Stepped Care for Depression and Musculoskeletal Pain

Study Overview
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Brief Summary
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This study will evaluate the effectiveness of a stepped care approach in treating depression and reducing pain.

Detailed Description
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In the United States, pain accounts for nearly 20% of all primary health care visits. In the majority of cases, the pain is musculoskeletal and primarily affects the lower back, hips, and knees. Studies have shown that at least one-third of patients with pain also suffer from depression. It has not been determined whether treatments for depression are effective in patients with comorbid pain and depression. The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study will determine the most effective treatment for patients with pain and depression. This study will last 12 months and will comprise depressed and nondepressed participants. Nondepressed participants will receive no treatment. Depressed patients will be randomly assigned to receive standard of care or stepped care for 12 weeks. Standard of care may include cognitive therapy, antidepressant treatment, or other treatments. The stepped care group will receive 12 weeks of antidepressant treatment. Participants who respond to antidepressant treatment will continue their treatment for the duration of the study. Participants who do not respond to the treatment after 12 weeks will receive 6 weekly pain self-management sessions. During these sessions, an educator will teach participants how to manage their pain through exercise and relaxation techniques. Self-report scales and questionnaires will be used to assess participants' pain, depressive symptoms, health care usage and costs, and quality of life. Depressed participants will undergo assessments at study start and at Months 1, 3, 6, and 12. Nondepressed participants will undergo assessments at study start and at Months 3 and 12. Study hypotheses: 1) Stepped care is more effective than usual care in improving depression and pain. 2) Stepped care is more effective than usual care in improving health-related quality of life, negative pain beliefs and behaviors, reduced opiate use, and health care costs. 3) Patients with musculoskeletal pain who are not depressed at baseline will have an incidence of depression less than 20% over 12 months of follow-up, characteristics that can be identified as risk factors for incident depression, baseline characteristics distinguishing them from depressed patients, and better pain and health status outcomes, compared to depressed patients.

Official Title
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Stepped Care for Affective Disorders and Musculoskeletal Pain

Conditions
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Pain, Depression

Intervention / Treatment
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* Behavioral: Stepped Care
* Drug: Antidepressants
* Drug: Usual Care


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Moderate or severe pain in the back, hips, or knees for at least 3 months prior to study entry History of or current use of at least one medication for pain English-speaking Exclusion Criteria: Moderate to severe cognitive impairment Schizophrenia or other psychotic disorders Receiving disability benefits for pain Anticipated life expectancy less than 12 months Pregnancy

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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Accepts Healthy Volunteers

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Allocation: Randomized
Intervention Model: Parallel Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Experimental: Stepped Care<br>Stepped care group | Behavioral: Stepped Care<br>* Stepped care will consist of 12 weeks of antidepressant therapy, followed by a pain self-management program (PSMP) in those who fail to achieve both a good pain and global clinical response to antidepressant therapy. Treatment will be delivered by a nurse depression-pain clinical specialist (DPCS) who will be trained in providing both components of the stepped care treatment. The DPCS will meet weekly to review cases with a physician-investigator who will also be available to discuss any management issues that arise between the weekly case meetings. All participants will have six clinical contacts with the DPCS during the acute treatment phase and two clinical contacts during the continuation phase to assess medication adherence, adverse effects, and depression response.<br>Drug: Antidepressants<br>* Participants will be assigned to one of the following antidepressant regimens: venlafaxine (37.5 mg, increased to 75, 150, 225 mg); duloxetine (60 mg, increased to 120 mg); fluoxetine (20 mg, increased to 30 to 40 mg); sertraline (50 mg, increased to 100 to 150 mg); citalopram (20 mg, increased to 30 to 40 mg); paroxetine (20 mg, increased to 30 to 40 mg); or nortriptyline (25 mg, increased to 50 to 75 mg).<br>|
| Active Comparator: Usual Care<br>Treatment as usual group | Drug: Usual Care<br>* This group will receive care as usual from their providers and completes the same outcome assessments as the stepped care group.<br>* Other names: Standard Care;|
| No Intervention: No Treatment<br>Participants without depression group | |

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Brief Pain Inventory Interference | The BPI interference scale consists of 7 items, each scored from 0 (no interference) to 10 (complete interference), and the total score is the average of the 7 individual item scores. Therefore, the BPI interference score can range from 0 (lowest pain) to 10 (worst or highest pain). | Measured at Year 1 | 
| HSCL-20 Depression Severity | This scale consists of 20 items, each scored from 0 (lowest) to 4 (highest or worst). The scale score is the average of the 20 items. Therefore, the HSCL-20 depression severity score can range from 0 (no depression) to 4 (highest or worst depression) | Measured at Year 1 | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Graded Chronic Pain Scale Disability Score | This scale ranges from 0 (no pain-specific disability) to 100 (highest or worst pain-specific disability) | Measured at Year 1 | 
| Primary Care Visits |  | Measured at Year 1 | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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Back Pain, Knee Pain, Hip Pain, Stepped Care, Antidepressant, Relaxation Techniques, Exercise