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Treating Depression and Pain in Primary Care Patients

This collaborative-care intervention using antidepressants and pain self-management had sustained effects.

Depression and pain are, respectively, the most common mental and physical syndromes found in primary care patients. These researchers compared outcomes from an intervention and from usual care in 250 patients from community-based or Veterans Administration clinics with pain (3 months of low back, hip, or knee pain) plus depression of at least moderate severity. Intervention recipients received 12 weeks of optimized antidepressant treatment of depression, followed by 6 biweekly instructional sessions on the behavioral management of pain, and then 6 months of relapse prevention.

A nurse care-manager, supervised by a psychiatrist, optimized antidepressant selection and dose (venlafaxine or an SSRI in 93% of patients) and led the behavioral sessions. At 12 months, significantly greater proportions of intervention patients than control patients responded on a depression measure (50% improvement; 37% vs. 16%), on a composite pain measure (30% reduction in pain and disability; 42% vs. 17%), and on both measures (26% vs. 8%). Intervention recipients averaged 2.5 in-person contacts and 11.5 telephone contacts. They were more likely than controls to use antidepressants (98% vs. 43%) and to use them for longer periods (9 vs. 2 months) and to have an antidepressant switched or added (35% vs. 17% of a usual-care subgroup with medical record data).

Comment: In this collaborative-care study, a short-term intervention optimizing antidepressants and providing brief behavioral pain treatment had sustained effects at 12 months on both depression and pain. Regarding depression response, the number needed to treat (NNT) was 4.8. This is comparable to the NNTs in studies of depressed patients without pain, but the absolute rates are closer to those found in medically ill depressed patients. Although a 30% reduction in pain is a modest threshold, the NNT of 4.1 is also excellent.

— Peter Roy-Byrne, MD

Published in Journal Watch Psychiatry June 8, 2009

Citation(s):

Kroenke K et al. Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial. JAMA 2009 May 27; 301:2099.

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