with chronic pain (28 men and 66 women). Based on the BDI scores, 33/94 (35.1%) patients with chronic pain had comorbid depression. The prevalence of depression was significantly higher in our cohort than it was in the general population (P < 0.001). The standardized incidence ratio, adjusted for age and sex, was 2.77 in men and 2.60 in women. Patients who were unmarried (odds ratio [OR] = 3.714, P = 0.044), and who had subjective sleep disturbance (OR = 8.885, P < 0.001), were more likely to have moderate to severe depression. Patients with high education levels (OR = 0.244, P = 0.016), and who were economically active (OR = 0.284, P = 0.023), were less likely to have moderate to severe depression.
Conclusions
Our results indicate that unrecognized depression in patients with chronic pain is common. Therefore, pain physicians should actively seek to identify these problems rather than relying on the patient to volunteer such information.
Patients with rheumatoid arthritis (RA) suffer from high rates of depression but depression often remains undiagnosed and untreated among RA patients. Because of its high prevalence and its profound impact on functional disability and health-related quality of life, prompt recognition and management of comorbid depression is urgently needed in patients with RA. Rheumatologists face the challenge of addressing depression in their clinical interactions with patients. The purpose of this paper is to present the prevalence of comorbid depression in RA, to delineate the consequences of depression among RA patients, to discuss the barriers to the identification of depression among RA patients, and to outline a set of recommendations to identify and treat comorbid depression that could be implemented within the rheumatology clinic setting. A comprehensive approach to the management of both physical and mental health needs of RA patients can aid in improving patient overall quality of life. New clinical protocols should be developed to include routine depression screening as part of the rheumatology visit. Patient education to address misconceptions, knowledge gaps, and destigmatize depression is also recommended. More counseling resources, including emotional support groups, are necessary to provide treatment for those suffering from depression. Such interventions could help mitigate disability, improve quality of life, patient function, and overall satisfaction.
Purpose:
To determine if persons with arthritis differ systematically from persons without arthritis in how they respond to questions on three depression questionnaires, which include somatic items such as fatigue and sleep disturbance.
Methods:
We extracted data on the Centers for Epidemiological Studies Depression (CES-D) scale, the Patient Health Questionnaire-9 (PHQ-9), and the Kessler-6 (K-6) scale from three large population-based national surveys. We assessed items on these questionnaires for differential item functioning (DIF) between persons with and without self-reported physician-diagnosed arthritis using multiple indicator multiple cause models, which controlled for the underlying level of depression and important confounders. We also examined if DIF by arthritis status was similar between women and men.
Results:
Although five items of the CES-D, one item of the PHQ-9, and five items of the K-6 scale had evidence of DIF based on statistical comparisons, the magnitude of each difference was less than the threshold of a small effect. The statistical differences were a function of the very large sample sizes in the surveys. Effect sizes for DIF were similar between women and men except for two items on the Patient Health Questionnaire-9. For each questionnaire, DIF accounted for 8% or less of the arthritis-depression association, and excluding items with DIF did not reduce the difference in depression scores between those with and without arthritis.
Conclusions:
Persons with arthritis respond to items on the CES-D, PHQ-9, and K-6 depression scales similarly to persons without arthritis, despite the inclusion of somatic items in these scales.
Chronic pain is a common pain condition. Some psychiatric disorders, such as anxiety and depression, are also common in the general population. Epidemiological studies found that some psychiatric disorders are more commonly found among persons with chronic pain (e.g., headache, back pain) than those without chronic pain. Why those psychiatric disorders co-occur with chronic pain, however, is not well understood. Further, studies demonstrated that some psychiatric disorders, such as depression, increase the risk of chronic pain as well as its persistence. It is also recognized that chronic pain has a negative impact on the persistence of psychiatric disorders. The observations from clinical studies suggest that chronic pain is not a common comorbidity among individuals with other psychiatric disorders, such as dementia and schizophrenia. It is not clear if this is a consequence of any specific biological mechanism, or methodology problems in the studies. This paper provides an overview on the distribution of chronic pain and psychiatric disorders, followed by a review of studies that have demonstrated the association between psychiatric disorders and chronic pain.
This systematic review is to explore the prevalence of depression in patients with rheumatoid arthritis (RA) in China. Articles of prevalence rates for depression in adult RA patients published before October 2015 were identified from PubMed, Embase, The Cochrane Library, CNKI, CBM, VIP, and Wanfang database and other internet databases. Relevant journals and the recommendations of expert panels were also searched manually. Two independent reviewers searched and assessed the literature. Therelevant data were applied with Meta-Analyst 3.13 software, and the forest plot and funnel plot were performed. 21 studies with a total of 4447 patients were selected to be enrolled in this study. The prevalence of depression by analyzing the effect size was 48% [95% CI (41%, 56%)]. The prevalence of minor depression and dysthymic disorder was 30% [95%CI (23%, 38%)], and the moderate or major depression was 18% [95%CI (11%, 29%)], respectively. Subgroup analysis showed that the depression rate of female RA patients was higher than male. The depression rate in the central and western areas were higher than that of the eastern region of China, the prevalence level estimated by the Geriatric Depression Scale (GDS) was higher than estimated by other tools. Sensitivity analysis showed that the pooled effect size had good stability and reliability, To be conclusive, the prevalence rate of depression in RA patients is 48%, which suggesting that medical staff should pay more attention to depression in adult patients with RA.
