‹date/time›
‹foot=
er›
‹#›
------=_NextPart_01C7747D.A3D04D60
Content-Location: file:///C:/8E7D3227/PelvicPain-ProfWing_files/pres.xml
Content-Transfer-Encoding: quoted-printable
Content-Type: text/xml; charset="utf-8"
![](3D"master17_image004.jpg")
![](3D"master17_image003.gif")
Depression in Chronic pai=
n
Prof YK Wing
Department of Psychiatry
=
;
CUHK
![](3D"slide0001_image006.gif")
![](3D"slide0001_image008.gif")
![](3D"slide0001_image010.gif")
![](3D"master16_image011.jpg")
Psychiatric morbidity of the case:
Differential diagnosis
Differential diagnosis
<=
span
style=3D'font-size:88%'>1.Depression
=
;
Presence of
depressive symptoms: depressed mood, negative thoug=
hts
including suicidal ideation, biological
symptoms such as sleep disturbance & low libido
<=
span
style=3D'font-size:86%'>Persisted symp=
toms
for months
Persisted symp=
toms
for months
<=
span
style=3D'font-size:86%'>Functional
impairment
Functional
impairment
<=
span
style=3D'font-size:88%'>2.Somatoform pain
disorder
Definition:
persistent, severe & distressing pain which cannot be
explained fully by a physiological process or a physical
disorder
<=
span
style=3D'font-size:86%'>Against: prese=
nce
of prominent depressive symptoms
Against: prese=
nce
of prominent depressive symptoms
Common psychiatric morbidities in Chronic Pain
=
1.Insomnia
<=
/span>
High prevalence
even in the absence of depression
=
Related to pain
& distress
Related to pain
& distress
Use of pain
mediation e.g. opioid, steroids
=
2.Anxiety
=
Generalized
anxiety disorder
Generalized
anxiety disorder
=
Panic disorder
Panic disorder
=
Agoraphobia,
social phobia
Agoraphobia,
social phobia
=
PTSD, OCD
=
PTSD, OCD
=
=
3.Depression
=
;
Melanocholic,
psychotic, atypical depression
=
Dysthymia
=
Dysthymia
=
=
Adjustment
disorder
Adjustment
disorder4. Substance
abuse
=
Alcohol
Alcohol
=
Opioid<=
span
lang=3DEN-US style=3D'mso-fareast-font-family:\65B0\7D30\660E\9AD4;mso-han=
si-font-family:
"Times New Roman";font-size:50%;mso-fareast-language:ZH-TW'>
Opioid<=
span
lang=3DEN-US style=3D'mso-fareast-font-family:\65B0\7D30\660E\9AD4;mso-han=
si-font-family:
"Times New Roman";font-size:50%;mso-fareast-language:ZH-TW'>
5. Somatoform
disorder
Presence of
physical symptoms that cannot be fully explained <=
span
style=3D'position:absolute;top:47.25%;left:61.42%;width:37.26%;height:4.0%=
'>by medical
disorder, substance abuse or another mental disorder
<=
/span>E.g. somatoform
pain disorder, conversion disorder, somatization
disorder, body dysmorphic disorder, hypochondriasi=
s
Symptoms not
feigned or intentionally produced
=
Female<=
span
style=3D'mso-bidi-font-family:"Times New Roman"'>> male
Female<=
span
style=3D'mso-bidi-font-family:"Times New Roman"'>> male
Depression: Conceptual sh=
ift
Depression is a medical
disorder
Analogous to diabetes or
hypertension
Depression is both a chronic=
and
recurrent disease
Requires maintenance or
long-term treatmentWhat is depression=
Normal unhappiness vs
‘pathological depression’: how to differentiate, why we need to
Quantitative and qualitative
differences, outcome and treatment implication![](3D"slide0005_image015.jpg")
Common features of depres=
sion
Core symptoms:
<=
span
class=3DBB> =
Low mood
=
Low mood
<=
span
class=3DBB> =
Loss of interest (anhedonia)
=
Loss of interest (anhedonia)
<=
span
class=3DBB> =
Fatigue or reduced energy
=
Fatigue or reduced energy![](3D"slide0070_image017.gif")
Common features of depres=
sion
Additional
features
Negative cognition (excessive guilt, hopelessness, worthlessness)&#=
13; Suicidal ideation
Disturbed sleep
Change in appetite and
weight
Inattention and poor
memory
Psychomotor retardation =
or
agitation
•
1. Persistent
symptoms for more than two weeks
2. ICD-10
classification requires 2 out of 3 core symptoms
3. DSM IV
classification requires either low mood or anhedonia
4. Atypical
symptoms like hypersomnia, increased appetite, weight gain <=
span
style=3D'position:absolute;top:77.75%;left:11.42%;width:81.08%;height:4.25=
%'>also present i=
n a
proportion of depressed patients
5. Anxiety,
irritability, anger ,hostility may be present
6. Psychotic
symptoms eg. Delusion of persecution, guilty, poverty, hypochondriasi=
s;
hallucination![](3D"slide0071_image019.gif")
Epidemiology of Clinical
Depression
<=
span
style=3D'font-size:88%'>
Depression is a
common illness
Depression occ=
urs
twice as often in women as it does in men=
3;Diagnosis of
depression is missed in (primary care) up to 50% of c=
ases
eg. primary care
<=
span
style=3D'font-size:88%'>Increasing in
prevalence rate and younger patients
Depression in Hong Kong A=
dult
<=
span
class=3DBB>Lifetime prevalence ~2-4% (C=
hen,
1993)
Lifetime prevalence ~2-4% (C=
hen,
1993)
Lower than America, United
Kingdom, Australia
<=
span
class=3DBB>Similar to Taiwan Chinese=
3;
Similar to Taiwan Chinese=
3;? related to under-reporting,
less alcoholic, better social support, more anxietyPrevalence of Depressive
Disorders in Various Patient
Population*
![](3D"slide0096_image021.gif")
*There is a range=
of
percentages depending on the study.
