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

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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