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Gerdle B, Dragioti E, Rivano Fischer M, Ringqvist Å. Acceptance and Fear-Avoidance Mediate Outcomes of Interdisciplinary Pain Rehabilitation Programs at 12-Month Follow-Up: A Clinical Registry-Based Longitudinal Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP). J Pain Res 2024; 17:83-105. [PMID: 38196970 PMCID: PMC10775695 DOI: 10.2147/jpr.s438260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 12/19/2023] [Indexed: 01/11/2024] Open
Abstract
Background Factors that influence outcomes of interdisciplinary pain rehabilitation programs (IPRP) are poorly known. It is unclear how outcomes are influenced by pain intensity, psychological distress, and coping strategies. Aim This clinical registry-based longitudinal cohort study has three aims: 1) to determine the relative importance of pain intensity, psychological distress, acceptance, and fear-avoidance for changes in three outcomes of IPRP at 12-month follow-up; 2) to investigate whether the effects of pain intensity and psychological distress on the three outcomes are mediated via acceptance and fear-avoidance; and 3) to determine whether sex is a moderator. Methods This study uses Patient-Reported Outcome Measures (PROMs) from specialist units reporting data (2008-2016) to the Swedish Quality Registry for Pain Rehabilitation (SQRP). Adult chronic pain patients (N = 1991) answered the PROMs (background, pain, psychological distress, coping, participation, and health-related quality of life (HRQoL)). Partial Least Squares Structural Equation Modelling (PLS-SEM) was used to explore the aims. Results Changes in acceptance (β:0.424-0.553; all P<0.001) were the strongest predictor of the three outcomes (changes in life control, interference, and HRQoL) at 12-month follow-up. The next strongest predictor was baseline acceptance (β: 0.177-0.233; all P<0.001) and changes in fear-avoidance (β: -0.152- -0.186; all P<0.001). Baseline pain intensity and psychological distress showed weak positive associations. Their effects on the three outcomes were mediated via acceptance aspects. Sex was not a moderator. Discussion and Conclusion Acceptance aspects (baseline and changes) were important predictors of IPRP outcomes. Changes in fear-avoidance were also important although to a lesser degree. Some of the effects of pain intensity and psychological distress on outcomes were mediated via acceptance at baseline. Future PLS-SEM analysis of real-world IPRP should include more potential mediators (eg, catastrophizing and more facets of psychological flexibility and fear-avoidance) and the components of IPRP.
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Affiliation(s)
- Björn Gerdle
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Elena Dragioti
- Pain and Rehabilitation Centre, and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Marcelo Rivano Fischer
- Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, Lund, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Åsa Ringqvist
- Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, Lund, Sweden
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Allen-Brady K, Fyer AJ, Weissman M. The multi-generational familial aggregation of interstitial cystitis, other chronic nociplastic pain disorders, depression, and panic disorder. Psychol Med 2023; 53:7847-7856. [PMID: 37458197 DOI: 10.1017/s0033291723001885] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/24/2023]
Abstract
BACKGROUND Interstitial cystitis/painful bladder syndrome (IC) is a chronic pelvic pain condition which has high comorbidity with other nociplastic, or unexplained, pain disorders [e.g. fibromyalgia (FM), irritable bowel syndrome (IBS), and myalgic encephalomyelitis/chronic fatigue (ME/CFS)] and some psychiatric conditions [major depressive disorder (MDD) and panic disorder (PD)]. Here we investigated the shared familiality of IC and these other nociplastic and psychiatric conditions. METHODS Subjects were identified in the Utah Population Database, which links genealogy data back to the 1800s to medical record diagnosis billing code data back to 1995. We computed the relative risk of each of these disorders among first (FDR), second (SDR), and third-degree relatives (TDR) of six proband groups: IC, FM, IBS, ME/CFS, PD, and MDD. Given the known familial aggregation of each of these disorders, we conducted our analyses to test for heritable interrelationships using proband subgroups whose members did not have the diagnosis assessed in their relatives. RESULTS We observed strong evidence for heritable interrelationships among all six disorders. Most analyses indicated significantly increased risk for each of the six disorders in FDR, SDR, and TDR of all or most proband groups. Out of 30 possible bidirectional disorder interrelationships, 26 were significant among FDR, 23 were significant among SDR, and 7 were significant among TDR. Clustering was observed in both close and distant relatives. CONCLUSIONS Our results support a common, heritable component to IC and other nociplastic and psychiatric conditions.