=
Depression & Chronic =
pain
Prevalence of depression among patient with persistent pain: 30-54% (Banks and Ker=
ns
1996)
Increased risk of suicidal
ideation, attempts & completed suicide with increasing severity of pain Suicidality & Chronic
pain
<=
span
class=3DBB>Prevalence of suicidal ideat=
ion:
5-20.6%
Prevalence of suicidal ideat=
ion:
5-20.6%
<=
span
class=3DBB>Suicidal attempt: ranges from
5.2%- 13.7%
Suicidal attempt: ranges from
5.2%- 13.7%
•Tang NKY et al. Psychological Medicine 2006 (Review)
Risk factor=
s of
suicide in Chronic pain
<=
span
class=3DBB>FHx of suicide
FHx of suicide
<=
span
class=3DBB>Previous suicide attempt
=
;
Previous suicide attempt
=
;<=
span
class=3DBB>Co-morbid depression, insomn=
ia
Co-morbid depression, insomn=
ia
Nature of pain: longer pain
duration, high pain intensity, widespread body pain & back pain
•Tang NKY et al. Psychological Medicine 2006 (Review)
Pathophysiology of Depres=
sion
<=
span
class=3DBB>Multifactorial
<=
/span>
Multifactorial
<=
/span>complex and multiple
interactions among biological, psychological, sociocultural and political domains
<=
span
class=3DBB>Stress-diathesis concept
Stress-diathesis conceptIntegrated Model <=
span
lang=3DEN-US style=3D'mso-fareast-font-family:\65B0\7D30\660E\9AD4;font-si=
ze:50%;
mso-fareast-language:ZH-TW'> =
Herbert
(1998)
Genetic=
Neural and endocrine
•<=
/span>Adrenal steroi=
ds
(cortisol, DHEA)
•<=
/span>Monoamines
(serotonin, noradrenaline)
•<=
/span>Altered gene
expression (immediate-early genes, genes for
neuropeptides and peptide receptors)
Social and psychological
•<=
/span>Chronic
difficulties (social adversity)
•<=
/span>Psychological
(e.g. low self esteem)
•<=
/span>Environment (e=
.g.
lack of confiding relationship)
•<=
/span>Life event
![](3D"slide0069_image022.gif")
![](3D"slide0069_image023.gif")
![](3D"slide0069_image024.gif")
Depression=
![](3D"slide0134_image025.gif")
Pathophysiology of
Depression & Chronic Pain
Depression & Chronic Pain
Depression
Chronic Pain<=
/span>
Biologica=
l:
5-HT,
NA, Substance P, CRF, opioid receptor
Psycholog=
ical:
distorted cognition
e.g.=
catastrophizing,
perceived helplessness,
exte=
rnal
locus of control
Childhood
experience
e.g.
