Depression in Chronic Pain Patients: Understanding Current Practices

Chronic pain and depression have become prevalent in society today. The National Institute of Mental Health reports that in 2019, 1 in 5 adults in the U.S. were living with a mental illness. In 2016, 20.4% (about 50 million) adults in the U.S. suffered from chronic pain. Having a more comprehensive understanding of how patients with co morbid depression are managed in chronic pain clinics may provide opportunities to enhance care for this patient population. There are multiple chronic pain guidelines that help guide providers in their treatment; however, none of these give any direct care protocols that are known to be best practice. Multiple providers employed in pain clinics throughout the state of Utah were asked to complete a questionnaire that was used to gather information on their current practice and how they screen and/ or manage patients with co morbid depression. Using the Google search engine, a search for pain clinic in Utah provided names of 27 pain clinics. 12 providers completed the survey anonymously. The results showed that while all 12 providers were following chronic pain guidelines, the specifics of the guidelines to which they incorporate are unclear. Additionally, the results showed that the approach to how and when patients were assessed for depression differed, as well as treatments or referral practices. The results support that more research needs to be done into best practices for assessment, treatment, and referral for depression in chronic pain clinics.

Running head: DEPRESSION IN CHRONIC PAIN PATIENTS Depression in Chronic Pain Patients: Understanding Current Practices Carina Chacon, MSN, APRN, FNP-C, DNP Student Project Chair: Julie Balk, DNP, APRN, FNP-BC Westminster College DEPRESSION IN CHRONIC PAIN PATIENTS 2 Abstract Chronic pain and depression have become prevalent in society today. The National Institute of Mental Health reports that in 2019, 1 in 5 adults in the U.S. were living with a mental illness. In 2016, 20.4% (about 50 million) adults in the U.S. suffered from chronic pain. Having a more comprehensive understanding of how patients with co morbid depression are managed in chronic pain clinics may provide opportunities to enhance care for this patient population. There are multiple chronic pain guidelines that help guide providers in their treatment; however, none of these give any direct care protocols that are known to be best practice. Multiple providers employed in pain clinics throughout the state of Utah were asked to complete a questionnaire that was used to gather information on their current practice and how they screen and/ or manage patients with co morbid depression. Using the Google search engine, a search for pain clinic in Utah provided names of 27 pain clinics. 12 providers completed the survey anonymously. The results showed that while all 12 providers were following chronic pain guidelines, the specifics of the guidelines to which they incorporate are unclear. Additionally, the results showed that the approach to how and when patients were assessed for depression differed, as well as treatments or referral practices. The results support that more research needs to be done into best practices for assessment, treatment, and referral for depression in chronic pain clinics. DEPRESSION IN CHRONIC PAIN PATIENTS 3 Background Mental illness has become increasingly prevalent in society, and a significant percentage of those impacted are not receiving adequate mental health care. The National Institute of Mental Health reports that in 2019, one in five adults (about 51.5 million people) in the United States of America were living with mental illness (NIMH, 2021). Additionally, in 2017 the National Institute of Health (NIH) found that 17.3 million adults in the United States experienced at least one major depressive episode. Of these 17.3 million adults, approximately 35% did not receive treatment for their depression (NIH, 2019). The Centers for Disease Control and Prevention (CDC) reports that 20.4% of adults in the United States (approximately 50 million people) suffered from chronic pain in 2016 (Dahlhamer, 2018). Evidence indicates that depression is more common amongst patients in chronic pain clinics. Notably, the article The Association Between Depressive Disorder and Chronic Pain claims that adults with chronic pain are four times more likely to develop anxiety and depression (Cosio & Meshreki, 2017). With the prevalence of depression on the rise, there is a higher likelihood that depression and chronic pain occur simultaneously in patients. There is concern that despite the likelihood that a chronic pain patient that presents to clinic also suffers from depressive symptoms, the discussion surrounding the topic of mental health by chronic pain clinic providers remains limited. Many patients are unaware that they are experiencing depression symptoms along with their chronic pain and chronic pain providers are not always screening patients for depression. As a result, opportunities for mental health illness treatment are being missed. DEPRESSION IN CHRONIC PAIN PATIENTS 4 Problem Statement Chronic pain and depression both pose a substantial social and economic burden on society. According to the article, The Economic Costs of Pain in the United States (2012), the cost associated with chronic pain was between $560-$635 billion in 2010. The economic toll of chronic pain exceeds the cost of conditions like heart disease, cancer, and diabetes (Gaskin & Richard, 2012). The estimated cost associated with chronic pain is conservative as it does not account for the cost of chronic pain treatment for nursing home