Pharmacologic Treatment of Depression and Anxiety
Transcript Of Pharmacologic Treatment of Depression and Anxiety
Pharmacologic Treatment of Depression and Anxiety
Snehal Bhatt, MD
Disclosure
The presenter has no financial relationship to this program.
Objectives
1. Describe the treatment of Depression for pain and addiction patients 2. Describe the treatment of Anxiety for pain and addiction patients 3. Explain the mechanism of indications for, and side effects of,
therapeutic agents, such as: TCAs, SSRIs, SNRIs
"[Pain] is unquestionably a sensation in part or parts of the body but it is also
unpleasant and therefore also an emotional experience."
Merskey & Bogduk, 1986
Mood/Anxiety in Pain
• N = 5877, US civilian population, survey • OR of having chronic pain, adjusted for sociodemographics (1)
and medical dx (2)
McWilliams, et al. Pain, 2003;106:127-133
Anxiety worsens suffering in Chronic Pain
Kinesiophobia is the strongest predictor of function (more than pain intensity, duration, biomedical findings)
Fear-avoidance beliefs about physical demands of a job are more predictive of disability and missed work than pain intensity
Reductions in pain-related anxiety improves function, pain levels, affective distress
McCracken & Gross, Journal of Occupational Rehabilitation,1998;8:179-189 Asmundson, et al. Clinical Psychology Review,1999;19:97-119 Crombez, et al. Pain, 1999;80:329-339 Turk, et al. Journal of Pain, 2004;5:483-490
Vlaeyen, et al. Journal of Occupational Rehabilitation,1995;5:235-252
Depression and Chronic Pain
40% - 50% prevalence in Chronic Pain population
Causality has not been established
In a prospective study of low back pain, baseline levels of depression increased the risk of developing chronic low back pain by a factor of 2.3
Jarvik, et al. Spine, 2005;30:1541-1548 Gatchel,Turk, et al. Psychological Bull, 2007;133(4):581-624
Pain & Suicidality
N = 5692 US Adults
Suicidality
Plan
Chronic
4.3x
4.6x
cephalgia
Back/Neck
1.7x
1.7x
pain
Other non-
2.5x
3.5x
arthritic
Ilgen, et al., Gen Hosp Psychiatry, 2008;30(6):521-527
X=fold increase
Attempt 6.5x 2.6x 6.2x
Medication Classes
TCA antidepressants
• Longest track record of any anti-depressants in the treatment of multiple pain conditions
• Typically, lower doses than used for anti-depressant effect, but titrating to higher doses may benefit a subset of patients
• Analgesic effects even in the absence of depression or antidepressant effect
• Benefits: long track record, low cost
• Risks: side effect profile [QTc prolongation, hypotension, sedation, falls in elderly, fatal in overdose]
Snehal Bhatt, MD
Disclosure
The presenter has no financial relationship to this program.
Objectives
1. Describe the treatment of Depression for pain and addiction patients 2. Describe the treatment of Anxiety for pain and addiction patients 3. Explain the mechanism of indications for, and side effects of,
therapeutic agents, such as: TCAs, SSRIs, SNRIs
"[Pain] is unquestionably a sensation in part or parts of the body but it is also
unpleasant and therefore also an emotional experience."
Merskey & Bogduk, 1986
Mood/Anxiety in Pain
• N = 5877, US civilian population, survey • OR of having chronic pain, adjusted for sociodemographics (1)
and medical dx (2)
McWilliams, et al. Pain, 2003;106:127-133
Anxiety worsens suffering in Chronic Pain
Kinesiophobia is the strongest predictor of function (more than pain intensity, duration, biomedical findings)
Fear-avoidance beliefs about physical demands of a job are more predictive of disability and missed work than pain intensity
Reductions in pain-related anxiety improves function, pain levels, affective distress
McCracken & Gross, Journal of Occupational Rehabilitation,1998;8:179-189 Asmundson, et al. Clinical Psychology Review,1999;19:97-119 Crombez, et al. Pain, 1999;80:329-339 Turk, et al. Journal of Pain, 2004;5:483-490
Vlaeyen, et al. Journal of Occupational Rehabilitation,1995;5:235-252
Depression and Chronic Pain
40% - 50% prevalence in Chronic Pain population
Causality has not been established
In a prospective study of low back pain, baseline levels of depression increased the risk of developing chronic low back pain by a factor of 2.3
Jarvik, et al. Spine, 2005;30:1541-1548 Gatchel,Turk, et al. Psychological Bull, 2007;133(4):581-624
Pain & Suicidality
N = 5692 US Adults
Suicidality
Plan
Chronic
4.3x
4.6x
cephalgia
Back/Neck
1.7x
1.7x
pain
Other non-
2.5x
3.5x
arthritic
Ilgen, et al., Gen Hosp Psychiatry, 2008;30(6):521-527
X=fold increase
Attempt 6.5x 2.6x 6.2x
Medication Classes
TCA antidepressants
• Longest track record of any anti-depressants in the treatment of multiple pain conditions
• Typically, lower doses than used for anti-depressant effect, but titrating to higher doses may benefit a subset of patients
• Analgesic effects even in the absence of depression or antidepressant effect
• Benefits: long track record, low cost
• Risks: side effect profile [QTc prolongation, hypotension, sedation, falls in elderly, fatal in overdose]