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TREATMENT OF CHRONIC PAIN WITH THE NEWER ANTIDEPRESSANTS
Drs PARIS P.C.*/** , POINDESSOUS J.L.**, STANEK M.**, MALLECOURT J.**
CHG de DREUX, Hopital V. JOUSSELIN
*Service de PSYCHIATRIE, CAC, CMP
**UNITE DOULEUR, Consultations pluridisciplinaires 44 Avenue du President-KENNEDY, BP 69, 28102 DREUX Cedex, FRANCE
The relationship between chronic pain and depression is complex. Also, many patients with chronic pain tend to mask their psychological distress. Others subjects sometimes deny that they are depressed. We know that andidepressants are effective in the treatment of varied pain syndromes including peripheral neuropathic pain, headache, migraine, fibrositis or rheumatic pain.
We summarize recent studies which show the efficacy of newer antidepressants as analgesics for chronic pain problems. We try to detail what are the most important characteristics of pains for the choice of the better antidepressive treatment. We want to specify what are the most predictive mental disorder of a good response in all the psychological states or personality dimensions.
Antidepressive medications should be selected not only on the side effect profile, the potential for drug interactions but also on the good efficacy on psychiatric comorbidity like chronic anxiety or insomnia.
When they are able to reduce the physical component of pain, they should also improve the quality of life and help to rehgabilitate in good conditions patients with severe chronic pain.
SIGNIFICANCE OF PERSONAL PECULIARITIES CORRECTION AT THE PAIN SENSITIVITY LEVEL AT SURGICAL PATIENTS
Regional center of psychotherapeutical rehabilitation and psychoprophylaxis, 6-th city clinical hospital, Dnepropetrovsk 490, Ukraine.
Aim of the investigation: Studying of the connection of indices reflecting pain syndrome intensity with the patients' personality psychological peculiarities in the pre-operational period.
Methods: (methodics): Psychological tests BVNK-300, Zung, at patients suffering with duodenal ulceration, who are being prepared for the operation and at the analogous patients group, taking the conservative treatment.
Results: The psychological testing of 120 patients showed, that the pain sensitivity threshold lowering in 23% is registrated against the background of moderate depression level preservation according to the Zung test at the patients suffering with duodenal ulceration, who are being prepared for the operation unlike the group of patients who are taking the conservative treatment. At that the pain syndrome expressing in pre-operational period has authentically high and straight correlative dependence with the degree of obsessive thoughts and actions ( r-0,76 ), unreasonable phobias (r-0,58) and phobic disorders (r-0,53).
Conclusions: The including in patients' pre-operational preparation of psychotherapeutical methodics aimed to the correction of depressive and phobic disorders, obsessive thoughts and unreasonable phobias allows to raise the pain sensitivity threshold.
PAIN SYNDROME INFLUENCES THE ONSET OF THE AFFECTIVE DISORDER IN PATIENTS OPERATED IN CONNECTION
WITH MYOMAS AND ADENOMYOSIS.
Aim of Investigation: To investigate the character of the affective disorder in patients with myomas of uterus and adenomyosis with and without pain.
Methods: Standard clinical psychiatric and gynaecological study, Lusher test, Spilberger Anxiety Inventory, Beck Depression Inventory (BDI), McGill pain questionnaire (MPQ).
Results: 70 patients were studied, age 45± 5, period of disease 3± 0,5 years. In 55 patients (78,5%) myomas developed rapidly. 22 patients had pain and menorrhagia.The intensity of pains was from 3 to 6 point. Index MPQ was 1,37± 0,4.The data has been collected three times: before the operation, 10 days and 6 months after the operation. During the study in the pain group the anxiety level was identically high: 45± 5,9; 43,9± 5,9; 43,9± 8,9. Depression had the same tendency: 20,7± 9,8; 14,7± 8,2;
21,4± 2,7 .The highest levels of anxiety and depression were in the patients with pain and the period of disease over 10 years. In group without pain anxiety was: 36,6± 8,6; 25,8± 7,5; 25,8± 7,5; depression was: 13,8± 5,0; 12,5±2,4; 9,0± 4,8. The results of Lusher test had similar dynamics:
Vegetetive coefficient. Total Aberration off Norm, Anxiety, Distress. State of patients with stable parasympathetic was the most troubled. The patients with pain before the operation had the worst indexes later in 6 months.