patients, children, military personnel, and incarcerated persons (Gaskin & Richard, 2012). Depression, like chronic pain, is also a high-cost condition among Americans. In 2013, $187.8 billion was spent on mental health and substance abuse disorders, making it the fourth highest healthcare expense in the United States (Winerman, 2017). From 1998-2015, there was an increased trend for insurance companies to provide health care coverage for mental health treatments; however, expenses continued to rise as the cost of treatment continued to increase by approximately 2% annually (Hockenberry et al., 2019). While the cost to treat both depression and chronic pain are significant, the data only accounts for patients who are diagnosed and/ or treated for those conditions. If the number of undiagnosed patients is accounted for, the economic impact of chronic pain and depression continues to escalate. It is evident that both chronic pain and depression have a huge economic burden on society in the United States. In addition to the cost associated with these conditions individually, the importance of addressing these issues is amplified when there is a cooccurrence of depression and chronic pain. The article, The Association Between Depressive Disorder and Chronic Pain suggests that patients with multiple pain symptoms are three to five times more likely to experience DEPRESSION IN CHRONIC PAIN PATIENTS 5 depression when compared to people without pain (Cosio & Meshreki, 2017). This article also reported that chronic pain and depression are found to exacerbate one another and share biological pathways and neurotransmitters. While these conditions can compound each other, studies indicate that chronic pain and depression also respond to similar treatments (Cosio & Meshreki, 2017). This further demonstrates the need to identify depression in chronic pain patients and to create a comprehensive health care plan directed at both disorders. Despite the prevalence of each disorder independently, the economic impact of treatment, and the cooccurrence of chronic pain and depression, clear guidelines for chronic pain clinics to screen for depression do not exist. Additionally, there are no clear protocols or guidelines for providing chronic pain patients with treatment options when depression was also identified. Review of literature Depression is a prevalent condition in the United States. While some people can carry out daily functions and responsibilities, persons with moderate-severe depression may develop severe impairments that make it difficult to function (NIH, 2019). As previously mentioned, depression and pain can exacerbate each other leading to worsening states in both conditions. With the already high prevalence of both depression and anxiety, it is important that both issues are addressed in these patients to ensure better outcomes. Pain Management Pain management is the use of opioid, analgesics, and adjunct medications along with non-pharmaceutical treatment (physical therapy, chiropractic therapy, massage therapy, steroid injections, epidurals) and is a component of caring for patients in healthcare. Pain DEPRESSION IN CHRONIC PAIN PATIENTS 6 management has always been a component of medical care, dating back to the 1860’s and the use of opiates before limb amputations (Florine, 2017). The demand for pain management significantly increased in response to injured World War II veterans (Bernard et al., 2018). The prescription of opioid analgesics is one modality of pain management that was being used by providers (in all specialties, when indicated). The number in opiate prescribing and use continued increasing throughout the 1900’s. In 1995, the “fifth vital sign” (pain level) was introduced by the American Pain Society which was then emphasized by the Joint Commission in 2001 (Bernard et al., 2018). The emphasis on pain as a vital sign by the Joint Commission caused an increase in opiate prescribing, being that they are responsible for certifying hospitals for reimbursement by Medicare. Another contributor to increased opiate prescribing was pharmaceutical marketing. In 1995, Purdue Pharma gained approval from the Food and Drug Administration (FDA) for Oxycontin. The company heavily advertised the “non-addictive” qualities of Oxycontin which is also thought to contribute to the increased use of opiates (Bernard et al., 2018). When this advertising began, other opiate brands were also increasing their advertisement. During this sudden increase in opiate prescribing and consumption, heroin became prevalent with its decreased cost but effective analgesic effects (Florine, 2017). In 2000, soon after the 5th vital sign implementation and the increased advertising, there was in increase in overdose related deaths (Florine, 2017). Prior to the 2000s, opiates were not a routine post-surgical prescription. Mancini (2017) found that most patients are prescribed opiates after surgery. It was also found that with these acute prescriptions (typically about 20 tablets), there were left over tablets that DEPRESSION IN CHRONIC PAIN PATIENTS 7 were not discarded and were stored by patients (Mancini, 2017). These historical events were attributed as part cause of the opioid epidemic. Opioid Epidemic The opioid epidemic is identified as the increased prescription and advertisement of opioid medication which led to widespread misuse of opioids (prescribed and non-prescribed) (U.S. Department of Health and Human Services, 2021). The U.S. Department of Health and Human Services declared the crisis as a public health emergency in 2017. With the acknowledgement of the opioid epidemic there has a big push to decrease the amount of opiates prescribed, both acute and chronic (Mancini, 