Objectives
To determine if we are missing clinical depression in patients with Rheumatoid Arthritis and its relationship with functional disability and level of formal education in such patients.
Methods
The data for this cross-sectional, analytical study was gathered from May 2015 till December 2015 and comprised of 128 with Rheumatoid arthritis diagnosed according to ACR/EULAR 2010 criteria. The study was conducted at Fauji Foundation Hospital Rawalpindi. Functional status was assessed with Modified Health Assessment Questionnaire (mHAQ) and Beck’s Depression Inventory (BDI) was used for evaluation of symptoms of depression. The relation between depression, functional disability and educational status was established using Pearson correlation coefficient.
Results
The study included 128 patients with no previous diagnosis of depression. 122 (95.3%) were females and 6 (4.7%) were males. The mean age was 51.75 ± 9.25 years. Mean duration of disease was 8.95 ± 7.1 years. According to this study, the diagnosis of clinical depression was missed in 47.7% of patients with Rheumatoid Arthritis who had been under regular follow up at a tertiary care facility. About 18% were keen to seek professional help for depressive symptoms while 62.6% had functional disability (mild – severe). There is a positive correlation with BDI (Pearson’s correlation +1) and functional disability. No correlation could be established between level of education and depression as out of 79 (61.7%) patients with no basic education, 45.5% had depression. In remaining 49 (38.2%) patients, with some formal education, 51.3% had clinical depression.
Conclusion
Almost half of the patients with Rheumatoid Arthritis coming to a tertiary care set up had clinical depression but were never diagnosed or referred to a Psychiatrist. There is a positive correlation between depression and functional disability; however no statistically significant correlation could be established with the level of formal education. The study further emphasizes the importance of early recognition and swift referral of such patients to a psychiatrist since it is known to improve both treatment outcomes and functional status.
Objectives:
To validate standard self-reporting questionnaires for depression screening in patients with rheumatoid arthritis (RA) and compare these measures to each other and to the Montgomery-Åsberg Depression Rating Scale (MADRS), a standardized structured interview.
Methods:
In 9 clinical centers across Germany, depressive symptomatology was assessed in 262 adult RA patients at baseline (T0) and at 12 ± 2 weeks follow-up (T1) using the WHO Five Well-Being Index (WHO-5), the Patient Health Questionnaire-9 (PHQ-9), and the Beck Depression Inventory (BDI-II). Construct validity of these depression questionnaires (using convergent and discriminant validity) was evaluated using Spearman correlations at both time points. The test-retest reliability of the questionnaires was evaluated in RA patients who had not undergone psychotherapeutic intervention or received antidepressants between T0 and T1. The sensitivity and the specificity of the questionnaires were calculated using the results of the MADRS, a structured interview, as gold standard.
Results:
According to the Spearman correlation coefficients all questionnaires met convergent validity criteria (ρ > |0.50|) with the BDI-II performing best while correlations with age and disease activity for all questionnaires met the criteria for discriminant validity (ρ < |0.50|). The only questionnaire to meet the predefined retest reliability criterion (ρ ≥ 0.70) was the BDI-II (rs = 0.77) which also achieved the best results for both sensitivity and specificity >80% when using the MADRS as the gold standard.
Conclusions:
The BDI-II best met the predefined criteria and the PHQ-9 met most validity criteria with lower sensitivity and specificity. This article is protected by copyright. All rights reserved.
Background and purpose:
Depression is a frequent co-morbid diagnosis in chronic pain, and has been shown to predict poor outcome. Several reviews have described the difficulty in accurate and appropriate measurement of depression in pain patients, and have proposed a distinction between pain-related distress and clinical depression. Aims of the current study were to compare (a) the overlap and differential categorisation of pain patients as depressed, and (b) the relationship to disability between the Structured Interview for DSM-IV (SCID-Depression module) and the Hospital Anxiety and Depression Scale (HADS-D).
Methods:
Seventy-eight chronic back pain patients were administered the SCID-D, the HADS-D and the Pain Disability Index (PDI).
Results:
Significantly more patients were categorised with possible and probable depression by the HADS than the SCID-D. Results from Receiver Operating Characteristic (ROC) curve analysis suggested that the HADS-D provided better discriminatory ability to detect disability, demonstrating a better balance between sensitivity and specificity compared to the SCID-D, although a direct comparison between the two measurements showed no difference.
