Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial

Kurt Kroenke, Matthew Bair, Teresa Damush, Jingwei Wu, Shawn Hoke, Jason Sutherland, Wanzhu Tu

Research output: Contribution to journalArticle

278 Citations (Scopus)

Abstract

Context: Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30% to 50% of the time and have adverse effects on quality of life, disability, and health care costs. Objective: To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression. Design, Setting, and Patients: Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) conducted at 6 community-based clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score ≥10). Intervention: Patients were randomly assigned to the intervention (n=123) or to usual care (n=127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3). Main Outcome Measures: Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months. Results: At 12 months, 46 of the 123 intervention patients (37.4%) had a50%or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5%) (relative risk [RR], 2.3; 95% confidence interval [CI], 1.5-3.2), corresponding to a much lower number of patients with major depression (50 [40.7%] vs 87 [68.5%], respectively; RR, 0.6 [95% CI, 0.4-0.8]). Also, a clinically significant (≥30%) reduction in pain was much more likely in intervention patients (51 intervention patients [41.5%] vs 22 usual care patients [17.3%]; RR, 2.4 [95% CI, 1.6-3.2]), as was global improvement in pain (58 [47.2%] vs 16 [12.6%], respectively; RR, 3.7 [95% CI, 2.3-6.1]). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients [26.0%] vs 10 usual care patients [7.9%]; RR, 3.3 [95% CI, 1.8-5.4]). Conclusion: Optimized antidepressant therapy followed by a pain self-management program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability. Trial Registration clinicaltrials.gov Identifier: NCT00118430

Original languageEnglish
Pages (from-to)2099-2110
Number of pages12
JournalJournal of the American Medical Association
Volume301
Issue number20
DOIs
StatePublished - May 27 2009

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Musculoskeletal Pain
Pain Management
Self Care
Antidepressive Agents
Primary Health Care
Randomized Controlled Trials
Depression
Pain
Confidence Intervals
Therapeutics
Patient Care
Veterans
Checklist
Mood Disorders
Health Care Costs
Hip
Knee
Quality of Life
Medicine
Outcome Assessment (Health Care)

ASJC Scopus subject areas

  • Medicine(all)

Cite this

@article{4492c278daa34ab89b8d561b473ee475,
title = "Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain: A randomized controlled trial",
abstract = "Context: Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30{\%} to 50{\%} of the time and have adverse effects on quality of life, disability, and health care costs. Objective: To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression. Design, Setting, and Patients: Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) conducted at 6 community-based clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score ≥10). Intervention: Patients were randomly assigned to the intervention (n=123) or to usual care (n=127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3). Main Outcome Measures: Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months. Results: At 12 months, 46 of the 123 intervention patients (37.4{\%}) had a50{\%}or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5{\%}) (relative risk [RR], 2.3; 95{\%} confidence interval [CI], 1.5-3.2), corresponding to a much lower number of patients with major depression (50 [40.7{\%}] vs 87 [68.5{\%}], respectively; RR, 0.6 [95{\%} CI, 0.4-0.8]). Also, a clinically significant (≥30{\%}) reduction in pain was much more likely in intervention patients (51 intervention patients [41.5{\%}] vs 22 usual care patients [17.3{\%}]; RR, 2.4 [95{\%} CI, 1.6-3.2]), as was global improvement in pain (58 [47.2{\%}] vs 16 [12.6{\%}], respectively; RR, 3.7 [95{\%} CI, 2.3-6.1]). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients [26.0{\%}] vs 10 usual care patients [7.9{\%}]; RR, 3.3 [95{\%} CI, 1.8-5.4]). Conclusion: Optimized antidepressant therapy followed by a pain self-management program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability. Trial Registration clinicaltrials.gov Identifier: NCT00118430",
author = "Kurt Kroenke and Matthew Bair and Teresa Damush and Jingwei Wu and Shawn Hoke and Jason Sutherland and Wanzhu Tu",
year = "2009",
month = "5",
day = "27",
doi = "10.1001/jama.2009.723",
language = "English",
volume = "301",
pages = "2099--2110",
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TY - JOUR

T1 - Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain

T2 - A randomized controlled trial

AU - Kroenke, Kurt

AU - Bair, Matthew

AU - Damush, Teresa

AU - Wu, Jingwei

AU - Hoke, Shawn

AU - Sutherland, Jason

AU - Tu, Wanzhu

PY - 2009/5/27

Y1 - 2009/5/27

N2 - Context: Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30% to 50% of the time and have adverse effects on quality of life, disability, and health care costs. Objective: To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression. Design, Setting, and Patients: Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) conducted at 6 community-based clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score ≥10). Intervention: Patients were randomly assigned to the intervention (n=123) or to usual care (n=127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3). Main Outcome Measures: Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months. Results: At 12 months, 46 of the 123 intervention patients (37.4%) had a50%or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5%) (relative risk [RR], 2.3; 95% confidence interval [CI], 1.5-3.2), corresponding to a much lower number of patients with major depression (50 [40.7%] vs 87 [68.5%], respectively; RR, 0.6 [95% CI, 0.4-0.8]). Also, a clinically significant (≥30%) reduction in pain was much more likely in intervention patients (51 intervention patients [41.5%] vs 22 usual care patients [17.3%]; RR, 2.4 [95% CI, 1.6-3.2]), as was global improvement in pain (58 [47.2%] vs 16 [12.6%], respectively; RR, 3.7 [95% CI, 2.3-6.1]). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients [26.0%] vs 10 usual care patients [7.9%]; RR, 3.3 [95% CI, 1.8-5.4]). Conclusion: Optimized antidepressant therapy followed by a pain self-management program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability. Trial Registration clinicaltrials.gov Identifier: NCT00118430

AB - Context: Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30% to 50% of the time and have adverse effects on quality of life, disability, and health care costs. Objective: To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression. Design, Setting, and Patients: Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain [SCAMP]) conducted at 6 community-based clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score ≥10). Intervention: Patients were randomly assigned to the intervention (n=123) or to usual care (n=127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3). Main Outcome Measures: Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months. Results: At 12 months, 46 of the 123 intervention patients (37.4%) had a50%or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5%) (relative risk [RR], 2.3; 95% confidence interval [CI], 1.5-3.2), corresponding to a much lower number of patients with major depression (50 [40.7%] vs 87 [68.5%], respectively; RR, 0.6 [95% CI, 0.4-0.8]). Also, a clinically significant (≥30%) reduction in pain was much more likely in intervention patients (51 intervention patients [41.5%] vs 22 usual care patients [17.3%]; RR, 2.4 [95% CI, 1.6-3.2]), as was global improvement in pain (58 [47.2%] vs 16 [12.6%], respectively; RR, 3.7 [95% CI, 2.3-6.1]). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients [26.0%] vs 10 usual care patients [7.9%]; RR, 3.3 [95% CI, 1.8-5.4]). Conclusion: Optimized antidepressant therapy followed by a pain self-management program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability. Trial Registration clinicaltrials.gov Identifier: NCT00118430

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