The paper reviewed here is ‘Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking’ by Bonnewyn and colleagues. In the conclusion to the abstract the authors write that
‘(Painful physical symptoms) were more likely in people with a 12-month major depressive episode (MDE) than in those without (OR=2.0)‘
In the introduction, the authors cite research showing a prevalence of pain in older adults of between 25 and 88%. The authors then briefly discuss the pain-depression dyad explaining the antecedent and consequence hypotheses which expand on the nature of the dyad. The aims of the study are clearly outlined and include an evaluation of the relationship between pain and depression in a community-dwelling sample of older adults (65 years and older) as well as the interactions with the use of mental health services and benzodiazepine use.
The data was obtained from the European Study on the Epidemiology of Mental Disorders (ESEMeD) a study which was initiated by the World Health Organisation. Data was obtained from 6 countries – France, Germany, Italy, Belgium, Holland and Spain. The researchers write that some of the specifics of the sampling process have been described in another paper. I wasn’t clear on the details of the sampling method as a result and the researchers note that
‘a stratified, multistage, clustered area, probability sample was used‘
59.4% of the sample were female and 38.4% were age 75 and over. 36.3% of the sample lived in rural areas compared to 26.6% that lived in urban areas. The majority of the sample (52%) had 0-11 years of education. Participants were interviewed using the Composite International Diagnostic Interview with major depressive disorder diagnosed using DSM-IV criteria and a list of questions used to detect the presence of painful symptoms specifying within the last 12 months in some of these questions. They were also asked if they had one of a number of chronic medical conditions some of which are common medical conditiosn (e.g. asthma and diabetes). They were also asked about antidepressant and benzodiazepine use. Their estimated point prevalence of painful physical symptoms in the sample was 31.8% and although they were calculated as more common in men there was no confidence intervals for this comparison. PPS were significantly more likely in females with major depressive episode than those without. Using depression as the dependent variable, the researchers ran a multvariate analysis which identified female gender and pain as predictors of depression. Without major depression, the likelihood of antidepressant use was three times greater in those with painful physical symptoms compared to those without. For participants with depression, there was no significant difference between those with and without painful physical symptoms in the use of antidepressant medication. There was a doubling in the use of benzodiazepines in those without major depression but with painful physical symptoms (PPS) compared to those with major depression but without PPS. Major depression was also found to be signficantly associated with benzodiazepine use.
In the discussion, the authors note that from their results somatic conditions mediated the relationship between depression and pain. The authors also comment on the two-fold increase in PPS with major depressive episode and the increased prevalence of PPS with female gender. Whilst these latter two findings were consistent with previous literature, like the researchers I found the results for antidepressant and benzodiazepine use interesting. Firstly antidepressant use was found to be higher in those without major depression but with pain. The use of benzodiazepines was increased in those with major depression also. I wasn’t clear if there was a prominent anxiety component in those using benzodiazepines but given that only 20% of those with depression were receiving antidepressants a different pattern of prescribing could be explored. This however would depend on local guidelines particularly as the sample is taken from 6 countries.
In conclusion, I thought there were some interesting findings here particularly the use of antidepressants in those with pain but not major depression. It could be that the depression had been previously treated and was in remission. Alternatively it could mean that the subject or the prescriber had intended for the antidepressants to be used for the pain. It would be interesting to see how factors such as pain duration and intensity impact on antidepressant use. The paper provides valuable insights into the relationship between pain and depression in older adults and I would be interested to see in particular if there are any follow-up studies examining the use or underprescribing of antidepressants as well as benzodiazepine in the same or other regions.
Bonnewyn A, Katona C, Bruffaerts R, Haro J M, de Graaf R, Alonso J and Demyttenaere K. Pain and Depression in Older People: Comorbidity and Patterns of Help Seeking. Journal of Affective Disorders. 117. 193-196. 2009.
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