Conclusions:
The HADS-D is a reasonably accurate indicator of pain-related distress in chronic pain patients, and captures the link between disability and mood.
Implications:
It is likely that the SCID-D is better suited to identifying sub-groups with more pronounced psychiatric disturbance.
Perspective:
Several reviews have proposed a distinction between pain-related distress and clinical depression. This study compared the overlap and differential categorisation of pain patients as depressed and the relationship to disability between the Structured Interview for DSM-IV (SCID-D; Depression module) and the Hospital Anxiety and Depression Scale (HADS-D).
Background: In order to provide effective care to patients suffering from chronic pain secondary to neurological diseases, health professionals must appraise the role of the psychosocial factors in the genesis and maintenance of this condition whilst considering how emotions and cognitions influence the course of treatment. Furthermore, it is important not only to recognize the psychological reactions to pain that are common to the various conditions, but also to evaluate how these syndromes differ with regards to the psychological factors that may be involved. As an extensive evaluation of these factors is still lacking, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) aimed to collate the evidence available across these topics.
Objectives: To determine the psychological factors which are associated with or predictive of pain secondary to neurological conditions and to assess the influence of these aspects on the outcome of neurorehabilitation.
Methods: Two reviews were performed. In the first, a PUBMED search of the studies assessing the association between psychological factors and pain or the predictive value of these aspects with respect to chronic pain was conducted. The included papers were then rated with regards to their methodological quality and recommendations were made accordingly. In the second study, the same methodology was used to collect the available evidence on the predictive role of psychological factors on the therapeutic response to pain treatments in the setting of neurorehabilitation.
Results: The first literature search identified 1170 results and the final database included 189 articles. Factors such as depression, anxiety, pain catastrophizing, coping strategies, and cognitive functions were found to be associated with pain across the various conditions. However, there are differences between chronic musculoskeletal pain, migraine, neuropathy, and conditions associated with complex disability with regards to the psychological aspects that are involved. The second PUBMED search yielded 252 studies, which were all evaluated. Anxiety, depression, pain catastrophizing, coping strategies, and pain beliefs were found to be associated to different degrees with the outcomes of multidisciplinary programs, surgery, physical therapies, and psychological interventions. Finally, sense of presence was found to be related to the effectiveness of virtual reality as a distraction tool.
Conclusions: Several psychological factors are associated with pain secondary to neurological conditions and should be acknowledged and addressed in order to effectively treat this condition. These factors also predict the therapeutic response to the neurorehabilitative interventions.
Background:
Diagnosing depression in chronic pain is challenging due to overlapping somatic symptoms. In questionnaires, such as the Beck Depression Inventory (BDI), responses may be influenced more by pain than by the severity of depression. In addition, previous studies have suggested that symptoms of negative self-image, a key element in depression, are uncommon in chronic pain-related depression. The object of this study is to assess the relationship of the somatic and cognitive-emotional items of BDI with the diagnosis of depression, pain intensity, and disability.
Methods:
One hundred consecutive chronic pain patients completed the Structured Clinical Interview for DSM Disorders (SCID) for the diagnosis of major depressive disorder (MDD) according to DSM-IV. Two subscales of BDI (negative view of self and somatic-physical function) were created according to the factor model presented by Morley.
Results:
In the regression analysis, the somatic-physical function factor associated with MDD, while the negative view of self factor did not. Patients with MDD had higher scores in several of the BDI items when analysed separately. Insomnia and weight loss were not dependent on the depression diagnosis.
Limitations:
The relatively small sample size and the selected patient sample limit the generalisability of the results.
Conclusions:
Somatic symptoms of depression are also common in chronic pain and should not be excluded when diagnosing depression in pain patients. Regardless of the assessment method, diagnosing depression in chronic pain remains a challenge and requires careful interpretation of symptoms.
Depression and depressed mood are common in people with persistent (chronic) pain, exacerbating disability and worsening quality of life. Yet the relationship between persistent pain and depression remains unclear, despite its importance for designing or adapting interventions to address both pain and depression. Meta-analysis of cognitive and behavioral interventions designed for rehabilitation of persistent pain shows small benefits for distress. However, substantial variation between studies in patients’ baseline levels of depression and in quality of treatments militates against any clear conclusions. Apart from these interventions, longitudinal studies on chronic pain and depression in adults from clinical populations provide weak evidence that depression worsens pain outcomes. We systematically searched for and reviewed 14 longitudinal studies that explored the association between persistent pain and depression, aiming to identify: (1) the effects on pain of baseline depression; (2) the effects on depression of baseline pain; and (3) possible mediating variables, with particular attention to methodology. Unfortunately, most studies used unsuitable instruments to measure depression, and we could draw only tentative conclusions about effects over time. Better models and clearer measurement strategies are required for a next generation of clinically useful treatment trials and, meanwhile, some implications for treatment are explored.
