Optimized antidepressant therapy and pain self-management produced substantial and sustained improvements in patients with comorbid depression and chronic pain.
The program, which was assessed in a study of 250 patients, was implemented in two primary care clinic systems by a nurse care-manager supervised by a physician, reported Dr. Kurt Kroenke of the divisions of internal medicine and geriatrics, Indiana University, Indianapolis, and his associates (JAMA 2009;301:2099-110).
They conducted the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study to determine whether pharmacologic and behavioral treatments would prove synergistic in treating the comorbid conditions.
A total of 123 adults were randomly assigned to receive the study intervention: 3 months of optimized antidepressant therapy, followed by an additional 3 months of pain self-management instruction, followed by 6 months of relapse prevention. The antidepressants that were selected for the trial were venlafaxine (Effexor), fluoxetine, sertraline (Zoloft), citalopram (Celexa), bupropion, mirtazapine (Remeron), and nortriptyline (Aventyl). The authors noted that the trial “was not designed to test any particular antidepressant.” The remaining 127 subjects served as a control group, receiving usual care.
The pain self-management program included at least five in-person and eight telephone contacts during which patients learned about “chronic pain triggers and flare-ups; coping with fear and other negative emotions; and strategies for physical activity, muscle relaxation, deep breathing, distraction, sleep hygiene, and working with clinicians and employers” to manage their disability.
Compared with usual care, the intervention produced “substantial” (at least 50%) reduction in depression severity within 1 month, which was sustained throughout 1 year of follow-up.
The intervention also produced a 30% or greater reduction in pain, which was evident within 1 month of starting the program and was sustained for 1 year. The authors noted several limitations of the study: Generalizability was limited because the subjects were drawn from urban underserved and Veterans Affairs clinics, a lack of blinding, and discordance between patient self-report and electronic health record data.
The study was funded by the National Institute of Mental Health. Dr. Kroenke reported receiving research funding and/or honoraria from Eli Lilly (Aventyl, Prozac), Pfizer (Zoloft), Wyeth (Effexor), and Astra-Zeneca and Forest Laboratories (Celexa). Dr. Blair reported receiving one-time consultant fees from Wyeth, Abbott, and Cephalon. None of the other authors reported any financial disclosures.