What Is the Relationship Between Depressive Symptoms and Pain During Functional Tasks in Persons Undergoing TKA? A 6-year Perioperative Cohort Study.

BACKGROUND: Preoperative depressive symptoms have been shown in some but not all studies to be associated with poor self-reported pain and function outcomes. In addition, depressive symptoms after surgery have been shown to improve relative to preoperative levels. QUESTIONS/PURPOSES: We hypothesized that (1) preoperative depressive symptoms would predict postoperative pain; (2) depressive symptoms would decrease after surgery; and (3) preoperative depressive symptoms would increase as the scheduled surgery date approached. METHODS: Data from the Osteoarthritis Initiative, a National Institutes of Health-funded prospective multiyear cohort study, were used in this retrospective analysis. Persons from four communities were eligible if they had radiographic knee osteoarthritis or were at risk for developing knee osteoarthritis based on occupational, medical history, or body weight risk factors. A total of 4796 persons participated and rates of followup were 80% or greater over the course of the study. Participants completed a validated depressive symptom scale and the Knee Injury and Osteoarthritis Outcome Scale pain scale each year for 3 years before and 3 years after TKA. Latent growth curve modeling was used to model intercepts and slopes of pre- and postoperative depression and pain. Preoperative trajectories and intercepts were then used to predict postoperative pain and depressive symptoms adjusting for confounding variables. RESULTS: After adjustment for potential confounding, we found no evidence that preoperative depressive symptoms predicted postoperative pain with function (estimate, 0.1; 95% confidence interval, -0.31 to 0.50; p = 0.64) or that depressive symptoms were reduced after surgery (z = 0.06, p = 0.80). We also found no evidence to indicate that preoperative depressive symptoms increased as the date of surgery approached (linear slope = 0.28, SE = 0.19, p = 0.15). CONCLUSIONS: Preoperative and postoperative depressive symptoms in patients before and after TKA did not appreciably change over a 6-year perioperative period. Patient depressive symptoms were not reduced after surgery and did not appear to be related to less pain postoperatively. Our findings of no association between preoperative depressive symptom severity and postoperative pain and no reduction in postoperative depressive symptoms run counter to other available evidence, potentially attributable, in part, to a data collection process that occurred outside of orthopaedic surgeons' offices. Future research is needed to more fully explore the potential role of social desirability, the concept that patients respond in a way that they think the researcher or clinician wants them to respond in lieu of responding in a way that truly reflects the patient's status. Social desirability may influence a TKA patient's pain and function outcome assessment. LEVEL OF EVIDENCE: Level I, prognostic study.

Effectiveness of abbreviated CBT for insomnia in psychiatric outpatients: sleep and depression outcomes.

OBJECTIVE: To test the efficacy of cogntive-behavioral therapy for insomnia (CBT-I) as a supplement treatment for psychiatric outpatients. Comorbid insomnia is prevalent among individuals with varied psychiatric disorders and evidence indicates that CBT-I may be effective for reducing insomnia and other psychiatric symptoms. METHOD: The present study randomly assigned 30 psychiatric outpatients (mean duration of treatment = 3.6 years) with low sleep quality and residual depressive symptoms to two sessions of CBT-I or a treatment as usual control group. Assessment included the Pittsburgh Sleep Quality Index (PSQI) for insomnia and the Patient Health Questionnaire (PHQ-9) for depression at pretreatment and 4 and 8 weeks posttreatment. RESULTS: Patients who received CBT-I demonstrated within group changes in PSQI and the PHQ-9 scores at both 4 and 8 weeks posttreatment, but did not show between-group differences. Additionally, 38% of the treatment participants achieved normal sleep at follow-up compared with none in the control condition. CONCLUSIONS: This study provides preliminary evidence that abbreviated behavioral treatment has beneficial effects on residual insomnia and depression in long-term psychiatric outpatients.

Pain coping skills training for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty: a quasi-experimental study.