Remarkable progresses have been achieved regarding the understanding of the neurobiological bases of pain and depression. The principal role of neurotransmitters, neuromodulators, and neurohormones has been proposed in the development of pain and depression. With the progression of molecular biology, an intricate interaction among biological factors accountable to the development and management of pain and depression has been also shown in a numerous preclinical and clinical researches. This mini-review will briefly describe the current issues and future research direction for better understanding of the relationship between pain and depression.
The Beck Depression Inventory II (BDI-II) has been suspected of overestimating the level of depression in individuals that endure chronic pain. Using a sample (N = 345) of male military veterans with chronic pain enrolled in an outpatient treatment program, a factor analysis on the BDI-II revealed a “Somatic Complaints” factor along with 2 other factors we labeled “Negative Rumination” and “Mood.” Standardized scores were provided for each BDI-II factor score, Total score, and Total minus Somatic score. The internal consistency reliabilities (Gilmer-Feldt and alpha coefficients) for all scores were found to be clinically acceptable. Item-Total score correlations found that all of the BDI-II items were good discriminators (r > .30). We conclude that the normative data provided in this study should help control for somatic responding by male chronic pain veterans on the BDI-II. We highly recommend that clinicians and researchers use the norm-referenced method when interpreting BDI-II scores from individuals suffering from chronic pain. (PsycINFO Database Record (c) 2013 APA, all rights reserved)
AimTo explore attitudes and confidence in professional competence of home nurses concerning depression and to evaluate the capacity of a minimal intervention in helping home nurses to detect depression in patients and their family caregivers.Background
Long-term ill patients have an elevated risk to develop comorbid depression, as do their family caregivers. However, most primary care providers have little training to detect patients at risk. A minimal intervention to help home nurses detect symptoms of depression was therefore evaluated.DesignQuasi-experimental field study with pre-measures, postmeasures and follow-up measures.Methods
From the Fall of 2012–Spring of 2013, home nurses (N = 92) in three regions in Antwerp (Belgium) were assigned to a 1-hour intervention (consisting of information, skill training and discussion; N = 63) or to a control condition (N = 29). The Depression Attitude Questionnaire and the Morris Confidence Scale were completed before the intervention and 3 and 7 months afterwards. For 3 months, the number of detections of depression in patients in each region was monitored.FindingsNo significant changes were found in attitude or confidence in professional competences, except for a decline in the role attitude for home nurses in the intervention group. Home nurses who followed the intervention did detect significantly more depressed patients compared with controls.Conclusion
These findings suggest that a minimal intervention can allow home nurses to be more responsive to symptoms of depression in patients and their family caregivers. The implications of these findings are discussed and suggestions for future research are made.
The dimensionality of the Hospital Anxiety and Depression Scale (HADS) is a current source of controversy among experts. The present study integrates a solid theoretical framework (Clark & Watson's, 1991, tripartite theory) and a fine-grained methodological approach (structural equation modeling; SEM) to examine the dimensionality and construct validity of the HADS in fibromyalgia (FM) patients. Using the HADS data of 269 Spanish patients with FM, we estimated the cross-sectional and, for the first time, longitudinal fit (autoregressive model) of 2 competing models (oblique 2-factor vs. bifactor) via confirmatory factor analysis. The pattern of relationships between the HADS latent dimensions and positive and negative affect (PA and NA) was analyzed using SEM. HADS reliability was assessed by computing the omega and omega hierarchical coefficients. The bifactor model, which accounted for the covariance among HADS items with regard to 1 general factor (psychological distress) and 2 specific factors (depression and anxiety), described the HADS structure better than the original oblique 2-factor model during both study periods. All latent dimensions of the bifactor model were temporally stable. The SEM analysis revealed a significant link between psychological distress and NA as well as between depression and low PA. Only the general factor of psychological distress showed adequate reliability. In conclusion, the HADS shows a clear bifactor structure among FM patients. Our results indicate that it is not recommendable to compute anxiety and depression scores separately because anxiety variance is tapped primarily by the broader construct of psychological distress, and both specific dimensions show low reliability. (PsycINFO Database Record (c) 2013 APA, all rights reserved).
Chronic pain and major depression commonly occur together. Major depression in patients with chronic pain is associated with decreased function, poorer treatment response and increased health care costs. The experience and expression of chronic pain vary between individuals, reflecting complex and changing interactions between physical, psychological and social processes. The diagnosis of major depression in patients with chronic pain requires differentiation between the symptoms of pain and symptoms of physical illness. Antidepressants and psychological therapies can be effective and should be delivered as part of a coordinated, cohesive, multidisciplinary pain management plan.
