Activity 6: Managing Coexisting Pain and Depression

Algorithms

Two algorithms are referred to in this series. They were created by the Institute for Clinical Systems Improvement (ICSI) to accompany their guideline ‘Assessment and management of chronic pain.’ The algorithms are available from the ICSI website:

On the ICSI website you can also find these tools:

Brief pain inventory (short form)
Patient health questionnaire (PHQ-9)
Functional ability questionnaire
Personal care plan for chronic pain

Evidence-based Recommendations

Recommendation #1: Chronic pain is frequently associated with psychological problems and even comorbid psychiatric diagnosis. If psychological difficulties or psychiatric comorbidities are found, the patient's treatment plan should include specific steps to address them.

Source: Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2008.

Website: http://www.guidelines.gov/summary/summary.aspx?doc_id=12998&nbr=006693

Strength of evidence: C,D,R (C = Non-randomized trial with concurrent or historical controls, casecontrol study, study of sensitivity and specificity of a diagnostic test, population-based descriptive study; D: Cross-sectional study, case series, case report; R: Consensus statement, consensus report, narrative review.)

Recommendation #2: Patient self report is the "most reliable indicator of the existence and intensity of pain" (National Institutes of Health) and is a key component of chronic pain assessment. Tools to assess chronic pain should:

Identifying significant areas of impairment or disability
Establishing specific functional outcome goals within a care plan
Measuring the effectiveness of the care plan or treatment interventions

Source: Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2008.

Website: http://www.guidelines.gov/summary/summary.aspx?doc_id=12998&nbr=006693

Strength of evidence: C,R (C = Non-randomized trial with concurrent or historical controls, case-control study, study of sensitivity and specificity of a diagnostic test, population-based descriptive study; R: Consensus statement, consensus report, narrative review.)

Recommendation #3: If comorbidity is found between chronic pain and mild to moderate major depression, treat both conditions for optimal outcomes. However, if the comorbid major depressive disorder is severe, depressive symptoms should be the primary focus of treatment.

Source: Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2008.

Website: http://www.guidelines.gov/summary/summary.aspx?doc_id=12998&nbr=006693

Recommendation #4: Patients with chronic pain and comorbid major depressive are at increased risk of suicide. Specifically assess if patient has considered harming him/herself or made plans to kill him/herself.

Source: Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2008.

Website: http://www.guidelines.gov/summary/summary.aspx?doc_id=12998&nbr=006693

Recommendation #5: The medical decision-making for treatment of chronic pain needs an understanding of the patient's ethnic and cultural background, age, gender and spirituality in order to work with the patient's chronic pain symptoms.

Source: Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2008.

Website: http://www.guidelines.gov/summary/summary.aspx?doc_id=12998&nbr=006693

Strength of evidence: R (R: Consensus statement, consensus report, narrative review.)

Recommendation #6: Because patient preferences for treatment may vary based on their ethnicity and culture, asking patients about treatment preference is recommended when discussing treatment options for major depressive disorder.

Source: Kaiser Permanente Care Management Institute. Depression clinical practice guidelines. Oakland (CA): Kaiser Permanente Care Management Institute, 2006.

Website: http://www.guideline.gov/summary/summary.aspx?doc_id=9632&nbr=5152&ss=6&xl=999

Strength of evidence: Evidence-based (Sufficient number of high-quality studies from which to draw a conclusion, and the recommended practice is consistent with the findings of the evidence.)

Recommendation #7: Cognitive-behavioral approaches to the rehabilitation of patients with persistent and unremitting chronic pain are considered to be among the most helpful available.

Source: Institute for Clinical Systems Improvement (ICSI). Assessment and management of chronic pain. Bloomington, MN: Institute for Clinical Systems Improvement (ICSI); 2008.

Website: http://www.guidelines.gov/summary/summary.aspx?doc_id=12998&nbr=006693

Strength of evidence: M,R (M: Meta-analysis, systematic review, decision analysis, cost-effectiveness analysis; R: Consensus statement, consensus report, narrative review.)

Recommendation #8: Cognitive-behavioral therapy, interpersonal therapy, short-term psychodynamic psychotherapy and problem-solving treatment have documented efficacy (A,C,D,M). In mild to moderate levels of depression, psychotherapy can be equally as effective as medication.(A)

Source: Institute for Clinical Systems Improvement (ICSI). Major depression in adults in primary care. Bloomington, MN: ICSI, 2008.

Website: http://www.icsi.org/depression_5/depression_major_in_adults_in_primary_care_3.html

Strength of evidence: A,C,D,M (A: randomized, controlled trial; C: non-randomized trial with concurrent or historical controls, case-control study, study of sensitivity and specificity of a diagnostic test, population-based descriptive study; D: cross-sectional study, case series or report; M: meta-analysis, systematic review, decision or cost-effectiveness analysis)

Download PDF with Recommendations

Medication Information

Approved and Off-label medications for Chronic Pain: Download PDF

PDA Tools

The first file contains a PDA version of the lecture notes for the material covered in the first six Learning Link activities.
Download Lecture Notes: Chronic pain-AAFP learning link.zip
Installation Instructions
RediReader for Palm OS
RediReader for Pocket PC

Presentation Slides

Presentation Slides for Managing Coexisting Pain and Depression.

References

Functional MRI: Gatchel RJ et al. Pain and the Brain. Practical Pain Management. 2008; 8(5):28-40