2017). While the literature does not specify why or when the use of pain clinics came into use, pain clinics have become the pain treatment source for extended pain management for patients with chronic pain that require chronic opioid therapy. Patients that are being treated in pain clinics should receive any pain treatment (acute and chronic) through their pain providers (Florine, 2017). The use of pain clinics allows for the pain providers to focus solely on pain management, leading to closer monitoring of opioid use in effort to decrease misuse. While this aids in monitoring opiate intake, it can lead to fragmented care due to only addressing the pain and not concurrent conditions (such as depression). Pain Management Guidelines Pain guidelines have been created to provide practitioners a benchmark for optimizing care of chronic pain patients. The review of pain guideline literature highlights the focus on prescribing opioids, with focused discussion on morphine milliequivalent levels, length of acute pain prescriptions, and risks to evaluate when considering starting chronic opioid therapy (COT) DEPRESSION IN CHRONIC PAIN PATIENTS 8 (Pain Management Best Practices Inter-Agency Task Force, 2019). There are currently a few chronic pain guidelines (Centers for Disease Control (CDC), Drug Enforcement Agency (DEA), Department of Health and Human Services (DHHS), American Academy of Pain Management, American Society of Anesthesiologists, American Academy of Family Physicians). The CDC, DHHS, and DEA guidelines state that high risk patients need to be assessed for depression/behavioral health issues but do not specify how this should be done. High risk patients are classified as patients with divergent drug behavior, personal or family history of substance abuse or addiction, major psychologic problems, poor coping, and unwilling to partake in multimodal treatment (Dydyk et al., 2021). The lack of clear guidelines addressing screening for depression can lead to providers interpreting the information differently, resulting in possible gaps or not identifying high risk patients that could benefit from mental health care. The CDC, DHHS, DEA, and AAFP guidelines to pain management all state that prior to starting opioid therapy the patients should have attempted alternative treatments (noncontrolled analgesics, physical therapy, interventional pain treatments, surgery, etc.) prior to starting opiates. In addition to prescribing recommendations, current guidelines also review deprescribing of opioids. Before prescribing opiates, providers should check the prescription monitoring program (PMP) and obtain results from a urine drug screen. The opiate therapy should start at the lowest functional dose using intermediate release medications (avoid extended release initially). DHHS varies from the other protocols in that it does have a portion that addresses behavioral health therapies that may aid in increased adherence to therapy while also DEPRESSION IN CHRONIC PAIN PATIENTS 9 decreasing risk for a substance use disorder (SUD) (Pain Management Best Practices InterAgency Task Force, 2019). DHHS encourages that providers ensure patients are getting appropriate treatment for their chronic pain as well as any behavioral health needs in order to reduce occurrence of medication misuse, opioid use disorder, and overdose (Pain Management Best Practices Inter-Agency Task Force, 2019). The review of literature supports that mental health conditions contribute to the challenge of managing chronic pain, but current guidelines lack specific recommendations of how this is accomplished. Depression Screening for and identifying depression in chronic pain patients can lead to the provision of additional and more appropriate adjuvant treatment, which may have implications for the success or otherwise of treatment directed specifically at the pain (Poole H et al., 2009). Standardizing the use of PHQ-9 during chronic pain visits did improve adherence to guidelines and led to an increase from 10% to 23.1% in mental health referrals (Spatar, 2019). The benefits associated with identification of depression in chronic pain patients should not be overlooked and underscore the importance of clear guidelines aimed at effectively screening for depression in chronic pain patients. The importance of screening and managing depression not being included in the pain treatment guidelines is creating a potential gap in care for the chronic pain population. Depression Screening Tools There are several tools available for providers to utilize when screening for depression. Depression screening tools commonly used include the World Health Organization- 5 Well Being Index (WHO-5), Patient Health Questionnaire-2 (PHQ-2), Patient Health Questionnaire-9 DEPRESSION IN CHRONIC PAIN PATIENTS 10 (PHQ-9), and Beck Depression Inventory for Primary Care. According to the US Preventive Services Task Force (USPSTF) (2014), there is very little evidence that one screening tool is superior to another and they suggest using the most practical tool. In terms of sensitivity and specificity, the WHO-5 has a 57.1% sensitivity and 82.5% specificity, the PHQ-2 has 97% sensitivity and 67% specificity, and the PHQ-9 has 61% sensitivity and 94% specificity (Furuya et al., 2013). Considering the sensitivity and specificity ratings, the Beck Depression Inventory for Primary Care is the most reliable, with a 97% sensitivity and 99% specificity (Williams & Nieuwsma, 2020). Despite its reliability, the Beck Depression is only available through a licensing agreement which requires a fee, creating a potential barrier. As a result, the PHQ-9 is widely known in the medical community and is used frequently in assessing people