Objective. There is substantial uncertainty regarding the prevalence of depression in RA. We conducted a systematic review aiming to describe the prevalence of depression in RA.
Methods. Web of Science, PsycINFO, CINAHL, Embase, Medline and PubMed were searched for cross-sectional studies reporting a prevalence estimate for depression in adult RA patients. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and a meta-analysis was performed.
Results. A total of 72 studies, including 13 189 patients, were eligible for inclusion in the review. Forty-three methods of defining depression were reported. Meta-analyses revealed the prevalence of major depressive disorder to be 16.8% (95% CI 10%, 24%). According to the PHQ-9, the prevalence of depression was 38.8% (95% CI 34%, 43%), and prevalence levels according to the HADS with thresholds of 8 and 11 were 34.2% (95% CI 25%, 44%) and 14.8% (95% CI 12%, 18%), respectively. The main influence on depression prevalence was the mean age of the sample.
Conclusion. Depression is highly prevalent in RA and associated with poorer RA outcomes. This suggests that optimal care of RA patients may include the detection and management of depression.
A critique, from a normal-psychological standpoint, is made of the concepts and measures current in depression in chronic pain populations. Psychiatric models have frequently been inappropriately applied, and those derived from classification systems have been overextended to define what they can at best partially describe. Poor fit of these models to the person with chronic pain has frequently been blamed on the patient. Uncritical use of measures standardized on populations from which people with medical problems had been carefully excluded, and on which chronic pain patients preferentially endorse somatic symptoms, have contributed to these problems. Here the experience of the person with chronic pain is explored using theories from normal and abnormal psychology, taking in particular the diathesis-stress model as a starting point, and proposing a more contextual and non-pathological description of depression in chronic pain. Implications for treatment are discussed.
Examined the contribution of individual symptoms to the diagnoses of major depressive disorder (MDD) in 29 adult patients with confirmed rheumatoid arthritis (RA) and a control sample of 150 university employees. Comparisons between Diagnostic and Statistical Manual of Mental Disorders (DSM-III) and DSM-III—Revised (DSM-III—R) rates of MDD were derived using the Inventory to Diagnose Depression (IDD). Cognitive-affective symptoms such as dysphoric mood, acknowledgment of guilt, and suicidal ideation were the most efficient predictors of MDD. According to DSM-III—R criteria, 16% of the RA sample met criteria for diagnosis of MDD, while 27% of the RA sample met criteria according to the DSM-III. RA patients reported that their arthritis affected their mood at least occasionally. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Depression has been observed to accompany chronic pain. Yet, controversy remains regarding the extent and nature of the relationship between these 2 disorders. The authors analyze the literature regarding depression rates in chronic pain and other chronic medical populations and argue that depression appears to be highest among chronic pain patients. Drawing from cognitive-behavioral models of depression, the authors explore the unique psychological experiences of living with chronic pain that may account for the high prevalence of depression. A diathesis-stress framework is proposed to conceptualize the development of depression in chronic pain. Clinical and heuristic implications are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Objective: The purpose was to develop a short-form version of the Center for Epidemiologic Studies Depression Scale (CES-D) for the identification of persons with major depressive disorder (MDD) within a population with rheumatoid arthritis (RA). Study Design: Data were analyzed from 337 persons with RA. Forty-six participants met the diagnostic criteria for MDD; 291 participants were classified in the non-MDD category (including 21 participants with dysthymia and 18 participants with minor depressive disorder). A short-form version of the CES-D was developed, and multiple cutoff scores were examined. Results: A cutoff score of ≥5 from a 9-item, short-form CES-D was found to be generally as efficient as the more commonly used full-scale cutoff score of ≥16 for classifying participants with MDD within an RA population. Although the shortened CES-D scale (cutoff score ≥5) was slightly more sensitive, it also exhibited slightly less specificity than the full-scale cutoff score of ≥16. Conclusion: The results suggest that a short-form CES-D can be used to screen for MDD within an RA sample with a degree of efficiency that is generally comparable to that of the full-scale instrument. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
• Chronic pain and major depression commonly occur together.
• Major depression in patients with chronic pain is associated with decreased function, poorer treatment response and increased health care costs.
• The experience and expression of chronic pain vary between individuals, reflecting complex and changing interactions between physical, psychological and social processes.
• The diagnosis of major depression in patients with chronic pain requires differentiation between the symptoms of pain and symptoms of physical illness.
• Antidepressants and psychological therapies can be effective and should be delivered as part of a coordinated, cohesive, multidisciplinary pain management plan.
