Pain perception: Personality goes a long way

Medical Tribune July 2009 P12

David Brill

Personality has a major influence on the way people perceive headaches, and should be considered when assessing patients, say Italian researchers.

In a recent study they found that ‘emotionally overwhelmed’ people report a greater affective dimension to their pain than those with other personality types, yet score the same on a simple measure of pain intensity.

The other personality types – conversive, depressive and copers – did not differ significantly in their perception of pain.

The findings should encourage physicians to routinely consider a patient’s personality and emotions before simply prescribing medications, said lead researcher Professor Franco Mongini, of the Headache and Facial Pain Unit at the University of Turin.

Moreover, presentation with a headache or migraine could be a warning sign of an underlying personality disorder or mental health problem, he said, adding that early recognition could facilitate referral to a specialist before the pain gets worse.

“I keep seeing patients with chronic migraine and chronic tension-type headache together, and they have been receiving new drugs. But very often the patient’s personality and the consequences of this personality have not been considered,” said Mongini, who typically questions new patients on their history of phobias, panic attacks and sleep disturbances, among others, before considering whether to treat with cognitive behavioral therapy.

“I’m convinced after years and years of work that the approach to the problem of chronic head pain should be remodeled and widened. I’m not saying that drugs should not be prescribed – I prescribe a lot of medications myself – but other factors should be considered and treated also with non-pharmacological methods,” he said.

Mongini and colleagues assessed 317 patients with migraine and/or tension-type headache with myogenic facial pain. They performed two types of pain assessment: the verbal MacGill Pain Questionnaire (MPQ), which classifies pain in a range of dimensions, and the visual analog scale (VAS), which measures pain intensity alone. [Pain 2009 Jul;144(1-2):125-9]

Personalities, meanwhile, were classified using 10 scales of the Minnesota Multiphasic Personality Inventory (MMPI). ‘Copers’ score normally across all domains, whereas ‘depressive’ and ‘conversive’ personalities show various elevation in scores of depression, hypochondria and hysteria. The ‘emotionally overwhelmed’ personality has elevation in all three of these scores, plus one other MMPI dimension.

The affective dimension of the MPQ was significantly higher in emotionally overwhelmed than in coper (P=0.003), depressive (P=0.027) and conversive (P=0.002) people, regardless of sex, age and type of pain. VAS score did not vary significantly between groups.

Mongini and colleagues also recently reported on a successful intervention to reduce head and neck pain in the office place. A combined educational and physical program reduced the frequency of headaches by 41 percent and the use of analgesics by 50 percent, when tested in a study of 384 civil servants in Turin. [Cephalalgia 2008 May;28(5):541-52]

Simple strategy effective in postpartum depression screening

Medical Tribune February 2009 P16
David Brill

Combining two existing screening tools could be a straightforward, time-saving and effective way to detect postpartum depression (PPD) in primary care, US research has shown.

The first screening stage, comprising two simple yes/no questions, was 100 percent sensitive at detecting PPD, according to the Annals of Family Medicine study. [2009; 7:63-70]

Patients with a positive result on the two-question screen should then progress onto the nine-item Patient Questionnaire (PHQ-9), say the University of Minnesota researchers, who report that this second stage was 92 percent specific. They tested the two-tiered strategy in 506 women who brought their newborn infants for well-child visits at pediatric and family medicine clinics over the course of 9 months.

The screening tools have already been incorporated into routine practice at several Minnesota clinics and are soon to be implemented in three large hospitals, according to Dr. Dwenda Gjerdingen, who led the study.

“We find them easy to administer, patients find them easy to complete, and they give us a good sense of where the patient is at in terms of their mental health,” she said.

“You want your initial screen to be highly sensitive, which this one is: the two-question screen does not miss depressed patients. Then the PHQ-9 is a very specific test so when depressed people complete it and it turns out to be positive, it is likely to be a true positive and not a false positive.”

The two-question screen focuses on the main symptoms of depression: diminished mood and loss of pleasure in activities.

