Pain May Modulate Response to Depression Treatment in Elderly

By Michelle Rizzo

NEW YORK (Reuters Health) Mar 08

Pain, through its interference with normal activities, impedes recovery from depression in older adults, according to findings reported in the February issue of the Journal of the American Geriatrics Society.

In a randomized, clinical trial, Dr. Shahrzad Mavandadi, of the University of Pennsylvania, Philadelphia, and colleagues examined the moderating role of pain on the effect of depression treatment in 524 adults aged 60 and older.

The subjects were assigned to integrated care or to enhanced specialty referral care. Those assigned to integrated care received services for mental health from a licensed mental health provider in a primary care clinic. This made it possible for the mental health and primary care clinicians to communicate about treatment plans for the patients. Subjects assigned to the enhanced specialty referral model received mental health services from a licensed mental health professional in a specialty setting that was physically separate from the primary care facility.

The researchers assessed pain severity, the degree to which pain interfered with work inside and outside the home, and depressive symptoms at baseline and 3, 6, and 12 months.

Results of intention-to-treat analyses showed that depressive symptoms decreased over time in both treatment groups. However, self-reported pain moderated these reductions in symptoms. Patients with higher levels of pain severity and work activity interference had blunted improvements in depressive symptoms.

The team reports that pain interference had a greater effect on depressive symptoms than did pain severity. Pain interference fully accounted for the moderating effects of pain severity on changes in symptoms of depression over time in patients with major depression.

"These findings and the fact that pain and depression have been shown to be highly comorbid among older primary care patients, suggest that the detection, diagnosis, and management of depression among older primary care patients might benefit from routine assessments of pain and other forms of medical comorbidity, as these conditions may complicate all phases of the depression management process," Dr. Mavandadi said in an interview with Reuters Health.

"Better assessment and treatment of these conditions may improve depression management outcomes," she said. "Also, clinical assessments used for the diagnosis and management of depression among individuals with comorbid pain may benefit from the incorporation of brief inventories (and interventions) that address multiple domains of the pain experience, as opposed to just pain severity."

Dr. Mavandadi noted that their findings may be attributed to a number of factors. She suggested, for example, that the mere experience of pain may contribute to greater distress and depressive symptoms both directly and indirectly via its impact on physical and psychosocial functioning.

"Experiencing and dealing with comorbid pain interferes with both the patients' and providers' ability to manage depression," Dr. Mavandadi said.

"Dealing with severe pain may be distracting and hinder, both physically and psychologically, the patient's ability to concentrate on a treatment regimen or successfully engage in treatment visits," she explained. "Furthermore, not only may mental health specialists have a more difficult time managing and treating depression in the presence of severe pain, but individuals may find it more challenging to cope with comorbid pain and depression, as both conditions require ample attention and management."

J Am Geriatr Soc 2007;55:202-211.

© Reuters 2007. All Rights Reserved

Posted 3-15-07