The Hospital Anxiety and Depression Scale (HADS) is a scale originally developed for the assessment of anxiety and depression in hospitalized patients. Despite its wide diffusion, research on its factorial structure has displayed inconsistent results, leaving doubts about its use in chronic musculoskeletal pain. The purpose of this study was to thoroughly assess the factorial structure of the HADS in patients with chronic pain and to give guidance for a potential refinement. Data from 2,522 patients with chronic pain from the Amsterdam Pain (AMS-PAIN) cohort were analyzed through: 1) exploratory bifactor analysis based on a Schmid-Leiman orthogonalization, 2) confirmatory factor analysis comparing a unidimensional model, the original correlated factors model and a bifactor model, 3) item response theory (IRT) analysis based on the graded response model. The results of the confirmatory factor analysis and of the IRT analysis were then cross-validated in an independent sample of patients with chronic pain (n = 8,604). Both exploratory and confirmatory analyses revealed the presence of a strong general emotional distress factor, suggesting that the HADS can be used as a unidimensional scale. The IRT analysis led to the exclusion of three items and to the recoding of one item. The refined 11-item HADS scale was successfully cross-validated and confirmed as a unidimensional, locally independent, monotonic, and reliable scale. PERSPECTIVE: An 11-item shorter version of the HADS could be used to measure emotional distress in patients with chronic musculoskeletal pain. Given its unidimensionality, the use of its total score seems appropriate.
Depression is a subjective illness that often goes undiagnosed and untreated. As the first point of contact for patients, primary care clinics should screen patients regularly for depression. This study evaluated annual depression screening in a rural primary care clinic and relationships among depression, chronic pain, and gender. Using the Patient Health Questionnaire-9 (PHQ-9), a convenience sample of 53 men and 49 women were screened for depression. Twenty-eight percent of patients scored positively for depression. Relationships among depression, chronic pain management, and gender surfaced in the results.
Objectives
Migraine and depression are common comorbid conditions. The purpose of this study was to assess how well the Patient Health Questionnaire (PHQ-9) and the Hospital Anxiety and Depression Scale (HADS) perform as depression screening tools in patients with migraine.
Methods
Three hundred consecutive migraine patients were recruited from a large headache center. The PHQ-9 and HADS were self-administered and validated against the Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders–IV, a gold standard for the diagnosis of depression. Sensitivity, specificity, positive predictive value, negative predictive value and receiver-operator characteristic curves were calculated for the PHQ-9 and HADS.
Results
At the traditional cut-point of 10, the PHQ-9 demonstrated 82.0% sensitivity and 79.9% specificity. At a cut-point of 8, the HADS demonstrated 86.5% sensitivity and specificity. The PHQ-9 algorithm performed poorly (53.8% sensitivity, 94.9% specificity). The point prevalence of depression in this study was 25.0% (95% CI 19.0–31.0), and 17.0% of patients had untreated depression.
Conclusions
In this study, the PHQ-9 and HADS performed well in migraine patients attending a headache clinic, but optimal cut-points to screen for depression vary depending on the goals of the assessment. Also, migraine patients attending a headache clinic have a high prevalence of depression and many are inadequately treated. Future studies are needed to confirm these findings and to evaluate the impact of depression screening.
Objective. To validate a Spanish version of the Beck Depression Inventory (BDI) in Mexican patients with rheumatoid arthritis (RA). Methods. Thirty-five patients with RA seen in our outpatient clinic were included. A semistructured psychiatric interview was applied, and the following instruments were administered: the BDI, the Hospital Anxiety and Depression Scale (HAD), and the Health Assessment Questionnaire Disability Index. Diagnostic properties of the BDI for both full-length and smaller versions taking out somatic items were compared against a gold standard. The gold standard for comparison was the diagnosis of depression according to the Diagnostic and Statistical Manual of Mental Disorders, Third Edition, Revised criteria. Results. Thirty-seven percent of RA patients had a diagnosis related to depression, most of which were major depression or dysthymia. The original BDI showed a high sensitivity (92%) and a high correlation with the HAD (r = 0.83). Exclusion of somatic items in modified versions of the BDI had a similar performance. Conclusions. The original BDI is a suitable instrument to detect depression in Mexican RA patients. Nevertheless, shorter versions without some of the somatic items also show an adequate performance.
Purpose. This study investigated the relationships among four methods of detecting depression in patients with fibromyalgia. Methods. Data were obtained from 100 women (mean age 43 years) who had been diagnosed with fibromyalgia. Instruments included a computerized Diagnostic Interview Schedule (C-DIS), Beck Depression Inventory (BDI), an adjusted 'disease-free' BDI (BDI-A), and Minnesota Multiphasic Personality Inventory depression subscale (MMPI-D). Chance-corrected concordance, sensitivity, specificity, and accuracy among the four methods were calculated. Results. The C-DIS detected 22% and BDI-A 29% with current major depression. The BDI and MMPI-D yielded higher estimates of 55% of the 44%, respectively. Agreement on the diagnosis among the four methods was significantly greater than chance. When compared with the C-DIS, the BDI was the most sensitive instrument and the BDI-A most specific. Conclusions. The C-DIS and BDI-A appear to be more reliable methods for determining the presence of major depression in women with fibromyalgia than are the MMPI-D or standard BDI.