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Affiliation(s)
- Kristina Allen-Brady
- Division of Epidemiology, Department of Internal Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Abby J Fyer
- Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, New York State Psychiatric Institute, New York City, New York, USA
| | - Myrna Weissman
- Department of Psychiatry, Columbia University Vagelos College of Physicians & Surgeons, New York State Psychiatric Institute, New York City, New York, USA
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Ogliari G, Ryg J, Andersen-Ranberg K, Scheel-Hincke LL, Collins JT, Cowley A, Di Lorito C, Booth V, Smit RAJ, Akyea RK, Qureshi N, Walsh DA, Harwood RH, Masud T. Association between pain intensity and depressive symptoms in community-dwelling adults: longitudinal findings from the Survey of Health, Ageing and Retirement in Europe (SHARE). Eur Geriatr Med 2023; 14:1111-1124. [PMID: 37450107 PMCID: PMC10587243 DOI: 10.1007/s41999-023-00835-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Accepted: 07/04/2023] [Indexed: 07/18/2023]
Abstract
PURPOSE To investigate the longitudinal associations between pain and depressive symptoms in adults. METHODS Prospective cohort study on data from 28,515 community-dwelling adults ≥ 50 years, free from depression at baseline (Wave 5), with follow-up in Wave 6 of the Survey of Health, Ageing and Retirement in Europe (SHARE). Significant depressive symptoms were defined by a EURO-D score ≥ 4. The longitudinal association between baseline pain intensity and significant depressive symptoms at follow-up was analysed using logistic regression models; odds ratios (ORs) and confidence intervals (CI) were calculated, adjusting for socio-demographic and clinical factors, physical inactivity, loneliness, mobility and functional impairments. RESULTS Mean age was 65.4 years (standard deviation 9.0, range 50-99); 14,360 (50.4%) participants were women. Mean follow-up was 23.4 (standard deviation 3.4) months. At baseline, 2803 (9.8%) participants reported mild pain, 5253 (18.4%) moderate pain and 1431 (5.0%) severe pain. At follow-up, 3868 (13.6%) participants-1451 (10.3%) men and 2417 (16.8%) women-reported significant depressive symptoms. After adjustment, mild, moderate and severe baseline pain, versus no pain, were associated with an increased likelihood of significant depressive symptoms at follow-up: ORs (95% CI) were 1.20 (1.06-1.35), 1.32 (1.20-1.46) and 1.39 (1.19-1.63), respectively. These associations were more pronounced in men compared to women, and consistent in participants aged 50-64 years, those without mobility or functional impairment, and those without loneliness at baseline. CONCLUSION Higher baseline pain intensity was longitudinally associated with a greater risk of significant depressive symptoms at 2-year follow-up, in community-dwelling adults without baseline depression.
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Affiliation(s)
- Giulia Ogliari
- Department of Health Care of Older People (HCOP), Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, Nottinghamshire, NG7 2UH, UK
| | - Jesper Ryg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Karen Andersen-Ranberg
- Department of Geriatric Medicine, Odense University Hospital, Odense, Denmark
- Geriatric Research Unit, Department of Clinical Research, University of Southern Denmark, Odense, Denmark
- Unit for Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, 5000, Odense, Denmark
| | - Lasse Lybecker Scheel-Hincke
- Unit for Epidemiology, Biostatistics and Biodemography, Department of Public Health, University of Southern Denmark, 5000, Odense, Denmark
| | - Jemima T Collins
- Department of Health Care of Older People (HCOP), Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, Nottinghamshire, NG7 2UH, UK
- University of Nottingham, Nottingham, UK
| | - Alison Cowley
- University of Nottingham, Nottingham, UK
- Research & Innovation, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Claudio Di Lorito
- Division of Primary Care and Population Health, University College London, London, UK
| | - Vicky Booth
- University of Nottingham, Nottingham, UK
- Research & Innovation, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Roelof A J Smit
- Novo Nordisk Foundation Center for Basic Metabolic Research, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3B, Building 7 (Maersk Tower), 2200, Copenhagen, Denmark
| | - Ralph K Akyea
- Primary Care Stratified Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - Nadeem Qureshi
- Primary Care Stratified Medicine, School of Medicine, University of Nottingham, Nottingham, UK
| | - David A Walsh
- Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
- Sherwood Forest Hospitals NHS Foundation Trust, Sutton-in-Ashfield, UK
| | - Rowan H Harwood
- Department of Health Care of Older People (HCOP), Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, Nottinghamshire, NG7 2UH, UK.