Despite the common nature of PPD – the condition affects around 22 percent of new mothers and is the most common complication of childbirth – less than half of mothers are presently being screened, the authors wrote. The condition not only affects the mother’s wellbeing but can also harm the cognitive development of the infant. [Arch Womens Ment Health 2003 Nov;6(4):263-74]

The results of the new strategy were validated against the Structured Clinical Interview from the Diagnostic and Statistical Manual of Mental Disorders (DSM)-IV. Forty-five (8.9 percent) of the women were found to have major depression.

Gjerdingen noted that the PHQ-9 still missed a few depressed patients, so suspicion should be retained in those who achieve a negative result having scored positively on the initial two-question screen. These women should be advised to see their doctor if they experience a dip in mood, she said.

Both the two-question screen and the PHQ-9 are already used in general depression but had yet to be validated in PPD. Other potential screening options for PPD are available but typically take longer to complete, Gjerdingen said.

Voluntary counseling could help doctors avoid burnout

Medical Tribune January 2009 P5
David Brill

Short counseling sessions can reduce burnout among doctors and encourage them to make positive changes to their working lives, a new study suggests.

Doctors who volunteered for an intervention program in Norway reported lower levels of emotional exhaustion, worked fewer hours per week and were less likely to be on full-time sick leave a year later.

They were also more likely to seek further professional help, with 53 percent having undergone psychotherapy at 1-year follow-up compared to just 20 percent at the time of enrollment.

Many had already reached high levels of distress and had considered attending the program for quite some time before actually doing so, according to Dr. Karin Rø of the University of Oslo, who led the study.

“The program legitimizes the need for doctors to take a step back for a while and think about their situation,” she said.

“A lot have come back to me and said that it was really important at that time in their life to have somebody to talk to, to get a different perspective on their own situation. Giving a little help, in time, is much better than having to give a lot of help when the situation is much worse.”

Volunteers at Villa Sana – the only center of its kind in Norway – chose between a single one-on-one counseling session of around 6 hours, or a week-long course involving daily lectures followed by group discussions. All sessions were confidential and no medical records were kept. A total of 227 doctors were included in the study, 185 of whom completed 1-year follow-up questionnaires. [BMJ 2008 Nov 11;337:a2004]

Dr. Sim Kang, a consultant psychiatrist at the Institute of Mental Health, Singapore, hailed the research as an important reminder of a timely issue.

“The healthcare profession is certainly susceptible to the onset of burnout if one is not careful about it. The demands of the job are changing and the expectations are quite high from the public nowadays,” he said.

“The symptoms of burnout encroach not just upon the sense of physical tiredness but also the sense that one is mentally wearied and emotionally drained. The message is that if prevention isn’t working and things are getting out of hand then they should seek help.”

Another BMJ study published this year reported that depressed pediatric residents made six times as many medication errors per month as non-depressed residents. [2008 Mar 1;336(7642):488-91]

Rø pointed to this finding as evidence that doctors need to take care of their own wellbeing in order to take care of others.

“When you fly on a plane and the oxygen masks come down you’re supposed to put your own one on before you help anyone who needs it. I think that’s a very good picture of doctors,” she said, adding that she hopes the study will prompt the creation of other similar centers in future.

A year on from the intervention the participants had reduced their mean working hours by an average of 1.6 hours per week. Just 6 percent were on full time sick leave, compared to 35 percent at baseline.

High rates of depression and suicide have been well documented among doctors. A recent study of Brazilian medical students found that as many as 38.1 percent had depressive symptoms, with females particularly susceptible. [BMC Medical Education, in press]

Rø noted that the Norwegian counseling intervention helped the doctors to normalize their situation, having previously felt that they were the only ones experiencing such feelings of distress. They often fail to seek help because they are used to focusing solely on the needs of their patients and do not realize when they are in need of help themselves, she said.

The exact prevalence of depression among the medical community in Asia is largely unknown.

However, Sim encouraged doctors to discuss their feelings of stress and anxiety in informal support groups with their peers whenever possible, adding that he would like to see longer-term data on the sustainability and generalizability of the Norwegian model before advocating the adoption of more formal, structured programs.