Three widely used depression scales - the Beck Depression Inventory (BDI), Center for Epidemiological Studies Depression scale (CES-D), and General Well-Being Schedule depression subscale (GWB-D) - were studied in rheumatoid arthritis (RA). Twenty-three rheumatologists identified 19 of the 45 items on these three questionnaires as likely to differ in patients with RA and control subjects because of the presence of RA, regardless of psychological status. Responses to 13 of these 19 individual scale items, designated as ''RA-related items,'' differed significantly in 41 RA patients versus 57 age-matched control subjects. Only three of the other 26 items differed significantly in the two groups. These data extend evidence that responses of people with RA on widely used depression scales might be affected by somatic disease regardless of psychological status.
Depression has been observed to accompany chronic pain. Yet, controversy remains regarding the extent and nature of the relationship between these 2 disorders. The authors analyze the literature regarding depression rates in chronic pain and other chronic medical populations and argue that depression appears to be highest among chronic pain patients. Drawing from cognitive-behavioral models of depression, the authors explore the unique psychological experiences of living with chronic pain that may account for the high prevalence of depression. A diathesis-stress framework is proposed to conceptualize the development of depression in chronic pain. Clinical and heuristic implications are discussed. (PsycINFO Database Record (c) 2012 APA, all rights reserved)
Several cross-sectional studies have reported a common comorbidity between depression and fibromyalgia syndrome (FMS). However, a bidirectional temporal association between these two distinct diseases has rarely been investigated. Using the Taiwan National Health Insurance Research Database, 25,969 patients with FMS and without any psychiatric disorder and 17,142 patients with depression and without FMS between 2000 and 2008 were enrolled and separately compared with age- and sex-matched (1:4) control groups. Patients with FMS who developed a new-onset depression and those with depression who developed a new-onset FMS were identified during the follow-up (to the end of 2011). The conditional Cox regression analyses, after adjustment for demographic data and medical comorbidities, showed that the patients with FMS were associated with an increased risk (hazard ratio [HR] = 7.46, 95% confidence interval [CI] = 6.77-8.22) of subsequent depression, and that those with depression were associated with an increased risk (HR = 6.28, 95% CI = 5.67-6.96) of subsequent FMS. Our results supported a bidirectional temporal association between depression and FMS. Each disease occurring first may increase the risk of the other subsequently. Further study may be necessary to determine the underlying mechanism between depression and FMS, and to clarify whether a prompt intervention for depression or FMS may decrease the risk of the other later in life.
Our study supported a bidirectional temporal association between depression and FMS that each disease occurring first may increase the risk of the other subsequently. This result may imply a shared pathophysiology between FMS and depression, but it needs the further investigation.
Copyright © 2015 American Pain Society. Published by Elsevier Inc. All rights reserved.
BACKGROUND
It is increasingly recognised that there is a strong association between pain and depression and that the presence of either component negatively affects the recognition and treatment of the other. In chronic health problems, where both are commonly present, it is therefore crucial to assess for the presence of both pain and depression.
AIM
Our aim was firstly to assess if there are any combined pain and depression tools. From this, our second aim was to then to outline and propose a future mechanism of screening for co-morbidity of depression and pain in a primary care setting.
DESIGN AND SETTING
We conducted a comprehensive review of the literature and following this, developed our suggested screening tool.
METHOD
We conducted a systematic MEDLINE search to look for combined pain and depression screening tools.
RESULTS
There is no validated tool which could be used to screen for co-morbid pain and depression in primary care.
CONCLUSION
In view of this, we have therefore developed an easy-to-use self-reported screening tool for patients presenting to primary care with chronic illness to screen for both depression and pain. We believe that this would lead to significantly better diagnosis, referral and hence treatment.
The difficulties inherent in obtaining consistent and adequate diagnoses for the purposes of research and therapy have been pointed out by a number of authors. Pasamanick12 in a recent article viewed the low interclinician agreement on diagnosis as an indictment of the present state of psychiatry and called for "the development of objective, measurable and verifiable criteria of classification based not on personal or parochial considerations, but on behavioral and other objectively measurable manifestations."Attempts by other investigators to subject clinical observations and judgments to objective measurement have resulted in a wide variety of psychiatric rating scales.4,15 These have been well summarized in a review article by Lorr11 on "Rating Scales and Check Lists for the Evaluation of Psychopathology." In the area of psychological testing, a variety of paper-and-pencil tests have been devised for the purpose of measuring specific
RECENT development and use of the Self-Rating Depression Scale (SDS) has Proven to be a valuable tool in the assessment of depressive disorders in a group of hospitalized inpatients.1 There is a similar need in outpatient clinics to quantitate the amount of depressive symptomatology present or absent in the patients seen for treatment. Depressive symptoms may be present in any of the psychiatric disturbances seen in such a clinic, and a diagnosis of depressive disorder must still be made on a clinical basis. However, the use of such a scale is valuable in documenting and quantitating initial symptoms and complaints, and following changes in the patient's clinical course subsequent to treatment, using any of the modalities available.