- University of Nottingham, Nottingham, UK.
- NIHR Applied Research Collaboration-East Midlands, Nottingham, UK.
| | - Tahir Masud
- Department of Health Care of Older People (HCOP), Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Derby Road, Nottingham, Nottinghamshire, NG7 2UH, UK
- NIHR Applied Research Collaboration-East Midlands, Nottingham, UK
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Xue D, Guo X, Li Y, Sheng Z, Wang L, Liu L, Cao J, Liu Y, Lou J, Li H, Hao X, Zhou Z, Fu Q. Risk Factor Analysis and a Predictive Model of Postoperative Depressive Symptoms in Elderly Patients Undergoing Video-Assisted Thoracoscopic Surgery. Brain Sci 2023; 13:brainsci13040646. [PMID: 37190611 DOI: 10.3390/brainsci13040646] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 03/30/2023] [Accepted: 04/09/2023] [Indexed: 05/17/2023] Open
Abstract
Among the elderly, depression is one of the most common mental disorders, which seriously affects their physical and mental health and quality of life, and their suicide rate is particularly high. Depression in the elderly is strongly associated with surgery. In this study, we aimed to explore the risk factors and establish a predictive model of depressive symptoms 1 month after video-assisted thoracoscopic surgery (VATS) in elderly patients. The study participants included 272 elderly patients (age > 65 years) undergoing VATS from April 2020 to May 2021 at 1 of 18 medical centers in China. The patients were divided into a depression group and a nondepression group according to the Chinese version of the nine-item Patient Health Questionnaire (PHQ-9). The patients' pre- and postoperative characteristics and questionnaires were collected and compared. Then, binary logistic regression was used to determine the risk factors that affect postoperative depressive symptoms, and the predictive model was constructed. The prediction efficiency of the model was evaluated by drawing the receiver operating characteristic curve (ROC), and the area under the curve (AUC) was calculated to evaluate the value of the predictive model. Among all of the included patients, 16.54% (45/272) suffered from depressive symptoms after VATS. The results of the univariate analysis showed that body mass index (BMI), chronic pain, leukocyte count, fibrinogen levels, prothrombin time, ASA physical status, infusion volume, anxiety, sleep quality, and postoperative pain were related to postoperative depressive symptoms (all p < 0.05). The results of multivariate logistic regression analysis showed that a high fibrinogen level (OR = 2.42), postoperative anxiety (OR = 12.05), poor sleep quality (OR = 0.61), and pain (OR = 2.85) were risk factors of postoperative depressive symptoms. A predictive model was constructed according to the regression coefficient of each variable, the ROC curve was drawn, and the AUC value was calculated to be 0.889. The prediction model may help medical personnel identify older patients at risk of developing depressive disorders associated with VATS and may be useful for clinical purposes.
