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Pain and Depression in Older Adults
Stephen ThielkeSeattle GRECC
Disclosures
My research is supported in part by a Geriatric Health Outcomes Research Award from the American Geriatric Society Foundation for Health in Aging
No other disclosures or conflicts of interest
Overview
DepressionPain1. Overlap of depression and pain in
aging
2. Similarities and differences
3. Depression through the lens of pain
4. Treatment recommendations
Depression and Aging
Thielke, Aging and Mental Health, 2009
Depression and Aging
Thielke, Aging and Mental Health, 2009
Incidence
Persistence
Chronic Pain and Aging
2/3 of older adults report chronic pain [lasting 3 months or more] (Gagliese 1997)
Of older adults with pain, 83% report that pain interferes with daily activities and negatively affects quality of life (Herr 2001)
Most frequent pain types in those 65 or older are osteoarthritis of hip or knee (58%) and low back pain (35%) (CDC)
Mean # of pain sites in older adults: 4.3
Chronic Pain and AgingHighest prevalence of chronic pain occurs at
about age 65, after which there is a slight decline with advancing age, even beyond age 85 (Gibson & Helme 1995)
Pain Intensity not associated with advancing age, but slightly greater intensity of low-level pain (Rustoen 2005)
Pain and AgingMany types of chronic pain disorders occur less
commonly with advancing age:HeadacheMigraineAbdominal painChest painLow back
Chronic pain is NOT a “natural part of getting older”
Depression is Common in Patients with Pain
US Geriatric Population 5%Ambulatory Medical Patients 5-9%Medical Inpatients 15-20%Pain Clinics 10-100% (~50%)
Pain is Common in Patients with Depression
~65%, regardless of treatment settingBair et al, Arch Int Med 2003
Pain Is Strongly Associated with Depression
**
**
**
** p < 0.001Thielke, HRS, 2008
Depression and Pain in Older Adults
European 11-country study, Aged in Home Care (AdHOC)3976 subjects, 65 years and older, receiving home carePain: any daily pain over the last week, or pain behaviorsDepression: MDS depression scale
Pain No Pain
Depression 19.5% 11.3%
No depression 80.5% 18.7%
Onder, J Clin Psy 2005
Pain No Pain
Depression 71.9% 18.1%
No Depression 57.5% 42.5%
Depression and Pain
Patients with pain have 2-5 times increased depression incidence
Greater risk of depression with:Multiple pain complaints Multiple episodesSevere pain
Patients with pain and depression have greater:Pain complaintsPain intensityChronicity
Directionality?
Similarities and Differences Between
Pain and Depression in Older Adults
Neuroimaging StudiesMany, but not all, of the same brain areas that
are stimulated by physical pain are also stimulated by:-Induced sadness-Social exclusion-Grief
“There is that cliché of a broken heart, but my ribs ached from the pain in my heart. I had to go to the doctor because I thought I was having heart attacks.”
Psychological and Physical Pain• “I have suffered from severe, recurrent depression for
40 years. The psychological pain that I felt during my depressed periods was horrible and more severe than my current physical pain associated with metastases in my bones from cancer.”
• “I woke up in the middle of the night to use the bathroom and forgot that my furniture had been re-arranged. I accidentally tripped over my cocktail table, breaking both of my legs. The pain that I experience from depression is so much worse than the pain associated with my breaking both of my legs.”
Mee et al, J Psychiatric Res2006
Physical Pain During Depression
Sleep, Pain, and Depression• 50-80% of patients with chronic pain have a
significant sleep disturbance• Sleep disturbance is one of the cardinal
symptoms of depression• Insomnia predicts depression onset• Experimental disruption of slow-wave sleep
increases pain sensitivity• Sleep deprivation can temporarily relieve
depressive symptoms
Pain Impairs Depression Treatment Response
Thielke, et al. Am J Geriatric Psych. 2007.