The purpose of a self-rating depression scale to be used in such an outpatient clinic setting would be similar to the ones stated previously with respect to its
Objective:
While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity.
Measurements:
The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients.
Results:
As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples.
Conclusion:
In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.
Chronic pain conditions are associated with an elevated risk for suicide. Of particular importance is the question of why pain conditions might be linked to increased suicide risk. We discuss the association between chronic pain and psychological pain, particularly in the context of depression, and the use of suicide as an attempt to escape from what is perceived as unbearable suffering. We also consider the role that chronic pain may play in increasing the capacity for suicide. Bridging across research areas and drawing on the interpersonal-psychological theory of suicide, we suggest that chronic pain may facilitate the development of a key risk factor for suicide: fearlessness about death. Given that chronic pain can lead to (and be exacerbated by) depression, engender hopelessness, facilitate a desire for escape through death, and erode the natural fear of dying, clinicians must be aware of psychological processes that can combine to create elevated suicide risk in patients with chronic pain, and they should also assess and treat suicide risk factors in these patients.
Although the experience of being believed is frequently alluded to in chronic pain literature, few studies have specifically explored this phenomenon and even fewer reviews have been offered. This narrative review sought to explore the wider social context in which individuals with chronic pain may experience disbelief toward their pain. Articles were obtained through a search of eight databases and a hand search of the references of full-text papers. Key results within the articles were noted and integrated to form three main themes: stigma, the experience of isolation, and the experience of emotional distress. The experience of stigma can occur in a number of ways. It may be through actual or perceived encounters with others; it can be through the use of psychologic explanations of pain; it can come through a perceived challenge to one's integrity and subsequently affect an individual's identity; and such stigma may be influenced by negative female stereotypes. The loss of relationships associated with being disbelieved can lead to the experience of isolation. This may be self-initiated, particularly when an individual has been given a contested diagnosis. Finally, disbelief can lead to emotional distress. This can take the form of guilt, depression, and anger. Throughout the article, implications for health care professionals, working with individuals living with chronic pain, are discussed.
Dyspareunia, caused by vulvodynia, has, like other sexual problems, evolved from being conceptualized as a psychological problem through a period when it became viewed by the medical world as a physical problem. It is now seen as being a combination of psychological and physical factors. However, no research to our knowledge has explored in depth the level of sexual and relationship difficulties of this population. This investigation involved 172 women (85 suffering with vulvodynia and 87 women in a control group with general dermatology conditions) to establish the prevalence of relationship and sexual difficulties, using validated questionnaires, a newly devised symptom checklist and a structured interview. The results demonstrated increased levels of sexual and relationship difficulties within the vulvodynia group that need further exploration.
The CES-D scale is a short self-report scale designed to measure depressive symptomatology in the general population. The items of the scale are symptoms associated with depression which have been used in previously validated longer scales. The new scale was tested in household interview surveys and in psychiatric settings. It was found to have very high internal consistency and adequate test- retest repeatability. Validity was established by pat terns of correlations with other self-report measures, by correlations with clinical ratings of depression, and by relationships with other variables which support its construct validity. Reliability, validity, and factor structure were similar across a wide variety of demographic characteristics in the general population samples tested. The scale should be a useful tool for epidemiologic studies of de pression.
Background:
Primary fibromyalgia syndrome (FMS) is associated with substantial psychiatric comorbidity. The aim of the present study was to investigate the interrelationship between self-reported symptoms of depression and pain in FMS compared with rheumatoid arthritis (RA).
Methods:
In a cross-sectional study, 100 patients with FMS and 50 patients with RA were compared with regard to depression and psychopathology using the Symptom Check List (SCL-27). Group comparisons were calculated by parametric and non-parametric tests. The association between pain intensity and depression was determined by correlation analyses and multivariate statistical procedures (CATREG).
Results:
Pain intensity was significantly higher in FMS compared with RA. FMS patients also scored significantly higher on all subscales of the SCL-27 including the depression scale and the General Symptom Index (GSI) (P < 0.001). These group differences remained stable even after correcting for pain intensity. Correlation analyses revealed an association between pain intensity and depression in FMS but not in RA (R = 0.419, P < 0.001).
Conclusion:
FMS patients in tertiary referral centers suffer from higher levels of pain intensity than RA patients. Depression predicts levels of pain in FMS but not in RA and is therefore an important target of intervention.