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Affiliation(s)
- Dinghao Xue
- Medical School of Chinese PLA, Beijing 100853, China
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xu Guo
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yanxiang Li
- Medical School of Chinese PLA, Beijing 100853, China
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhuoqi Sheng
- Medical School of Chinese PLA, Beijing 100853, China
| | - Long Wang
- Department of Pain Medicine, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Luyu Liu
- Medical School of Chinese PLA, Beijing 100853, China
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jiangbei Cao
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Yanhong Liu
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Jingsheng Lou
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Hao Li
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Xinyu Hao
- Medical School of Chinese PLA, Beijing 100853, China
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Zhikang Zhou
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
| | - Qiang Fu
- Department of Anesthesiology, The First Medical Center, Chinese PLA General Hospital, Beijing 100853, China
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Pengpid S, Peltzer K. A Cross-Sectional and Longitudinal Study of Pain among Middle-Aged and Older Adults in Thailand. Pain Res Manag 2023; 2023:1158899. [PMID: 36935876 PMCID: PMC10019971 DOI: 10.1155/2023/1158899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/13/2022] [Accepted: 03/03/2023] [Indexed: 03/21/2023]
Abstract
Objective The present study aimed to assess the prevalence and risk factors of pain among ageing adults in Thailand. Methods Cross-sectional and longitudinal data were analysed from two consecutive national waves of the Health, Aging, and Retirement in Thailand (HART) study in 2015 and 2017. The dependent variable pain was defined as moderate or severe pain in any of the 13 areas of the body over the past month. Independent variables included sociodemographic factors, health risk behaviour, physical and mental health conditions, and healthcare utilization. Results The baseline or cross-sectional sample consisted of 5,616 participants (≥45 years), and the follow-up or incident sample consisted of 2,305 participants. The proportion of pain in the cross-sectional/baseline sample was 36.0%, and in the incident/follow-up sample 39.9%. In the cross-sectional/baseline multivariable model, poor self-reported mental health, sleep problem, arthritis or rheumatism, brain disease and/or psychiatric problems, lung disease, use of hospital in-patient, conventional out-patient, and traditional medicine practitioners were positively associated with pain. In the incident/follow-up multivariable model, older age, Buddhist religion, class I obesity, poor self-reported mental health, hospital in-patient, private clinic out-patient, and use of a practitioner of traditional medicine were positively associated with pain. Male sex and higher education were negatively associated with both cross-sectional and incident pain. Conclusions More than one-third of older adults in Thailand had past month moderate or severe pain. Risk factors of pain from cross-sectional and/or incident analysis included older age, female sex, lower education, obesity, poor self-reported mental health, sleep problem, arthritis or rheumatism, brain disease and/or psychiatric problems, lung disease, and conventional and traditional healthcare utilization.
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Affiliation(s)
- Supa Pengpid
- 1Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Bangkok, Thailand
- 2Department of Public Health, Sefako Makgatho Health Sciences University, Pretoria, South Africa
- 3Department of Healthcare Administration, College of Medical and Health Science, Asia University, Taichung, Taiwan
| | - Karl Peltzer
- 1Department of Health Education and Behavioral Sciences, Faculty of Public Health, Mahidol University, Bangkok, Thailand
- 4Department of Psychology, University of the Free State, Bloemfontein, South Africa
- 5Department of Psychology, College of Medical and Health Science, Asia University, Taichung, Taiwan
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Gerdle B, Dragioti E, Rivano Fischer M, Ringqvist Å. Pain intensity and psychological distress show different associations with interference and lack of life control: A clinical registry-based cohort study of >40,000 chronic pain patients from SQRP. FRONTIERS IN PAIN RESEARCH 2023; 4:1093002. [PMID: 36937562 PMCID: PMC10017552 DOI: 10.3389/fpain.2023.1093002] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Background Both chronic pain and depressive and/or anxiety symptoms are associated with negative impacts on daily living, including interference and lack of life control. However, little is known about how pain and psychological distress affect these impacts. Aim The first aim was to assess how pain intensity, psychological distress, and social support interact with interference and lack of life control. A second aim was to investigate whether the strength of these relationships is moderated by the presence or absence of depression and/or anxiety. Subjects and methods Patient-Reported Outcome Measures (PROMs), which are available in the Swedish Quality Registry for Pain Rehabilitation (SQRP), were retrieved for patients with chronic pain (N = 40,184). A theoretical model with the constructs/latent variables pain intensity, psychological distress, interference, lack of life control, and social support was proposed and analyzed using Partial Least Squares Structural Equation Modelling (PLS-SEM). Indicators for these constructs were identified from the PROMs of the SQRP. Two models of the total cohort, which differed with respect to the causal relationship between pain intensity and psychological distress, were investigated. The moderating effects of anxiety and/or depression were also analyzed. Results Relatively low correlation and explanatory power (R 2 = 0.16) were found for the pain intensity-psychological distress relationship. Pain intensity had a stronger effect on interference than on lack of life control. The reverse was found for psychological distress - i.e., psychological distress seemed to have a higher negative influence on function than on interference. The underlying assumption of the causal relationship between pain intensity and psychological distress determined how strong pain intensity and psychological distress influenced interference and lack of life control. Social support showed very similar absolute significant correlations with interference and lack of life control. Interference and lack of life control showed relatively weak associations. The psychological distress level was a moderating factor for several of the paths investigated. Discussion and conclusion A clinical treatment consequence of the low correlation between pain intensity and psychological distress may be that clinically treating one may not reduce the effect of the other. The relative importance of pain intensity and psychological distress on interference and lack of life control depends on the underlying assumption concerning the pain intensity-psychological distress relationship. Interference and lack of life control showed relatively weak associations, underscoring the need to clinically assess them separately. Social support influenced both impact constructs investigated. The cohort display heterogeneity and thus presence of definite signs of anxiety and/or depression or not was a moderating factor for several of the associations (paths) investigated. The results are important both for the assessments and the design of treatments for patients with chronic pain.