for depression symptoms. It has been shown to successfully identify patients with depression and can also be a good manner to reassess success of treatments for depression (Foss, 2020). Typically, when the PHQ-2 is positive, patients will also then fill out the PHQ-9 (Williams & Nieuwsma, 2020). Additionally, patients who were screened for depression using PHQ-9 had more diagnoses of depression than those that used “self-reporting” (Haefner et al., 2017). These tools have proven to be valid and can be effectively incorporated into routine practice when treating chronic pain patients. Purpose of the Project The purpose of this project was to understand current practices among Utah chronic pain clinics relative to screening and management of depression. The goal was to identify gaps DEPRESSION IN CHRONIC PAIN PATIENTS 11 in current practice and chronic pain treatment guidelines regarding depression screening and management. Theoretical Framework The theoretical framework used for this project was the Star Model of Knowledge Transformation as it best reflects the goal for this project. The Star Model is a five-step process: 1) discovery research, 2) evidence summary, 3) translation into guidelines, 4) practice integration, and 5) process, outcome evaluation. The model depicts the stages of knowledge transformation that is then incorporated into practice. This model has been utilized in various aspects of clinical care to optimize management or continuously enhance patient care. Considering that the purpose of this study was to evaluate current practices and the introduction of consistent guidelines, it aims at discovery research and practice integration. The information discovered in this research could lead to a more in-depth look into the gaps with current pain management guidelines regarding comorbid depression. New evidence could lead to refined guidelines that would be placed into practice and ultimately lead to better outcomes for patients with comorbid depression and chronic pain. Figure 1 is a depiction of the STAR Model described above retrieved from The Impact of Evidence-Based Practice in Nursing and the Next Big Ideas (Stevens, 2013). DEPRESSION IN CHRONIC PAIN PATIENTS Figure 1 Objectives The first objective for this project was to Identify which, if any, chronic pain guidelines are being utilized by providers working in chronic pain clinics. Then create a questionnaire for participants to evaluate their current practices regarding depression screening and management in chronic pain patients. The questionnaire was created after reviewing the 12 DEPRESSION IN CHRONIC PAIN PATIENTS 13 current literature regarding pain guidelines and current suggestions for depression in pain management. Prior to distribution, the questionnaire was reviewed by 4 current chronic pain clinic providers for feedback. The second objective was to identify how screening for and managing depression is being completed in these participants’ practice. The third objective was to evaluate where providers are referring their patients. Objectives, implantation, and evaluation of the project is summarized in Figure 2. Figure 2 Objectives Implementation Evaluation 1) Identify chronic pain guidelines are being utilized by providers working in Utah chronic pain clinics. Questionnaire was developed to evaluate what chronic pain guidelines providers are using in clinic. Questionnaire was distributed to chronic pain providers throughout Utah. Data collected was analyzed to determine what chronic pain guidelines are currently being utilized by Utah chronic pain providers. 2) Identify what, if any, screening tools are being used to assess for and manage depression in Utah’s chronic pain clinics Questionnaire was developed to evaluate if they were being screened for depression, if so, what screening tools providers used in their chronic pain patients. Data collected was analyzed to determine depression screening tools currently being utilized by Utah Chronic Pain providers. DEPRESSION IN CHRONIC PAIN PATIENTS 3) Identify what the current referral practices are for clinicians screening for depression. Surveyed pain providers referral practices regarding depression in chronic pain patients. 14 Data collected was analyzed to determine the referral practices currently being completed by Utah Pain providers. Implementation An internet search, using the Google search engine, was made to identify pain clinics in Utah. The search provided a total of 27 pain clinics throughout Utah. The number of pain providers in Utah was difficult to quantify because not all providers were listed with the clinic information on the websites. Evaluation of chronic pain clinic websites that did list their providers amounted to a count of 39 providers. That is not conclusive of all providers in Utah seeing that multiple clinics did not display their providers. The search also found that many pain providers practice in multiple pain clinics in the state creating a barrier to getting a definite count of pain providers. The clinic managers were contacted over a 4-week period via phone calls to request participation in the study. They were asked to distribute the email containing information on the questionnaire, with the link to the questionnaire and consent form attached. If there was no response 3 days after contacting clinic managers and providers, another call and/or email was sent again to request participation. This process was repeated 3 days later if no response had been received. DEPRESSION IN CHRONIC PAIN PATIENTS 15 Responses were received from 4 clinic managers. 