Seven tips for avoiding burnout

Dr. Sim Kang, a consultant psychiatrist at the Institute of Mental Health, Singapore, offers his advice on how to de-stress before it gets too late.

1 – Acknowledge and accept that we are all equally vulnerable and can feel trapped and overwhelmed like anyone else. Medical professionals are not superheroes.

2 – Be willing to communicate with others, particularly through informal networks of colleagues, family and friends.

3 – Clarify your responsibilities within the job and resolve any ambiguities that may be causing additional stress.

4 – Determine your own strengths and weaknesses and play to them.

5 – Educate yourself about the symptoms of burnout.

6 – Find time off to unwind and relax.

7 – Group together with your peers to discuss the difficult issues and identify any problems you may be experiencing.

Chronic disease management: Depression

Medical Tribune November 2008 P14-15

Depression is a serious global health issue. Some 121 million people are affected worldwide, according to 2001 estimates from the WHO, with 1 million committing suicide each year and a further 10 to 20 million attempting to do so.

The prevalence of depression in the general adult population of Singapore is around 5 percent. This figure is lower than in the US but comparable to most developed European countries. The prevalence in developing Asian countries is unclear but is likely to rise, placing an increasing burden on society and healthcare systems.

The WHO, as part of a new program launched on World Mental Health Day 2008, recently called on governments and donors to urgently upscale mental health services and better integrate mental health into primary care. Depression in particular is increasingly treatable, and making an early and effective diagnosis in this setting will lead to considerable improvements in outcome.

Diagnosis

Routine screening for depression is not recommended but should be carried out among those who are at the highest risk. There are several risk factors which GPs should be aware of in order to effectively target these patients.

The presence of multiple medical problems is strongly associated with depression. Chronic but stable conditions such as heart disease, stroke and cancer all place a strain upon patients’ wellbeing, and the coexistence of more than three conditions has been shown to significantly increase depression risk.

The link between depression and diabetes, for example, is well established. Depressed patients often lose the motivation to take their medications, which contributes to a worsening of their diabetes. This can be a two-way process, with the resulting deterioration of blood sugar control affecting the vessels and tissues in the brain, leading to a further worsening of depressive symptoms and an even greater loss of motivation.

GPs should also consider the social factors affecting their patients, as this type of information is invaluable in identifying those who should be screened for depression. Do they live alone? Are they recently divorced or widowed? Is there support from their family? Are they likely to have financial problems?

Once the GP has identified a high-risk patient they can initiate screening with two quick, simple questions: “Have you persistently felt depressed in the last 2 weeks to a month? Have you experienced a loss of interest in your daily activities over this time period?” If the patient answers yes to either of these questions then the physician should move on to try and identify further symptoms. A formal diagnosis can then be established according to the criteria laid out in the relevant guidelines.

There are, however, two major obstacles to initiating this process. The first is shyness on the part of the patient. Asian patients tend to perceive doctors as being primarily concerned with their physical wellbeing and may not expect to discuss mental health issues with them. They are often shy and might find the subject awkward.

Doctors nonetheless have a responsibility to overcome this barrier and broach the subject. This can be done by gradually and tactfully guiding the conversation in the right direction. Ask the patient gently about their mood, how they have been feeling in light of recent problems, and whether there are any other issues they would like to discuss. If they clam up, try not to charge in and pry them open in a single visit. Primary care physicians have the advantage of seeing patients regularly, and introducing the subject in one visit might make it easier to return to at a later date.

The second barrier, however, lies with the doctor, since the process of diagnosing depression can only begin if they are willing to ask these difficult questions. There is sometimes a reluctance to open up Pandora’s Box which, although understandable, needs to be overcome. This fear typically lies in the unknown, so doctors can avoid this by reading around the subject and being prepared for what might follow. Continuing Medical Education courses and workshops are often available to help physicians gain confidence in dealing with these issues, while there is a wide range of useful information available on the internet for further reading (see below).

Once doctors are comfortable with broaching the subject they can also use their intuition to guide them in making an early diagnosis. Depressed patients may seem withdrawn and quieter than usual, or may display a steady deterioration in chronic conditions which were previously well controlled. These signs should all arouse suspicion that the patient is not simply having a bad day and may be in need of help.

