Depression and Chronic Pain

1
Depression and Chronic Pain

• Agrability National Conference
• November 18, 2004
• Crowne Plaza Hotel
• Springfield, IL
• David Weis, LCPC, Chestnut Health Systems
  Employee
• Assistance And Workplace Services, ADM National
  Account Manager
• Services, ADM National Account Manager

2
About Chestnut Health Systems

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

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About Chestnut Health Systems

• Diverse array of services
• -addiction treatment
• -community mental health services
• -prevention and school based programs
• -applied research evaluation
• -domestic and international employee assistance
  services

4
Facts about depression

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

5
Types of depression

• Unipolar
• Bipolar
• Dysthymia
• Seasonal Affective Disorder (SAD)

6
Symptoms of depression DSM- IV Criteria

• Occurring over a two week period
• Helplessness/hopelessness
• Anhedonia
• Poor concentration
• Sleep disturbance (initiating and/or maintaining
  sleep)
• Suicidal ideations
• Appetite disturbance (typically weight loss, but
  in a small subgroup, weight gain).

7
Symptoms of depression

• Depressed mood
• Tearfulness
• Irritability
• Low energy level
• Guilt

8
Pain perception

• Is it all in my head?
• Emotional aspects of pain
• Biology of pain perception
• Cultural factors

9
Models of pain

• Peripheral vs. Central
• Disease vs. illness-behavior
• Reductionistic vs. systems
• Biomedical vs. Biopsychosocial
• Medical vs. Self-Management

10
Assessment of chronic pain and depression

• Patient Health Questionnaire (PHQ)
• Zung Depression Inventory (ZDI)
• Beck Depression Inventory (BDI)

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Assessment of chronic pain and depression

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

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Assessment of chronic pain and depression

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

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Million Behavioral Health Inventory (MBHI)
Assessment of chronic pain depression

• Overview administration to individuals 18 year
  and older, reading level is 8th grade, 150
  questions and takes approximately 20 minutes to
  complete
• Report includes basic coping styles,
  psychosomatic correlates, and psychogenic
  attitudes such as stress level, premorbid
  pessimism and future despair. Also includes a
  section on prognostic indicators such as pain
  treatment responsitivity and emotional
  vulnerability
•   Cost is approximately 27/report with software
•  

14
Assessment of chronic pain and depression

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

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Assessment of chronic pain and depression

• Clinical interview (Biopsychosocial factors)
• Substance abuse evaluation (prescription and/or
  illicit)
• Suicide assessment
• Case management

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Psychological management of chronic pain

• Locus of control (internal vs. external)
• Stress Management
• Assertiveness Training
• Exercise

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Psychological management of chronic pain

• The role of attention focus and complaint
• Treatment personnel
• The faith factor
• Accessing support systems
• Lifestyle changes

18
Psychological management of chronic pain

• Medication use (indications/contraindications)
• Cognitive-behavioral approaches
• Family systems approaches
• Case Management

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Barriers to treatment

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

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Intervention considerations for Agrability

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