4 email addresses were received from the clinic receptionists, with no direct contact or response from clinic managers. Providers, including physicians, nurse practitioners, and physicians’ assistants, currently caring for patients in chronic pain clinics in the state of Utah were asked to complete the questionnaire (appendix A). The questionnaire was distributed via email describing the purpose of the study and the consent form that was attached to the email. While providers that completed the questionnaire gave informed consent- none signed the informed consent form provided to them and discussed in the emails that contained the questionnaire information. The email included the link to the questionnaire created using Qualtrics free survey feature. The Qualtrics feature collected all the questionnaire responses with no identifying factors of participants. The feature also allowed for a breakdown of the answers for each question. After 4 weeks working to connect with clinic managers and providers in the 27 clinics, 12 completed surveys. Figure 3 illustrates the sample group. Figure 3 DEPRESSION IN CHRONIC PAIN PATIENTS 16 Results The responses from the 12 participants are summarized in Appendix B, the following is a breakdown of those responses. Ten participants answered “yes” to currently working in pain management, making the yes 83.3%, and two participants omitted the answer. Of the 12, 10 (83.3%) of the zip codes provided were in Salt Lake County (Murray, West Jordan, Holladay, West Valley, South Jordan, and Salt Lake City). The other response (8.3%) was in St. George, Washington County, and 1 (8.33%) did not answer. Figure 4 shows the zip codes received in the questionnaires. Figure 4 DEPRESSION IN CHRONIC PAIN PATIENTS 17 Most of the responses indicated that the providers worked in pain management between 1 and 10 years (83.75%). There was 1 response each for less than one year and greater than 10 years (both 8.33%) (see figure 5). Figure 5 91.67 % of the participants reported using guidelines, while 8.33% reported they did not follow any current guidelines. The questionnaire allowed for a “select all that apply” regarding what guidelines were being used in practices. 25% of participants were using a combination of CDC and DHHS guidelines, 25% are using a combination of CDC, DHHS and AAPM, 16.67% were using a combination of CDC, DHHS, AAPM, and ASA guidelines, 16.67% were following only the CDC guidelines, 8.33% reported using only ASA guidelines, and 8.33% are using only DHHS DEPRESSION IN CHRONIC PAIN PATIENTS 18 guidelines. No participants reported using AAFP Guidelines. Figure 6 illustrated the responses to guidelines used. Figure 6 Of the participants, 83.33% are currently screening their patients for depression while 16.67% are not. Half (50%) of the participants that are screening for depression do so at every visit/appointment. 41.67% are doing screenings monthly, and 8.33% are only completing screenings at an initial visit. 75% of the participants screening for depression are using the PHQ9, 8.33% using PHQ-2, 8.33% using WHO-5, and 8.33% selected “other”- without additional information regarding what guideline was being used. Data regarding management and referral practices included 83.33% of the study participants reported referring the patient to another provider/clinic, 8.33% reported they DEPRESSION IN CHRONIC PAIN PATIENTS 19 would treat the depression, and 8.33% reported that treatment or referral was dependent on the severity of the depression. The vast majority, 75% of the providers, that reported they would refer the patient for depression treatment would refer to the patient’s primary care, while 25% would refer the patient to a therapist (LCSW, LMFT). In addition to evaluating the data regarding screening and management of depression referral practices were also evaluated. Participants were asked “what would lead you to refer your patients out for depression?”. This question was displayed as “select all that apply”. 66.67% of providers reported they would refer the patient if they presented with a positive depression screen, verbalized feelings of depression, thoughts of self-harm, thoughts of suicidal ideation or homicidal ideation, and/or if they exhibited symptoms of depression. 8.33% reported they would refer due to a positive depression screen only. 8.33% would refer for verbalized thoughts of self-harm, SI, and or HI. 8.33% would refer for a positive depression screen, verbalized feelings of depression, self-harm SI, and or HI. 8.33% would refer for verbalized feelings of depression only. See figure 7. Figure 7 DEPRESSION IN CHRONIC PAIN PATIENTS 20 Respondents were allowed to answer the following question, “Please provide any thoughts/comments/concerns regarding concurrent depression in chronic pain patients “. The responses identified that caring for patients with concurrent depression and chronic pain is inevitable. They also placed importance of prioritizing chronic pain patients in need of care for their depression and suggested providing these services within pain clinics. Discussion The responses from chronic pain providers indicate that that they are overwhelmingly aware of the published guidelines for the management of chronic pain and are currently utilizing them into their patient care plans. Most of the participants are referring to the common guidelines, screening patients, and providing referrals when needed, either to their primary care physician or to a licensed therapist. However, it is unclear what elements of these guidelines they are choosing to incorporate into their care and when exactly they are choosing to refer. The limitations to this study include lack of responses from clinic managers responses DEPRESSION IN CHRONIC PAIN PATIENTS 21 to the outreach email, having a small number of participants, not all questions being