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      Diagnosing Depression in Chronic Pain Patients: DSM-IV Major Depressive Disorder vs. Beck Depression Inventory (BDI)

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          Abstract

          Background

          Diagnosing depression in chronic pain is challenging due to overlapping somatic symptoms. In questionnaires, such as the Beck Depression Inventory (BDI), responses may be influenced more by pain than by the severity of depression. In addition, previous studies have suggested that symptoms of negative self-image, a key element in depression, are uncommon in chronic pain-related depression. The object of this study is to assess the relationship of the somatic and cognitive-emotional items of BDI with the diagnosis of depression, pain intensity, and disability.

          Methods

          One hundred consecutive chronic pain patients completed the Structured Clinical Interview for DSM Disorders (SCID) for the diagnosis of major depressive disorder (MDD) according to DSM-IV. Two subscales of BDI (negative view of self and somatic-physical function) were created according to the factor model presented by Morley.

          Results

          In the regression analysis, the somatic-physical function factor associated with MDD, while the negative view of self factor did not. Patients with MDD had higher scores in several of the BDI items when analysed separately. Insomnia and weight loss were not dependent on the depression diagnosis.

          Limitations

          The relatively small sample size and the selected patient sample limit the generalisability of the results.

          Conclusions

          Somatic symptoms of depression are also common in chronic pain and should not be excluded when diagnosing depression in pain patients. Regardless of the assessment method, diagnosing depression in chronic pain remains a challenge and requires careful interpretation of symptoms.

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          Most cited references22

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          Suicidality in chronic pain: a review of the prevalence, risk factors and psychological links.

          This paper reviews and integrates the growing literature concerning the prevalence of and risk factors for suicidality in chronic pain. A series of systematic searches in MEDLINE and PsychINFO identified 12 relevant articles examining suicide, suicide attempts, and suicidal ideation in chronic pain. A selection of theoretical and empirical work identifying psychological processes that have been implicated in both the pain and suicide literature and which may be related to increased suicidality was also reviewed. Relative to controls, risk of death by suicide appeared to be at least doubled in chronic pain patients. The lifetime prevalence of suicide attempts was between 5% and 14% in individuals with chronic pain, with the prevalence of suicidal ideation being approximately 20%. Eight risk factors for suicidality in chronic pain were identified, including the type, intensity and duration of pain and sleep-onset insomnia co-occurring with pain, which appeared to be pain-specific. Helplessness and hopelessness about pain, the desire for escape from pain, pain catastrophizing and avoidance, and problem-solving deficits were highlighted as psychological processes relevant to the understanding of suicidality in chronic pain. Programmatic research is urgently required to investigate the role of both general and pain-specific risk factors for suicidality, to examine how the psychological processes mentioned above mediate or exacerbate suicidality, and to develop enhanced interventions for pain patients at risk.
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            Comorbid depression, chronic pain, and disability in primary care.

            The objectives of this study were to provide estimates of the prevalence and strength of association between major depression and chronic pain in a primary care population and to examine the clinical burden associated with the two conditions, singly and together. A random sample of Kaiser Permanente patients who visited a primary care clinic was mailed a questionnaire assessing major depressive disorder (MDD), chronic pain, pain-related disability, somatic symptom severity, panic disorder, other anxiety, probable alcohol abuse, and health-related quality of life (HRQL). Instruments included the Patient Health Questionnaire, SF-8, and Graded Chronic Pain Questionnaire. A total of 5808 patients responded (54% of those eligible to participate). Among those with MDD, a significantly higher proportion reported chronic (i.e., nondisabling or disabling) pain than those without MDD (66% versus 43%, respectively). Disabling chronic pain was present in 41% of those with MDD versus 10% of those without MDD. Respondents with comorbid depression and disabling chronic pain had significantly poorer HRQL, greater somatic symptom severity, and higher prevalence of panic disorder than other respondents. The prevalence of probable alcohol abuse/dependence was significantly higher among persons with MDD compared with individuals without MDD regardless of pain or disability level. Compared with participants without MDD, the prevalence of other anxiety among those with MDD was more than sixfold greater regardless of pain or disability level. Chronic pain is common among those with MDD. Comorbid MDD and disabling chronic pain are associated with greater clinical burden than MDD alone.
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              Cognitive-processing bias in chronic pain: a review and integration.

              Do patients with chronic pain selectively process pain- and illness-related stimuli? The evidence with regard to attention, interpretation, and recall biases is critically reviewed. A model is proposed to account for the findings in which it is suggested that biases in information processing in chronic pain are the result of overlap between 3 schemas: pain, illness, and self. With frequent repeated or continued experience of pain, the pain schema becomes enmeshed with illness and self-schemas. The extent of the enmeshment and the salient content of the schema determine the bias. A fundamental assumption is that all patients with pain selectively process sensory-intensity information. A clinical implication of the results is that processing biases that extend beyond this healthy and adaptive process to enmesh the self-schema with pain and illness schemas could maintain and exacerbate distress and illness behavior in patients with chronic pain.
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                Author and article information

                Contributors
                Role: Editor
                Journal
                PLoS One
                PLoS ONE
                plos
                plosone
                PLoS ONE
                Public Library of Science (San Francisco, CA USA )
                1932-6203
                23 March 2016
                2016
                : 11
                : 3
                : e0151982
                Affiliations
                [1 ]Pain Clinic, Department of Anaesthesiology, Intensive Care and Pain Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
                [2 ]Department of Clinical Science, University of Turku, Turku, Finland
                [3 ]Faculty of Medicine and Institute for Molecular Medicine, University of Helsinki, Helsinki, Finland
                Medical University of Vienna, AUSTRIA
                Author notes

                Competing Interests: The authors have declared that no competing interests exist.

                Conceived and designed the experiments: EK PK AME JK HK. Performed the experiments: PK. Analyzed the data: PK JK. Contributed reagents/materials/analysis tools: PK AME EK JK. Wrote the paper: PK EK AME JK.

                Article
                PONE-D-15-28019
                10.1371/journal.pone.0151982
                4805196
                27008161
                223bb30b-dbdd-428e-bf01-92ed2ed18ea5
                © 2016 Knaster et al

                This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

                History
                : 26 June 2015
                : 6 March 2016
                Page count
                Figures: 0, Tables: 4, Pages: 9
                Funding
                Funded by Grants from the Signe and Ane Gyllenberg Foundation ( stiftelsen@ 123456gyllenbergs.fi ), the Founfation for Psychiatric Research ( psykiatrian.tutkimussaatio@ 123456psy.fi ), the Wilhelm and Else Stockmann Foundation (Tempelgatan 1 a 17/Stockmann Karl, 00100 Helsinki), the Finnish Association for the Study of Pain ( http://www.suomenkivuntutkimusyhdistys.fi), and Helsinki University Central Hospital Research Funds ( http://www.hyksinstituutti.fi). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.
                Categories
                Research Article
                Medicine and Health Sciences
                Mental Health and Psychiatry
                Mood Disorders
                Depression
                Medicine and Health Sciences
                Diagnostic Medicine
                Medicine and Health Sciences
                Neurology
                Sleep Disorders
                Dyssomnias
                Insomnia
                Medicine and Health Sciences
                Diagnostic Medicine
                Signs and Symptoms
                Pain
                Neuropathic Pain
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                Pathology and Laboratory Medicine
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                Biology and Life Sciences
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                Custom metadata
                Data are available at DRYAD (DOI: 10.5061/dryad.14955).

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