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Affiliation(s)
- Björn Gerdle
- Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
- Correspondence: Björn Gerdle
| | - Elena Dragioti
- Pain and Rehabilitation Centre, Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Marcelo Rivano Fischer
- Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, Lund, Sweden
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Åsa Ringqvist
- Department of Neurosurgery and Pain Rehabilitation, Skåne University Hospital, Lund, Sweden
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Munipalli B, Allman ME, Chauhan M, Niazi SK, Rivera F, Abril A, Wang B, Wieczorek MA, Hodge DO, Knight D, Perlman A, Abu Dabrh AM, Dudenkov D, Bruce BK. Depression: A Modifiable Risk Factor for Poor Outcomes in Fibromyalgia. J Prim Care Community Health 2022; 13:21501319221120738. [PMID: 36036260 PMCID: PMC9424873 DOI: 10.1177/21501319221120738] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background: About 4 out of 10 fibromyalgia patients suffer from depression. The European
Alliance of Associations for Rheumatology (EULAR) guidelines recommend using
antidepressants to treat fibromyalgia. Objective: To determine predictors of improved outcomes following a multicomponent
treatment program. Design: We designed this longitudinal treatment outcome study to evaluate the
prevalence of depression symptoms in patients diagnosed with fibromyalgia at
a tertiary care facility, and the impact of depression on functional
outcomes after completing a multicomponent fibromyalgia treatment
program. Setting: Tertiary care center. Patients: This study included 411 adult patients with fibromyalgia who completed a
multicomponent treatment program for fibromyalgia. Expert physicians
performed comprehensive evaluations following American College of
Rheumatology (ACR) criteria to confirm fibromyalgia before referral to the
program. Intervention: An intensive outpatient multicomponent treatment program consisting of
16 hours of cognitive behavioral strategies served as the intervention. Measurements: Functional status was assessed using the Fibromyalgia Impact Questionnaire
Revised (FIQR). Depression was evaluated with the Center for Epidemiologic
Study of Depression (CES-D) measure. Measures were administered prior to
participation in the program and approximately 5 months following completion
of the program. Results: The cohort had a high prevalence of depressive symptoms (73.2% had depression
at admission). Higher depression scores at baseline predicted poorer
outcomes following multi-component treatment. Effectively treated depression
resulted in improved functioning at follow-up. Limitations: Findings limited to tertiary care center cohort of fibromyalgia patients.
Patients did not undergo a structured clinical diagnostic interview to
diagnose depression. Conclusions: The current data links depression to poorer outcomes in patients with
fibromyalgia. Depression is an important modifiable factor in the management
of fibromyalgia. Guidelines should reflect the importance of assessing and
effectively treating depression at the time of diagnosis of fibromyalgia, to
improve functional outcomes. Registration: Specific registry and specific study registration number—Institutional Review
Board—(IRB# 19-000495). Funding Source: No funding.
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Affiliation(s)
| | | | | | | | | | - Andy Abril
- Mayo Clinic Florida, Jacksonville, FL, USA
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