Practice Guidelines

Practice guidelines on major depressive disorder are available from the American Psychiatric Association website. The Ministry of Health in Singapore also publishes its own guidelines on depression, most recently in March 2004. These state that a diagnosis can be made when a depressed mood or loss of interest is accompanied by a minimum of four specific symptoms (from a list of eight) over a period of 2 or more weeks.

Depression can be a culturally sensitive issue, and guidelines will need to be applied within the context of the local social environment. The ability to adhere to the various guidelines will also depend heavily on the availability of local resources.

A range of advice and information is also available from the Malaysian Psychiatric Association and the Hong Kong College of Psychiatrists.

Treatment

Once the criteria for diagnosis are fulfilled GPs should move on to discuss treatment with their patients. If the patient is not severely agitated or suicidal then it can be useful to spread this discussion over more than one clinic visit. Start by making them aware that they have a medical condition which goes beyond just experiencing difficulties in life, and let them know that it is treatable and that safe and effective medications are available. This will give the patient time to digest the information, discuss the options with their family and do their own research before committing to a plan of action.

This approach also gives the GP a little more time to review options and prepare for prescribing an antidepressant. Medication access and guidelines will vary by country, but GPs should typically aim to begin with a selective serotonin reuptake inhibitor (SSRI) or a tricyclic antidepressant (TCA) for 4 to 6 weeks and wait to see whether there is a response. Algorithms such as the Texas Implementation of Medication Algorithm (see below) can then be used to guide further decisions around medication use.

Patients may have common misunderstandings about medications which physicians should try to allay. They may fear that the medications are addictive, or they may expect them to provide instantaneous relief. Managing these expectations in advance is important, and can help prevent patients from becoming disappointed or frustrated and stopping their medications.

Close follow-up is also crucial. Guidelines suggest that medication use should continue for 6 months to a year even if the patient shows signs of recovery. Early discontinuation leads to a higher risk of relapse, so it is important to make sure that patients finish their course. Side effects such as gastrointestinal complaints, drowsiness, dry eyes and dry throat will also need to be managed and patients should be warned about these in advance.

Psychotherapy, where available, is also a useful tool for treating depression. Few GPs are trained in psychotherapy themselves, and they should prepare for this eventuality by thoroughly researching the options in the local community and knowing how and where to refer their patients.

Treatment can be augmented by attempting to tackle some of the underlying triggers for depression. Rather than focusing solely on medical issues, GPs should also explore a patient’s psychosocial problems to understand what is troubling them. Community resources and support groups may be on hand to help, and many patients will benefit from further advice and referrals. With patients facing many problems this approach can be time-consuming for GPs, and they may like to plan ahead and deal with these issues one session at a time.

Patients with multiple psychiatric disorders or very complex or refractory depression should generally be referred on to a specialist center, particularly if they show signs of suicidal thoughts or self-harming behavior.

These centers may also offer further training which can help primary care physicians to improve their knowledge of depression. The Institute of Mental Health, for example, offers a partnership program for GPs which seeks to provide continuity of care for stable patients and increase the accessibility of treatment within the community. Participants complete a series of lectures and guided clinical sessions on depression and other mental health disorders, and can subsequently receive case consults and phone advice for difficult cases. Having specialist advice on hand can take some of the pressure off busy GPs, and can help them feel more comfortable discussing depression with their patients.

Conclusion

Depression is becoming easier to treat as our understanding of the condition continues to improve. Medications are safer and more effective than ever before and there is a wide range of information available to guide our clinical decisions. Primary care is an important setting for making an early diagnosis, and physicians should be proactive in screening patients who are at high risk.


Online Resources:

The American Psychiatric Association practice guidelines:
http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspx

The World Psychiatric Association:
http://www.worldpsychiatricassociation.org/

Texas Implementation of Medication Algorithm (TIMA):
http://www.dshs.state.tx.us/mhprograms/disclaimer.shtm

Institute of Mental Health patient information: http://www.imh.com.sg/patient_education/depression.htm

Depression.com:
http://www.depression.com/