answered, and lack of diversity in the convenience sample of participants as most of the providers were in Salt Lake County. Using Qualtrics was an easy process and made the quiz easily accessible. However, it was difficult to complete any correspondence with clinic managers and providers. Despite multiple attempts. There was difficulty in identifying participants seeing that no identifying factors were requested nor given. Lastly, while all participants were given the consent form in the same email that contained the link to the questionnaire, no participants returned these forms. Implied consent is present as they were given a description of the project and informed that all identifying factors were kept private and secure. Future considerations gained from this project are providing all participants with identifying factors that would allow for anonymity and allow for further correspondence with the participants. The results of this project could be a base to further evaluating guidelines mentioned and identifying if changes to them regarding depression evaluation and implementation could lead to universal practices amongst pain management providers. If the guidelines were edited to include more in-depth, descriptive information on depression assessment and management in chronic pain patients, providers could have a more defined plan of care for depression in their chronic pain patients. This project could also lead to research into identifying if improved patient outcomes are seen with more specified guidelines in chronic pain when addressing depression in this population. Conclusion DEPRESSION IN CHRONIC PAIN PATIENTS 22 Chronic pain and depression are prevalent conditions that cooccur and affect each other. The review of the chronic pain guidelines identified that depression is inconsistently addressed, leaving the providers with little guidance into what best practices would be with these patients. The results of this project found that while most providers that participated did follow chronic pain guidelines, their approach to addressing depression in chronic pain patients varied. Further research should be done to identify what best practices would be in screening and managing comorbid depression in patients managed in chronic pain clinics. DEPRESSION IN CHRONIC PAIN PATIENTS 23 References Bernard, S. A., Chelminski, P. R., Ives, T. J., & Ranapurwala, S. I. 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Furuya, M., Hayashino, Y., Tsujii, S., Ishii, H., & Fukuhara, S. (2013). Comparative validity of the WHO-5 Well-Being Index and two-question instrument for screening depressive symptoms in patients with type 2 diabetes. Acta Diabetologica, 50(2), 117–121. https://doi.org/10.1007/s00592-010-0219-z DEPRESSION IN CHRONIC PAIN PATIENTS 24 Gaskin, D. J., & Richard, P. (2012). The eonomic costs of pain in the united states. The Journal of Pain, 13(8), 715–724. https://doi.org/10.1016/j.jpain.2012.03.009 Haefner, J., Daly, M., & Russell, S. (2017). Assessing depression in the primary care setting. Journal of Doctoral Nursing Practice, 10(1), 28–37. CINAHL with Full Text. https://doi.org/10.1891/2380-9418.10.1.28 Hockenberry, J. M., Joski, P., Yarbrough, C., & Druss, B. G. (2019). Trends in treatment and spending for patients receiving outpatient treatment of depression in the United States, 1998-2015. JAMA Psychiatry, 76(8), 810–817. CINAHL with Full Text. https://doi.org/10.1001/jamapsychiatry.2019.0633 Mancini, G. J. (2017). Challenges and opportunities to change the course of the opioid epidemic: A surgeon’s perspective. Postgraduate Medicine, 129(1), 1–4. https://doi.org/10.1080/00325481.2017.1268901 NIH. (2019, February). Major depression. The National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/major-depression.shtml NIMH. (2021, January). Mental illness. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml Pain Management Best Practices Inter-Agency Task Force. (2019). Pain management best practices. U.S. Department of Health And Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. The Online Journal of Issues in Nursing, 18. https://doi.org/10.3912/OJIN.Vol18No02Man04 DEPRESSION IN CHRONIC PAIN PATIENTS 25 U.S. Department of Health and Human Services. (2021, February). What is the U.S. opioid epidemic? [Text]. HHS.Gov; https://plus.google.com/+HHS. https://www.hhs.gov/opioids/about-the-epidemic/index.html Williams, J., & Nieuwsma, J. (2020, June). Screening for depression in adults. UpToDate. https://www.uptodate.com/contents/screening-for-depression-inadults?search=phq%209&source=search_result&selectedTitle=1~69&usage_type=defau lt&display_rank=1#H278060398 Winerman, L. (2017, March). By the numbers: The cost of treatment. American Psychological Association. https://www.apa.org/monitor/2017/03/numbers DEPRESSION IN CHRONIC PAIN PATIENTS 26 Appendix A The Purpose of this questionnaire is to gather information of current practices in pain clinics in Utah regarding depression in chronic pain patients. 