Conclusion: The structure of disorder, discovered in patients with pain before the operation, resembled the presenile depression. This fact allowed us to attribute the patients with pain in clinic myomas of uterus and adenomyosis as a risk group for anxiety-depression disorders, which develops in the distant period after the operation.
COGNITIVE BIAS & COGNITIVE CONTENT IN CHRONIC PAIN PATIENTS WITH DEPRESSION.
Aim of Investigation We hypothesised that there would be differences in the cognitive biases and content within a sample of patients with chronic pain and concurrent depression, related to the presence or absence of a previous history of depression.
Methods 60 chronic pain patients were assessed with the WHO SCAN to establish current and former diagnostic status, and BDI. Cognitive bias was assessed by a self-referential word judgement and recall task: words were positive & negative exemplars of three categories — situational (frustrated), enduring (unlovable), bodily (aching). Cognitive content was assessed by the Sentence Completion for Depression (SCD) task
Results Data analysis is ongoing but will be completed by August 2000 Preliminary work suggests that patients without history of depression show cognitive bias towards situation and bodily words, patients with a prior history of depression show bias towards self-denigratory words found in the enduring category. There will be corresponding differences in object-agent referential SCD measures.
Conclusions This study suggests new ways in which 'depression' in the context of chronic pain may be analysed The methods are advantageous because they do contain endorsement response biases present in questionniare methodology and they can detect differences in cognitive content.
DISTINGUISHING DEPRESSION FROM DISTRESS IN CHRONIC PAIN.
Aims of investigation The Beck Depression Inventory (BDI) is widely used in chronic pain, despite doubts about its structure and appropriateness. This study used a very large sample to test the structure of the BDI and we hypothesised that pain patients would show relatively low scores on a factor containing items referencing negative self appraisal.
Methods BDI scores were obtained from 1947 patients entering a pain management programme. A random split of cases produced samples for exploratory and confirmatory factor analysis.
Results Many possible 2 factor solutions from exploratory factor analysis, and reasonable fit of several in confirmatory factor analysis. All demonstrated a first factor concerned with a negative view of the self (failure, guilt, self-blame, self-denigration, punishment, disappointment, self-harm), on which most patients score low, and a second factor mainly concerned somatic or physical function (health concern, work, sleep, fatigue, appetite, weight, libido). There was no coherent affect factor (sadness, loss of interest, dissatisfaction, pessimism, crying, irritability).
Conclusions This version of depression is strikingly different from the psychiatric model of depression which is primarily defined by affective disturbance, and secondarily supported by cognitive and somatic symptoms. The finding is consistent with a reconsideration of what constitutes depression in the presence of chronic pain. It offers a means to distinguish depressed patients with typical cognitive biases requiring specific treatment for depression, from non-depressed patients with somatic and functional problems which require pain management.
Acknowledgements South Thames Region NHS Executive Research and Development for Small Project Grant SPGS 558,
THE SEVERITY OF DEPRESSION AND ITS INFLUENCING FACTORS IN CANCER PAIN PATIENTS
Aim of Investigation: This study was conducted to provide database for the effective depression management program for terminal cancer pain patients. Survey was undertaken to investigate the rates and severity of depression and the influencing factors and their correlations between pain and depression in Korean cancer patients.
Methods: 142 patients, admitted at major metropolitan tertiary care hospital for cancer treatment from February to June of 1999 were included. The aim of survey and guidelines for questionnaires were carefully explained to the patients. Demographic data and clinical information were obtained by reviewing their medical records in cooperation with primary care physician. Sex, economic status, educational level, age, religion, treatment method, stage of disease, primary tumor site, metastasis, ECOG performance scale, and current analgesic use were investigated. Depression and pain scores were evaluated with self-report of Korean Beck Depression Inventory and simplified of Brief Pain Inventory. The differences in the level of depression by BDI and intensity of pain by BPI were analyzed with Student t-test and ANOVA. The correlations between factors were evaluated with Pearson correlation coefficient.
