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

Summary of: Kroenke K, Bair MJ, Damush TM, Wu J, Hoke S, Sutherland J, Tu W (2009) Optimized antidepressant therapy and pain self-management in primary care patients with depression and musculoskeletal pain; a randomized controlled trial. JAMA 301: 2099-2110. [Prepared by Mark Elkins, CAP Editor.]

Commentary

Over 6 000 000 Australians suffer from musculoskeletal conditions such as low back pain, knee, and hip pain (ABS 2006). Over twice that number report some level of psychological distress, the most commonly reported problems being mood disorders such as depression (ABS 2006). Musculoskeletal pain and depression frequently coexist, impacting on health outcomes, disability, and quality of life (Bair et al 2003). For primary care practitioners, treatment of patients with co-morbid pain and depression presents a challenge and treatments do not always result in clinically worthwhile benefits for patients.

This clinical trial represents a significant step forward to address this dilemma. The authors investigated the long-term outcomes of a combination of pharmacological and behavioural interventions in primary care patients with musculoskeletal pain and co-morbid depression. The evaluation of the synergistic effects of these two treatments in this patient group is novel. The design, conduct, and analysis of the trial were robust. The investigators found that optimised antidepressant therapy followed by a self-management program resulted in substantial reductions in the severity of depression. The combined intervention also produced clinically significant improvements in pain, which is impressive in this patient group with musculoskeletal pain of long duration (up to 20 years).

The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) program was evaluated in North America and implemented by a nurse care manager, under the supervision of a physician depression specialist. It would be valuable to trial this inter-disciplinary primary care program in Australia, in which physiotherapists with expertise in cognitive-behavioural approaches to pain management could play a prominent role. If found to be equally effective in the Australian health care setting, the establishment of this program for co-morbid musculoskeletal pain and depression has the potential to substantially reduce the burden on primary care practitioners and enhance long term patient outcomes.

Julia Hush

The University of Sydney 

References

ABS (2006) National Health Survey: Summary of Results 2004-05. ABS cat. no. 4390.0. Canberra: Australian Bureau of Statistics.

Bair MJ et al (2003) Arch Intern Med 163: 2433-2445.