1. Do you currently work in a clinic that specifically manages pain? a. Yes b. No (please do not complete the remainder of the survey) 2. What zip code is your pain practice located in? 3. How many years have you been working in chronic pain management? a. Less than 1 year b. 1-5 years c. 6-10 years d. Over 10 years 4. Do you or your practice currently follow any published pain management guidelines? a. Yes b. No 5. Which published pain management guideline/s do you currently follow: a. Centers for Disease Control and Prevention (CDC) b. The U.S. Department of Human and Health Services (DHHS) c. American Academy of Pain Management (AAPM) d. American Society of Anesthesiologists (ASA) e. American Academy of Family Physicians (AAPA) f. Other DEPRESSION IN CHRONIC PAIN PATIENTS 27 g. Not applicable 6. In your current pain management clinic do you screen patients for depression? a. Yes b. No 7. How often are you screening patients for depression? a. Only at initial visit b. At every appointment c. Once a month d. Once a year e. Other f. Not applicable 8. Which depression screening tool do you currently use? a. Patient self-reporting symptoms b. PHQ-2 c. PHQ-9 d. WHO-5 e. Beck Depression Inventory for Primary Care f. Other g. Not applicable 9. If a patient has a positive depression screen, do you manage their depression or refer them to another provider/setting? DEPRESSION IN CHRONIC PAIN PATIENTS 28 a. Manage their depression b. Refer them to other health care provider/clinic c. It depends on the severity of their depression 10. If you refer your patients out for their depression, where do you refer them to? a. Primary care b. Therapist (LCSW, LMFT) c. Psychiatry/Mental Health Provider 11. What would lead you to refer your patients out for their depression? a. Positive depression screen b. Patient verbalizing feelings of depression c. Patient verbalizing suicidal/homicidal ideation d. Patient reporting thoughts of self-harm e. Patient reporting symptoms consistent with a diagnosis of depression (fatigue, sleep disturbance, changes in weight/appetite, etc.) 12. Please provide any thoughts/comments/concerns regarding concurrent depression in chronic pain patients. 13. If you would like to receive aggregate results of this survey, please provide an email here. The link to the Qualtrics survey is as follows: https://qfreeaccountssjc1.az1.qualtrics.com/jfe/form/SV_d9UrOOfmSHloMaG DEPRESSION IN CHRONIC PAIN PATIENTS 29 Appendix B Table 1 Questions Answers Q1 - Do you currently work in a clinic that specifically manages pain? Yes 10/12 (83.3%) No 0/12 (0%) No response 2/12 (16.67%) Less than 1 year 1/11 (8.33%) 1-5 years 5/11 (41.67%) 6-10 years 5/11 (41.67%) Over 10 years 1/11 (8.33%) Q4 - Do you or your practice currently follow any published pain management guidelines? Yes 11/12 (91.67%) No 1/12 (8.33%) Q5 - Which published pain management guideline/s do you currently follow? (select all that apply) CDC 10/12 DHHS 8/12 AAPM 5/12 ASA 3/12 AAFP 0/12 Other 0/12 N/A 0/12 Q3 - How many years have you been working in chronic pain management? Results DEPRESSION IN CHRONIC PAIN PATIENTS 30 Q6 - In your current pain management clinic do you screen patients for depression? Yes 10/12 (83.3%) No 2/12 (16.67%) Q7 - How often are you screening patients for depression? Only at initial visit 1/12 (8.33%) Once a year 0/12 (0%) Once a month 5/12 (41.67%) At every appointment 6/12 (50%) Other 0/12 (0%) Patient self-reporting sx 0/12 (0%) PHQ-2 1/12 (8.33%) PHQ-9 9/12 (75%) WHO-5 1/12 (8.33%) Beck Depression Inventory 0/12 (0%) Other 1/12 (8.33%) Q9 - If a patient has a positive depression screen, do you manage their depression or refer them to another provider/setting? Manage their depression 1/12 (8.33%) Refer to another clinic 10/12 (83.33%) Depends on severity 1/12 (8.33%) Q10 - If you refer your patients out for their depression, where do you refer them to? Primary care 9/12 (75%) Therapist (LCSW, LMFT) 3/12 (25%) Q8 - Which depression screening tool do you currently use? 0/12 (0%) DEPRESSION IN CHRONIC PAIN PATIENTS 31 Psychiatry/Mental health provider Q11 - What would lead you to refer your patients out for depression? (select all that apply) Verbalize feelings depression 10/12 Verbalize SI/HI 10/12 Thoughts of self-harm 10/12 Positive depression screen 10/12 Patient reporting symptoms 8/12 of depression Depression in Chronic Pain Patients Understanding Current Practices Carina Chacon, MSN, APRN, FNP-C, DNP candidate Background • Mental illness has become increasingly prevalent in society affecting one in five adults (NIMH, 2021). • Chronic pain impacts about 20.4% of the adult population in the United States (approximately 50 million people) (Dahlhamer, 2018). • Patients with chronic pain are four times more likely to develop anxiety and depression (Cosio & Meshreki, 2017). Problem Statement • Chronic pain and depression both pose a substantial social and economic burden on society. • The cost associated with chronic pain was between $560-$635 billion in 2010 (Gaskin & Richard, 2012). • $187.8 billion was spent on mental health and substance abuse disorders in 2013 (Winerman, 2017). • Chronic pain and depression are found to exacerbate one another and share biological pathways and neurotransmitters (Cosio & Meshreki, 2017). History of Pain Management •Bernard et al., (2018) •Florine, (2017) •Mancini, (2017) The Opioid Epidemic Review of Literature •Florine, (2017) •Mancini, (2017) •U.S. Department of Health and Human Services, (2021) Pain Management Guidelines •AAFP, (2021) •AAPM, (2020) •CDC, (2016) •DEA, (2015) •DHHS, (2019) •Dydyk et al., (2021) •Pain Management Best Practices Inter-Agency Task Force, (2019) Depression Screening Tools •Foss, (2020) •Furuya et al., (2013) •Haefner et al., (2017) •Siu & US Preventative Services Task Force, (2016) •Williams &Nieuwsma, (2020) Benefits of Screening for Depression •Poole H et al., (2009) •Spatar, (2019) Purpose Statement The purpose of this project is to understand current practices among Utah chronic pain clinics relative to screening and management of depression. The goal was to identify gaps in current practice and chronic pain treatment guidelines regarding depression screening and management. Theoretical Framework Objectives Objectives Implementation Questionnaire was developed to 1- Identify chronic pain evaluate what chronic pain guidelines guidelines are being utilized by providers are using in clinic. providers working in Utah Questionnaire was distributed to chronic pain clinics. chronic pain providers throughout Utah. 2-Identify if depression is being screened and which screening tools are being used to assess for depression in Utah’s chronic pain clinics. 