OBJECTIVES: To (1) describe a behavioral intervention designed for patients with elevated pain catastrophizing who are scheduled for knee arthroplasty, and (2) use a quasi-experimental design to evaluate the potential efficacy of the intervention on pain severity, catastrophizing cognitions, and disability. DESIGN: Quasi-experimental nonequivalent control group design with a 2-month follow-up. SETTING: Two university-based orthopedic surgery departments. PARTICIPANTS: Adults (N=63) scheduled for knee replacement surgery who reported elevated levels of pain catastrophizing. Patients were recruited from 2 clinics and were assessed prior to surgery and 2 months after surgery. INTERVENTIONS: A group of 18 patients received a psychologist-directed pain coping skills training intervention comprising 8 sessions. The other group, a historical cohort of 45 patients, received usual care. MAIN OUTCOME MEASURES: Western Ontario and McMaster Universities Arthritis Index Pain and Disability scores, as well as scores on the Pain Catastrophizing Scale. RESULTS: Two months after surgery, the patients who received pain coping skills training reported significantly greater reductions in pain severity and catastrophizing, and greater improvements in function as compared to the usual care cohort. CONCLUSIONS: Pain catastrophizing is known to increase risk of poor outcome after knee arthroplasty. The findings provide preliminary evidence that the treatment may be highly efficacious for reducing pain, catastrophizing, and disability, in patients reporting elevated catastrophizing prior to knee arthroplasty. A randomized controlled trial is warranted to confirm these effects.

Electronic source materials in clinical research: acceptability and validity of symptom self-rating in major depressive disorder.

OBJECTIVES: Clinical research projects gather large amounts of data. Typically, information is captured on paper source documents for later transcription to an electronic format, where responses can be checked, and errors, omissions, and inconsistencies can be resolved. These steps contribute delays, cost, and complexity to clinical research, particularly in large-scale multi-site investigations. To address these issues, we used a mobile computing device with a touch-screen display ("tablet PC") to capture clinical data from depressed patients directly into electronic format. We then examined ease of use, the equivalence of responses between paper and electronic methods, and the acceptability of the tablet PC for this clinical population. SETTINGS: Outpatient clinics at four medical centers. METHODS: 80 adults with major depressive disorder (MDD) completed the 16-item Quick Inventory of Depressive Symptomatology--Self-Rated (QIDS-SR(16)), using both traditional paper forms and an electronic representation of the same questions; participants also completed a survey to evaluate their experience. RESULTS: QIDS-SR(16) responses from paper and electronic versions were highly correlated (mean total: 15.3 (SD=5.2) electronic vs. 15.1 (SD=5.2) paper format), and showed high inter-rating reliability for overall score (intra-class correlation 0.987 (with a 95%CI [0.979,0.992])) and high degree of association for individual symptom items. Participants found both methods acceptable and overall found the electronic implementation easier to use. CONCLUSIONS: QIDS-SR(16) values collected electronically from research participants were equivalent to those collected using traditional paper self-assessment forms. Participants with MDD found the tablet PC version to be acceptable and easier to use than the paper forms.

Development of an abbreviated Social Phobia and Anxiety Inventory (SPAI) using item response theory: the SPAI-23.

An abbreviated version of the Social Phobia and Anxiety Inventory (SPAI) was developed using methods based in nonparametric item response theory. Participants included a nonclinical sample of 1,482 undergraduates (52% female, mean age = 19.4 years) as well as a clinical sample of 105 individuals (56% female, mean age = 36.4 years) diagnosed with either generalized (73%) or specific social phobia (27%). Twenty-three of the 45 SPAI items demonstrated good discrimination along the social anxiety continuum. In addition, option characteristic curves (OCCs) indicated that the SPAI's 7-point scale may generate errors in ranking individuals. Thus, options were collapsed to improve item performance. No gender differences emerged between any of the items' OCCs, suggesting that items function similarly among men and women. The abbreviated version also correlated highly with the original 45-item SPAI and exhibited similar patterns of correlations with measures of social anxiety. The SPAI-23 has considerable practical benefits, including a screening of both social and agoraphobic anxiety as well as decreased assessment and scoring time.

Attentional bias to threat and emotional response to biological challenge.

Attentional bias towards threat reliably correlates with clinical anxiety status as well as elevated trait anxiety. Although such findings have led many to posit a potential causative or predictive role of threat-biased attentional processes on anxiety problems, little informative research exists. The present investigation was designed to address the role of threat-biased attentional processes on emotional/fearful responding. Eighty-seven participants provided baseline measures of anxiety vulnerability (i.e., anxiety sensitivity; unmasked/masked emotional Stroop task indices) and then underwent biological challenge procedures (inhalations of 20% carbon dioxide (CO2)-enriched air). Following challenge, participants completed measures of emotional response. Regression analyses indicated that both unmasked and masked attentional bias indices significantly predicted emotional responding above and beyond anxiety sensitivity. Exploratory analyses also revealed a gender effect, with prediction of emotional response largely attributable to females. These findings support attentional bias towards threat as a relatively independent factor predictive of emotional responding.