Pain called a major sign of depression in older patients.
"Pain is a core symptom of depression, [and] physical symptoms are a major part of the depressive disorder," said Dr. Verma, director of the Geriatric Psychiatry Education Programs, McLean Hospital in Belmont, Mass. "Not recognizing them, and not taking account of them, is basically not diagnosing depression, and if you don't diagnose it, you are not going to treat it adequately."
Most patients with depression are not treated aggressively enough, creating the impression treatment is not very effective, Dr. Verma said. Many patients are told they may stop their medication when they first have a response, but that is generally not long enough, he said.
There are several pain and depression studies, Dr. Verma explained at a symposium sponsored by Eli Lilly & Co.
One study of 1,146 patients who met criteria for a major depressive disorder found that 69% came to the doctor with just complaints of physical symptoms. In another study, of 685 patients meeting criteria for depression, 80% reported painful physical symptoms. And, finally, a survey that used data from 118,533 Canadian patients said that the strongest predictor of major depressive disorder was chronic back pain.
There also appears to be a direct correlation between depression and how many physical symptoms a person has. In one study, 1% of those individuals with no physical symptoms or one symptom were depressed. But the rate increased as the number of symptoms increased, until, among those who had nine or more symptoms, the rate was 48%.
In addition, a study in 2003 reported that depression tended to last much longer in those with painful physical symptoms, an average of 19 months, compared with those without pain for an average of 13 months.
This evidence means that older patients who have pain should be queried about mood and/or evaluated for depression, especially since depression is so common in the elderly, Dr. Verma said.
Despite the fact that acknowledgement of depression has improved in recent years, it is still vastly underad-dressed, he added. In 2003, one report from a household survey of more than 9,000 persons found that only 22% of persons with a major depressive disorder received adequate treatment. In that study, 48% of those with a major depressive disorder received no treatment at all. Of those who received less than optimal treatment, 58% received inadequate treatment, and 42% received minimally adequate treatment.
The reason that so many patients are not adequately treated is because drug treatment often stops after a few months when the patient has a response, but also still has some symptoms. But, persons with some improvement who still have a few symptoms when their treatment ends have a threefold higher risk of relapse than those with no symptoms, Dr. Verma said. That same study also reported that patients with residual symptoms relapsed three times faster.
Patients need to be pushed all the way into remission, he said. That often means 8-9 months of aggressive treatment, and maybe longer.
"Once you've got someone responding, you've got to keep treating them with the same dose of the drug for at least 9 months," he said.
The drug chosen for a patient should be the one most likely to be effective, not the drug with the most acceptable side-effect profile, as many experts used to advise, he said. The most effective drug may be one the patient previously used that worked.
If one drug does not work, then another can be tried, he noted.
Remission can be judged by scores on standardized tests, but the definition of remission is the easiest metric to use in clinical practice, and the definition of remission is complete functional restoration, Dr. Verma said.
"What should be most important is that there are no symptoms or very few symptoms left, and the person is back to usual function. Anything short of that is inadequate treatment," he said.
When patients are treated aggressively, 65% will have significant improvement and fully 50% will achieve remission, he said. But the treatment must be aggressive. Moreover, in the patients with pain, the depression is more likely to be significantly improved by depression treatment than is the pain, but that is no reason not to do it, Dr. Verma said. "Treat them to the point they are well, and keep them there," he said.
BY TIMOTHY F. KIRN
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|Title Annotation:||Geriatric Psychiatry|
|Author:||Kirn, Timothy F.|
|Publication:||Clinical Psychiatry News|
|Date:||Jul 1, 2007|
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