3- Identify what the current referral practices are for clinicians screening for depression. Questionnaire was developed to evaluate if they were being screened for depression, if so, what screening tools providers used in their chronic pain patients. Surveyed pain providers referral practices regarding depression in chronic pain patients. Evaluation Data collected was analyzed to determine what chronic pain guidelines are currently being utilized by Utah chronic pain providers. Data collected was analyzed to determine depression screening tools currently being utilized by Utah Chronic Pain providers. Data collected was analyzed to determine the referral practices currently being completed by Utah Pain providers. Results Sample size 27 Pain Clinics About 35 providers 8 Clinic Managers • 4 direct contact • 4 email only 12 Responses From providers Results • 83.3% worked in Salt Lake County, 8.3% in Washington county • 1 participant did not provide a zip code. • Most participants have been employed in pain management for 1-10 years 8.33% have been in pain management for greater than 10 years Results • Most providers used a combination of 2 or more guidelines. Results • 83.33% of providers reported they are currently screening their patients • 50% screening at every visit • 41.67% complete monthly screens • 8.33% selected “other” but did not provide a write in answer. Results • Referrals • 83.33% report they refer patients to another clinic for positive depression screens • 75% of providers would refer to primary care • 25% to therapist (LCSW, LMFT). • 8.33% reported a referral was dependent on severity of symptoms. Results • The following are factors that would lead providers to refer their patients due to depression Future Considerations Areas for Improvement Future Implications • Enhanced sample size • Questionnaire distribution and retrieval. • Additional outreach • Evaluating current pain guidelines to incorporate depression screening • Identify gaps in holistic care of chronic pain patients • Expanding current guidelines Conclusion • Chronic pain and depression are prevalent conditions that cooccur and affect each other • Depression is inconsistently addressed in pain management guidelines • The results of this project found that providers follow guidelines, but their management differed. • Need for further research to identify best practices would be in screening and managing comorbid depression in chronic pain References • Cosio, D., & Meshreki, L. (2017). The association between depressive disorder and chronic pain. Practical Pain Managemnet, 17(1). https://www.practicalpainmanagement.com/pain/other/co-morbidities/association-between-depressive-disorder-chronic-pain • Dahlhamer, J. (2018). Prevalence of chronic pain and high-Impact chronic pain among adults. MMWR. Morbidity and Mortality Weekly Report, 67. https://doi.org/10.15585/mmwr.mm6736a2 • Florine, B. L. (2017). The prescription painkiller epidemic: The short history of a rapid evolution. Northwest Dentistry Journal, 96(1), 33–36. • Gaskin, D. J., & Richard, P. (2012). The eonomic costs of pain in the united states. The Journal of Pain, 13(8), 715–724. https://doi.org/10.1016/j.jpain.2012.03.009 • NIMH. (2021, January). Mental illness. National Institute of Mental Health. https://www.nimh.nih.gov/health/statistics/mental-illness.shtml • Pain Management Best Practices Inter-Agency Task Force. (2019). Pain management best practices. U.S. Department of Health And Human Services. https://www.hhs.gov/sites/default/files/pmtf-final-report-2019-05-23.pdf • Stevens, K. (2013). The impact of evidence-based practice in nursing and the next big ideas. The Online Journal of Issues in Nursing, 18. https://doi.org/10.3912/OJIN.Vol18No02Man04 • Winerman, L. (2017, March). By the numbers: The cost of treatment. American Psychological Association. https://www.apa.org/monitor/2017/03/numbers APPROVAL of a thesis/project submitted by Author(s): Carina Chacon School Department: DNP Title of Thesis: Depression in Chronic Pain Patients: Understanding Current Practices The above named master's thesis/project has been read by each member of the supervisory committee and has been found to be satisfactory regarding content, English usage, format, citations, bibliographic style, and consistency, and is ready to be deposited and displayed in the Westminster College—Institutional Repository. Chairperson, Supervisory Committee: Julie Balk, DNP Approved On 10/12/2021 11:00:53 AM Dean, School: Sheryl Steadman Ph.D Approved On 2/17/2023 8:20:22 AM STATEMENT OF PERMISSION TO DEPOSIT & DISPLAY THESIS IN THE INSTITUTIONAL REPOSITORY Name of Author(s): Carina Chacon School Department: DNP Title of Thesis: Depression in Chronic Pain Patients: Understanding Current Practices With permission from the author(s), the staff of the Giovale Library of Westminster College has the right to deposit and display an electronic copy of the above named thesis in its Institutional Repository for educational purposes only. I hereby give my permission to the staff of the Giovale Library of Westminster College to deposit and display as described the above named thesis. I retain ownership rights to my work, including the right to use it in future works such as articles or a book. Submitted by the Author(s) on 10/10/2021 3:29:50 PM The above duplication and deposit rights may be terminated by the author(s) at any time by notifying the Director of the Giovale Library in writing that permission is withdrawn.