Optimized Antidepressant Therapy and Pain Self-management in Primary Care Patients With Depression and Musculoskeletal Pain

CONTEXT: Pain and depression are the most common physical and psychological symptoms in primary care, respectively. Moreover, they co-occur 30% to 50% of the time and have adverse effects on quality of life, disability, and health care costs. OBJECTIVE: To determine if a combined pharmacological and behavioral intervention improves both depression and pain in primary care patients with musculoskeletal pain and comorbid depression. DESIGN, SETTING, AND PATIENTS: Randomized controlled trial (Stepped Care for Affective Disorders and Musculoskeletal Pain SCAMP) conducted at 6 community-based clinics and 5 Veterans Affairs general medicine clinics in Indianapolis, Indiana. Recruitment occurred from January 2005 to June 2007 and follow-up concluded in June 2008. The 250 patients had low back, hip, or knee pain for 3 months or longer and at least moderate depression severity (Patient Health Questionnaire 9 score > or = 10). INTERVENTION: Patients were randomly assigned to the intervention (n = 123) or to usual care (n = 127). The intervention consisted of 12 weeks of optimized antidepressant therapy (step 1) followed by 6 sessions of a pain self-management program over 12 weeks (step 2), and a continuation phase of therapy for 6 months (step 3). MAIN OUTCOME MEASURES: Depression (20-item Hopkins Symptom Checklist), pain severity and interference (Brief Pain Inventory), and global improvement in pain at 12 months. RESULTS: At 12 months, 46 of the 123 intervention patients (37.4%) had a 50% or greater reduction in depression severity from baseline compared with 21 of 127 usual care patients (16.5%) (relative risk RR, 2.3; 95% confidence interval CI, 1.5-3.2), corresponding to a much lower number of patients with major depression (50 40.7% vs 87 68.5%, respectively; RR, 0.6 95% CI, 0.4-0.8). Also, a clinically significant (> or = 30%) reduction in pain was much more likely in intervention patients (51 intervention patients 41.5% vs 22 usual care patients 17.3%; RR, 2.4 95% CI, 1.6-3.2), as was global improvement in pain (58 47.2% vs 16 12.6%, respectively; RR, 3.7 95% CI, 2.3-6.1). More intervention patients also experienced benefits in terms of the primary outcome, which was a combined improvement in both depression and pain (32 intervention patients 26.0% vs 10 usual care patients 7.9%; RR, 3.3 95% CI, 1.8-5.4). CONCLUSION: Optimized antidepressant therapy followed by a pain self-management program resulted in substantial improvement in depression as well as moderate reductions in pain severity and disability. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00118430.