Combo Treatment Best for Late-Life Depression and Pain

LAS VEGAS — Late-life depression affects adults aged 60 years and older and is associated with increased healthcare utilization and costs, reduced quality of life, poorer prognosis for comorbid conditions, lower survival rates, and suicide.1,2

Approximately 5% of community-dwelling older adults are estimated to be affected by depression; the prevalence increases to 10% among those with medical comorbidities in primary care settings and as high as 35% after critical care hospitalizations.3,4

Chronic pain warrants attention in older adults due to its high prevalence. An estimated  25% to 50% of community-dwelling older adults and 49% to 83% of nursing home residents report chronic pain, and the condition is independently associated with anxiety and depression. 

Chronic low back pain (CLBP) is one of the most disabling and therapeutically challenging pain conditions afflicting older adults,” explained Jordan F. Karp, MD, an associate professor of psychiatry, anesthesiology, and clinical and translational science and medical director for psychiatry at the University of Pittsburgh Medical Center in Pennsylvania. 

In a study comparing patients with CLBP to those with knee arthritis, Dr. Karp and colleagues found that patients with CLBP had higher rates of mood disorders, slower gait (0.88 m/s vs 0.96 m/s; P = .002), and more comorbid conditions (mean 3.36 vs 1.97; P < .001).4 Furthermore, patients with CLBP performed significantly worse on psychological measures than those with knee arthritis. 

“Treating these chronic conditions together may minimize the stigma of depression treatment and improve treatment acceptability,” Dr. Karp said.

Cognitive impairment is common in late-life depression, affecting executive functioning, attention, and memory; it is associated with long-term risk for dementia. “Cognitive deficits may thus be signs of accelerated brain aging that confers a predisposition to and perpetuates depression,” Dr. Karp said.

How pain contributes to treatment response variability

A 2002 study by Brown et al that involved 121 community-dwelling rheumatoid arthritis patients aged 34 to 84 years sought to examine the effects of pain and depression on cognitive function.5 Participants completed a battery of cognitive tasks, and pain and depression were assessed using multiple measures. The researchers then used structural equation modeling to assess how pain, depression, and age contributed to cognitive performance.

Higher levels of pain and depression and older age were associated with poor performance on cognitive tasks, the researchers found. Similarly, higher levels of pain were associated with depression, and analyses revealed that depression mediated the relationship between pain and cognition. 

“When depression was entered into the analyses, the previously significant effects of pain on cognition were no longer found,” Dr. Karp reported. “Interestingly, depression still mediated the pain-cognition relationship even after controlling for age.”

Because the effects of pain and depression—cognitive impairment, disability, insomnia, physical deconditioning, polypharmacy, high costs, and worsening caregiver burden—are interrelated, Dr. Karp advises the use of a unified approach.

ADAPT: Addressing Pain and Depression Together

The ADAPT trial assessed the utility of a stepped-care approach for older patients presenting in primary care settings with depression and CLBP for whom previous treatment failed.6

The primary aim of the study was to compare combined high-dose venlafaxine with problem-solving therapy for depression and pain (PST-DP) with high-dose venlafaxine with supportive management (SM) to determine outcomes on depression, pain, and disability scales.

The study involved 250 patients assigned to 6-week treatment with lower-dose venlafaxine (up to 150 mg/d) with SM. Those who responded to treatment as defined as a score less than 5 on the 9-item Patient Health Questionnaire (PHQ-9) and a greater than 30% improvement on the Numeric Rating Scale for Pain (NRS) left the study. 

In phase 2, patients whose depression did not respond to treatment were assigned to either 14-week treatment with higher-dose venlafaxine (up to 300 mg/d) and SM (n = 71) or 14-week treatment with higher-dose venlafaxine (up to 300 mg/d) and PST-DP (n = 68). The median venlafaxine dosage was 244 mg/d. On average patients in the PST-DP group received 8.4 sessions and those in the SM group received 9.2 sessions.

Remission was defined as a positive response as demonstrated by a PHQ-9 score less than 5 and a greater than 30% reduction on the NRS on two sequential visits. 

Comparing the PST-DP group vs the SM group, final remission rates were 31% vs 18% on both pain and depression outcomes (P = .11); 44% vs 33% on depression outcomes (P = .17); and 43% vs 47% on pain (P = .73), respectively.

“In older adults, no significant difference in depression was seen when comparing medication and psychotherapy, but combined treatment is significantly better than medication alone,” Dr. Karp said. “Combined treatment seems to be the best treatment option in this group.”

Disclosures: Pfizer and Reckitt Benckiser provided medication for the trials reported.

References

  1. Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life.  Consensus statement update. JAMA. 1997;278:1186-1190.
  2. Lenze EJ, Mulsant BH, Shear MK, et al. Comorbid anxiety in depressed elderly patients. Am J Psychiatry. 2000;157:722-728.
  3. Blazer DG. Depression in late life: review and commentary.  J Gerontol. 2003; 58A(3):3249-265.
  4. Lyness JM, Caine ED, King DA, Cox C, Yoediono Z. Psychiatric disorders in older primary care patients.  J Gen Intern Med. 1999;14(4):249-254.
  5. Brown SC, Glass JM, Park DC. The relationship of pain and depression to cognitive function in rheumatoid arthritis patients. Pain. 2002;96(3):279-284.
  6. Karp JF, Rollman BL, Reynolds CF III, et al. Addressing both depression and pain in late-life: the methodology of the ADAPT study. Pain Med. 2012;13(3):405-418.
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