sexual abuse
Chronic
Stress
Pain
modulation
Ampli=
fy
pain signals & attention
Clinical approach to depression in <=
span
lang=3DEN-US style=3D'mso-fareast-font-family:\65B0\7D30\660E\9AD4;font-si=
ze:90%;
mso-fareast-language:ZH-TW'>chronic pain
Early detection of co-morbid psychiatric morbidity e.g. insomnia,
depression, alcohol & substance abuse
<=
span
class=3DBB>Risk assessment: suicidal
risk
Risk assessment: suicidal
risk
Adequate treatment for co-mo=
rbid
depression and psychiatric morbidities
<=
span
class=3DBB>Adequate pain management
Adequate pain management
Suicidal risk assessment<=
/span>
Direct questioning about suicide do not<=
span
lang=3DEN-US style=3D'mso-fareast-font-family:\65B0\7D30\660E\9AD4;mso-han=
si-font-family:
"Times New Roman";mso-fareast-language:ZH-TW'> increase risk of suicide =
3;Multi-axial assessment: curr=
ent
suicidal thoughts, past history, family history, presence of psychiatric
illnesses, psychosocial assessment and coping stratgies
Questionnaires: Beck depress=
ion
inventory (BDI)![](3D"slide0102_image026.gif")
Treatment Goals
Treatment
![](3D"slide0102_image027.gif")
Reduce/Remove
=
Signs, Symptoms
Minimize Relapse/
Recurrence Risk
![](3D"slide0102_image028.gif")
Restore Role/
=
Function
![](3D"slide0102_image029.gif")
![](3D"slide0102_image030.gif")
![](3D"slide0102_image031.gif")
Management
<=
span
class=3DBB>Pharmacological treatment=
3;
Pharmacological treatment=
3;<=
span
class=3DBB>Psychosocial intervention
Psychosocial interventionPharmacological treatment=
Demonstration =
of
analgesic effect among chronic pain patients with no
concomitant depression
Dosage require=
d to
achieve an optimum analgesic response is usually lower =
than
the therapeutic dose for antidepressant effect
Delay of actio=
n of
antidepressants in chronic pain management is shorter than t=
hat
observed in depression
![](3D"slide0123_image032.gif")
Antidepressant: proposed mechanisms of <=
span
lang=3DEN-US style=3D'mso-fareast-font-family:\65B0\7D30\660E\9AD4;font-si=
ze:90%;
mso-fareast-language:ZH-TW'>analgesic effect
TCAs
Substance P
DNRIs
dopamine
availablity
Dopamine mediated
TCAs, SNRIs,
SSRIs, NRIs, DNRI, mianserin, mirtazapine
Activation of =
d and m-opioid receptors,
induction of endogenous opioid peptide release=
Opioid mediated
TCAs
NMDA receptors
TCAs, SSRI
GABA-B receptors
TCAs, SSRIs SN=
RIs,
NRIs, mirtazapine
Noradrenaline availability
<=
/div>
NA mediated
TCA, SSRIs, SNRIs
trazodone
5-HT availabli=
ty
5-HT mediated
Antidepressant
Action
Pain mechanism
Antidepressants
Duloxetine: fi=
rst
antidepressant approved by FDA for treating
neuropathic pain in diabetic patients
------=_NextPart_01C7747D.A3D04D60
Content-Location: file:///C:/8E7D3227/PelvicPain-ProfWing_files/slide0029.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
<=
span
style=3D'font-size:88%'>1.Tricyclics (TC=
A):
<=
/span>
<=
span
style=3D'font-size:86%'>Established
analgesic effect esp for neuropathic pain
Established
analgesic effect esp for neuropathic pain
<=
span
style=3D'font-size:86%'>Risk of lethal
overdose & undesirable side effects
Risk of lethal
overdose & undesirable side effects
<=
span
style=3D'font-size:88%'>2.Selective
serotonin reuptake inhibitors (SSRI):
<=
span
style=3D'font-size:86%'>Less toxic when
overdose
Less toxic when
overdose
<=
span
style=3D'font-size:86%'>Better
tolerability
Better
tolerability
<=
span
style=3D'font-size:86%'>Relatively low=
er
efficacy when compared to TCAs
Relatively low=
er
efficacy when compared to TCAs
3.Serotonin &
noradrenalin reuptake inhibitors (SNRI):
<=
/span>
<=
span
style=3D'font-size:86%'>Better
tolerability
Better
tolerability
Duloxetine: fi=
rst
antidepressant approved by FDA for treating
neuropathic pain in diabetic patients
Side effects of TCAs and
SSRIs
Dry mouth
=
Blurred
vision
Sedation
<=
/span>Weight gain=
3;Postural
hypotension and fall
Cardiac
arrhythmia
Constipation&#=
13;<=
span
style=3D'font-size:86%'>
Cognitive
impairments
Nausea
Headache
<=
/span>Sleep
disturbances
Sexual
dysfunction
Anxiety
<=
span
style=3D'font-size:86%'>Apathy =
Psychological interventio=
n
<=
span
class=3DBB>Cognitive Behavioral
Therapy
Cognitive Behavioral
Therapy
Marital: marital therapy,
management of sexual dysfunctionPain management
Early & more aggressive management of pain
Prevent development of
biological & psychological mechanisms that contribute to the maintenance of chronic p=
ain
and disability (Taylor et al 2001)
------=_NextPart_01C7747D.A3D04D60
Content-Location: file:///C:/8E7D3227/PelvicPain-ProfWing_files/slide0072.htm
Content-Transfer-Encoding: quoted-printable
Content-Type: text/html; charset="us-ascii"
Early & more aggressive management of pain
Prevent development of
biological & psychological mechanisms that contribute to the maintenance of chronic p=
ain
and disability (Taylor et al 2001)Treatment of depression
<=
span
style=3D'font-size:75%'><=
span
style=3D'font-size:75%'>=
=
relapse of the same depressive episode.
recurrence of =
=
=
relapse of the same depressive episode.
‹head=
er›
‹date/time›
Clic=
k to edit
Master text styles
Sec=
ond
level
Thi=
rd
level
Fou=
rth
level
Fif=
th level
‹foot=
er›
‹#›
=
' + ENDSHOW_MESG + '
![](3D"notes_flag.gif")
No=
tes![](3D"buttons.gif")
![](3D"master16_image001.jpg"){kind=link}
![](3D"master17_image002.jpg"){kind=link}
![](3D"slide0005_image014.jpg"){kind=link}