Results: Total 142 subjects of 79 male and 63 female patients, with mean age of 51.86 years were included. The mean pain scores from the worst to least during last 24 hours ranged from 6.08 ± 2.23 to 2.25 ± 1.83 by BPI. At cutting point 21, the mean BDI scores were 23.73 ± 0.99 and 55.6% of patients were to be in depression. The correlations between depression and pain were significant with the worst pain for last 24 hours, average pain for last 24 hours and present pain. Significant correlations with depression were found among groups of cancer patients in regard to gender, educational level, and ECOG.
Conclusions: These findings could be used to identify high-risk patients who are in need of early intervention and to plan for effective therapeutic strategies. Further study will be necessary to evaluate the cultural differences and the influencing factors on depression in Korean cancer patients.
"PAIN PERCEPTION IN MAJOR DEPRESSION"
Background: Pain and depression are often associated. This association may be the result of disturbances in common neurotransmitter systems in the brain and spinal cord.
Aim of the Study: Determination of associations between pain parameters and the degree of depression.
Materials and Methods: Depressed patients with a Hamilton depression score > 18 were included from Aarhus University Hospital of Psychiatry. The patient's reaction time was measured. Subsequently pain perception thresholds and pain tolerance thresholds were measured with pressure algometry and graduated on a VAS scale. Cold pressure test was performed. Immediately after, present pain index, VAS and McGill pain Questionnaire - short form was obtained. Patients were examined when electroconvulsive therapy for depression were initiated and after recovery. The patients were gender and age matched with non-depressed control persons.
Preliminary Results: There was a significant longer reaction time in 8 depressed patients than in 6 non-depressed control persons using an independent samples 2-tailed t-test (p= 0.009).
The Hamilton depression scale predicted elevated reaction time and the scale were shown efficient to determine the degree of depression.
There was a tendency (p=0,094) for depressed patients to describe the cold pressor test with words from the affective category of the McGill pain questionnaire more often than the non-depressed controls.
Preliminary analysis did not detect significant differences between depressed patients and non-depressed controls in pain parameters before electroconvulsive therapy.
Conclusion: Elevated reaction time in depressed patients influence psychophysical measurements. Final analysis of pain parameters before and after depression will be ready for presentation at the congress.
ANXIETY, DEPRESSION AND CHRONIC PAIN
Aim of Investigation: The authors try to determine and evaluate the relationship between pain, anxiety, depression and functional incapacities in chronic pain patients in a first approach in the multidisciplinary pain facility at Madeira Hospital (Centre Hospitalar do Funchal).
Methods: In a universe of 500 patients we applied the Vaz Serra, test to evaluate depression and functional incapacity and made their relationship with pain, evaluated by a Visual Analogical Scale converted to a numeric scale (0 to 10).
Results: We analyse the studied variables and its correlation, and, as they were significant we calculated the predictive equation, being now in final conclusion, the statistic analyses.
Conclusion: In this study the authors documented the relationship between pain, anxiety, depression and its functional incapacities.
OCCUPATIONAL THERAPY OF PATIENTS WITH ALGIA CAUSED BY ENDOGENOUS DEPRESSION
Aim of investigation: Studied were different' kinds and ways of occupational therapy and its efficiency at senestoalgia caused by endogenous depression.
Methods: Sociotherapy (art-therapy, workshop therapy etc.)
Results: Examined were 428 patients aged from 10 to 52 years, 45% whom were male. All the patients had senestoalgia disorders caused by endogenous depression. Individual courses took place at library, art studio, knitting classes and at assembling workshops. Group treatment was conducted the participation of other patients and included dancing, theatrical performances, chess, billiards, excursions, chorus singing. Each occupational therapy class lasted from 1 to 4 hours with the intervals in every 30-60 minutes. Examination showed that senestoalgia regressed greatly with 15% of patients just in 10-15 sessions. After 30 sessions 89% of patients were freeed of aches, their mental disposition and communicative skills improved, they started to enjoy a hearty appetite and got rid of insomnia. All the patients wanted to continue "'occupational therapy sessions.
Conclusions: The fact that treatment and rehabilitation procedures include occupational therapy helps to quickly eliminate symptoms and to significantly lower the cost of treatment. Moreover, it provides the patients with hope for optimistic somatic and psychic outcome of further treatment.
Pain in Europe III. EFIC 2000, Nice, France, September 26-29, 2000. Abstracts book, p. 313, 335, 339, 340, 341, 345, 346, 347, 348.
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