Baseline Pain Interference Category
Increasing Pain
% w
ith D
epre
ssio
n Re
spon
se
DepressionPain
Treatment Overlap for Pain and Depression
“Opium cure” for depression never workedECT not effective for chronic painAntidepressant response:
-Depression response usually 6-8 weeks-Pain response usually 3-4 weeks
Noradrenergic drugs have direct analgesic propertiesPure serotonergic drugs have no direct effect on painDoses for pain are roughly ½ of those for depression
Placebo Response Rates
Brief Pain Inventory - Severity
Depression trials show ~30% placebo response
Only 48% of placebo-controlled trials of antidepressants showed superiority to placebo
Khan & Bhat, J Clin Psy, 2008
Key Similarities and DifferencesHuman sufferingSleep disturbanceHigh placebo responseBrain areas
Human sufferingPrevalenceNeurotransmittersMedication effects
Pain and depression often occur together
“Psychic Pain” and “Physical Pain” are different
Pain and depression are a bad combination
Depression Through the Lens of Pain
• Why do we need physical pain?
• What would happen if we didn’t have pain?
• Why don’t people treat their pain?
• What does psychological pain do for us?
• Why don’t more people treat their depression?
Congenital Analgesia
Depression = Guarding from Social Pain?
Most Patients Do Not Seek Out Treatment for Pain or for
Depression
The Experience of Pain in Aging
• Belief that pain is “just a part of getting older”
• “Many [osteoarthritis patients] were unwilling to use medication. For these individuals, treating pain with medication was seen as masking rather than curing symptoms, and was seen as potentially harmful because of an increased risk of unwanted side effects.”
Gignac, Hawker et al 2006
Evidence-Based Options for Treating Pain
OTC analgesics
Prescription analgesics
Physical therapy
Exercise
Weight loss
Acupuncture
Massage
Injections
Joint replacement
Supplements
“Taking” Taking Effectively
19 older adults with osteoarthritis pain
Qualitative interview4/19 (21%) taking medications as prescribed or
directedOthers use lower doses than prescribed or less
often than directedNone using analgesics in advance of activities
Sale, Gignac, Hawker 2006
Filling Percodan prescription and throwing the whole bottle away
Filling higher-dose bottle with lower-dose pillsRationing pain medications to refill far less than
allowedNot telling family members about using less than
prescribedAdhering to pain medications differently than to
other medications
Sale, Gignac, Hawker 2006
Medication-Related Behaviors
Willingness to Undertake Risk in Pain Treatment
Preference for topical treatments such as capsaicin over oral agents; pills preferred only if they were reported as being three times as effective as capsaicin
All the patients switched their preferences when offered a safer but less effective treatment option
20% of older patients are unwilling to accept any additional risk for reductions in pain
Many patients consider medications to be a treatment of last resort
Fraenkel et al, 2004
Ross et al, 2001
Values and Perceived Need Thrifty Wasteful
Cautious Rash
Stoical Hedonistic
Patient Hurried
Selfless Selfish
“I need to take something to feel better now.”
“I don’t need to treat this. I’ll hold out.”
Responses to Pain May Explain Responses to Depression
• Depression as a form of “social pain”?• Social comparison as the cause of depression
in older adults? (Blazer 2008)• Patients resist NEEDING a treatment for pain
or depression• Suffering the symptom often feels like the
right thing to do• Suffering the symptom often seems safer than
risking something unknown just to placate it
TREATMENT RECOMMENDATIONS
• Ask about pain and about depression• Ask about pain and depression treatments• Work to understand effects of mental health
on use of pain treatments• Do not assume that one problem is causing
the other• Do not assume that addressing one problem
will fix the other
TREATMENT RECOMMENDATIONS
• The realistic goal is to make the depression go away, but not to make the pain go away
• Consider antidepressants for pain and for depression, but do not expect them to fix the problem
• Placebo response is large in both depression and pain: use this to your advantage
• Understand patient’s sense of “as needed”
Be Careful with Opioid Analgesics• Accidental deaths in US from prescription opioids
exceed deaths from heroin & cocaine
• More deaths in Washington State last year from prescription opioids than from traffic fatalities!
Collaborative Care Interventions for Pain and Depression Improve Both
IMPACT-DP, n = 13
Dobscha, S. K. et al. JAMA 2009;301:1242-1252.
n = 401
Collaborative Care Interventions for Pain and Depression Improve Both