Combined pain self-management and antidepressant therapy are effective in patients with chronic musculoskeletal pain with depression

Question

Does a combination of pain self-management and antidepressant therapy improve pain and depression in people with musculoskeletal pain and depression?

Design

Randomised, controlled trial with concealed allocation and blinded outcome assessment.

Setting

Six primary care clinics and five tertiary outpatient clinics in the USA.

Participants

Primary care patients were eligible if they had at least moderate pain in the low back, hip, or knee, present for at least 3 months despite analgesic medication, and depression of at least moderate severity. People taking antidepressants but who still met the inclusion criteria were eligible. Severe cognitive impairment, major psychoses, and current pain-related disability claims were exclusion criteria. Randomisation of 250 participants allotted 123 to an intervention group and 127 to a control group.

Interventions

The intervention group participated in the Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) program. During the initial 3 months (Step 1), this group optimised their antidepressant medication according to an algorithm based on clinical response, with a potential increased dose at 3 weeks and change of medication at 6 weeks for those who had not improved. During the following 3 months (Step 2), fortnightly pain self-management sessions were conducted by a nurse care manager, modelled on the Stanford self-management program. Participants were taught to modify their behaviour through behavioural plans and problem-solving techniques. During the final 6 months (Step 3), two telephone calls from the nurse care manager were used to assess symptoms and adherence, and to adjust management if required. The control group were informed that they had depressive symptoms and that they should seek advice about treatment, but received no other intervention unless a psychiatric emergency arose.

Outcome measures

The primary outcome was a combined improvement in both depression and pain. Depression was assessed using the 20-item Hopkins Symptom Checklist and pain severity using the Brief Pain Inventory. Global improvement in pain was also assessed.

Results

205 (82%) participants completed the final assessment. At 12 months, 26% of the intervention group achieved the primary outcome, compared with 8% of the control group (RR 3.3, 95% CI 1.8 to 5.4). For depression specifically, 37% of the intervention group had a 50% or greater reduction in depression severity from baseline compared with 16% of the control group (RR 2.3, 95% CI 1.5 to 3.2). When expressed in terms of major depression, 41% of the intervention group had major depression at 12 months compared to 68% of the control group (RR 0.6, 95% CI 0.4 to 0.8). A reduction in pain of at least 30% was more likely in the intervention group (41%) than the control group (17%) (RR 2.4, 95% CI 1.6 to 3.2). Global improvement in pain also significantly improved.

Conclusion

Combined pain self-management and antidepressant medication result in substantial improvement in depression as well as moderate reductions in pain severity and disability.