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June 2012
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Study examines back pain, depression

By Jack Kelly Pittsburgh Post-Gazette

PITTSBURGH - Researchers at the University of Pittsburgh School of Medicine are studying the most effective means of treating chronic low back pain and symptoms of depression  in those 60 or older.

The ADAPT (Addressing Depression And Pain Together) study has been going on for four years. Seventy-five men and 123 women, ranging in age from 60 to 94, have taken part.

But researchers need 55 more participants to ensure the conclusions they reach at the end of the study will be statistically valid.

About a third of seniors suffer from low back pain. Nearly 20 percent of Americans age 65 and older have clinically significant symptoms of depression, according to the National Alliance on Mental Illness. Up to 25 percent of seniors may suffer from both, said Dr. Jordan F. Karp, associate professor of psychiatry, the principal investigator.

"Chronic low back pain and depression make each other worse," Karp said. "Both can cause poor sleep, keep people from enjoying their usual activities, isolate them at home. Patients can enter a vicious cycle of the blues, pain, physical deconditioning and feeling hopeless."

Nearly 40 percent of those who've participated in the ADAPT study so far have had back surgery that has not worked, Karp said.

"People who are contemplating surgery need to have their depression treated, because depression can negatively affect outcomes," he said.

About 30 percent of ADAPT participants to date have fibromyalgia, which may make it more difficult to treat depression.

Doctors aren't sure what causes fibromyalgia, and there is no cure for it, but there are treatments that ease the discomfort it causes. About 12 million Americans - roughly 90 percent of them women - suffer from it.

People with fibromyalgia ache all over. Muscles may feel as if they've been overworked or pulled. Some patients may be very sensitive to touch and pressure. Other symptoms include fatigue, chronic headaches, trouble with concentration and memory, hypersensitivity to cold or heat, and tingling in extremities.

Although fibromyalgia is the second most common musculoskeletal disorder after osteoarthritis, the percentage of ADAPT participants who suffer from it is higher than he expected, Karp said. Only about 7 percent of older women have fibromyalgia, he said.

There are two phases to the ADAPT study. In the first, which lasts six weeks, all participants take the anti-depressant drug venlafaxine (Efflexor).

About a third of those who've participated in the ADAPT study so far have shown improvement during phase one, Karp said.

In the second phase, which lasts 14 weeks, participants who haven't improved during the first phase are given a higher dose of venlafaxine and are divided into two groups. Half receive the higher dose of venlafaxine only. The other half also get counseling on how to manage pain, mood, sleep and other difficulties seniors who suffer from both conditions typically experience.

The purpose of phase two is to determine whether people who didn't improve during phase one need the problem-solving therapy to get them feeling better, or if the higher dose of venlafaxine will suffice.

"One of the reasons we picked the medicine we used is not only because the FDA approves it for depression, but it also has been observed to have analgesic (painkilling) effects," Karp said.

Low doses of venlafaxine increase levels of the neurotransmitter serotonin, which regulates mood. Higher doses of the drug also increase levels of the neurotransmitter norepinephrine, which may regulate both mood and pain.

Neurotransmitters are chemicals in the brain that relay signals between nerve cells to tell the brain what's going on in the body. Both serotonin and norepinephrine tend to block some pain messages.

When people are depressed, they tend to feel pain more acutely. Having less pain can relieve depression. Attacking both problems at once can produce a double benefit.

"Getting people moving and in better control of their pain through healthy behavior changes may also help their mood and improve quality of life," Karp said. Zelienople, Pa., resident Robert Boykin, 73, a financial consultant with AXA, emphatically agrees. He's suffered from chronic back pain due to spinal stenosis.

"On top of that, back in November, I went into a real tailspin of depression," Boykin said. Then he learned of the ADAPT study. His final session was a few weeks ago.

"It was a godsend," Boykin said. "They brought me out of the hole I was in."

The venlafaxine provided immediate relief. But for him, "the talk therapy was almost as important as the drug therapy," Boykin said. "(Senior clinician) Sunita (Chickering) was extremely effective at uncovering problems _ chiefly anger issues _ I've had over the years."

His back pain is pretty much gone, Boykin said. And although he still feels depressed from time to time, "at least I know now how to deflect it."

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