Patients’ representations and antidepressant prescription in chronic pain patients:

1. Lugano, November 2009 Patients’ representations and antidepressant prescription in chronic pain patients: a typical case for non-congruence?

2. Background • Clear-cut evidence that antidepressants (ADs) are associated with pain relief • Patients’ adherence to AD medication is low • Adverse effects and patients’ representations of adverse effects are major determinants of non-adherence

3. Aims of the study Investigation of: • Chronic pain patients’ representations about medication and antidepressants • Possible role of these representations in the poor adherence with antidepressant medication

4. Methods Standardized semi-structured interviews: • Chronic pain patients and pain-free non-patient controls, matched for age, gender, educational status and origin • Representations of ADs (including AE, risks, personal experience, readiness to take ADs) • Responses were audio-taped, transcribed and submitted to content analysis

5. Population PatientsControls Age (mean, SD, 46.2 (14) 44.3 (16.2) range)19-89 18-86 Gender (% female) 52 55 Educational status (%) - elementary school 32 35 - qualified worker 37 28 - high school 16 18 - university 15 19 Pain duration (median) 3 years Pain intensity (mean) 76 (19)

6. Key results • Ambivalent representations about antidepressants in both groups • These representations hardly include the pain relief effects of antidepressants • No influence of pain, gender, age and previous AD intake on these issues

7. Ambivalent representations about antidepressants Five main themes: • Psychological and social effects • Chemical effect in the brain • Crutch effect • Danger and addiction • Somatic effects

8. Psychological and social effects Concern with possible combined positive and negative physical, psychological and social effects expressed in the majority of the respondents. Antidepressants indicated for psychological problems (e.g. uneasiness, irritability, anxiety, as well as for severe problems, including madness). Viewed as possibly “helping to cope with emotions”, “restoring mood” or as having soothing effects in the context of negative life events and interpersonal problems, But also as leading to “loss of drive” and thus of capacity to deal efficiently with life problems And to “loss of desire”

9. Psychological and social effects “To be calmer, or so that you accept more than you’d like to… it makes you do things you wouldn’t normally do. It helps accept a situation that normally I wouldn’t accept. I don’t know if it’s a good thing or not…” Patient 39, female, 52 years, fibromyalgia

10. Ambivalent representations about antidepressants Part of the danger seen as due to action in the brain (e.g. “inhibiting the brain functions” or “inducing brain atrophy”) Help but not cure the problems and may even prevent cure Need for additional treatments was often mentioned, ADs being a crutch or a spare wheel in the meantime Dependence as a major risk

11. Crutch only – danger of addiction "It’s something one becomes very quickly addicted to… in 15 days already… so it doesn’t solve the problems… it can even mask them… instead of trying to understand, to go to psychotherapy, one believes that the pill will solve everything" Patient 7, female, 54 years, musculoskeletal pain

12. Somatic effects - pain Somatic adverse effects (e.g. "cardiac problems", "sexual problems“, "weight increase“) in both groups Main between-group difference: pain as an indication mentioned by 23 patients However, 13 referred to pain consequences and only 10 to pain relief Pain alleviation due to antidepressants not as a decrease in pain intensity but rather as a ways to get used to pain or help to think less about pain

13. Somatic effects - pain "It helps me… maybe to forget my pain a bit… not being on the edge of tears all the time because I think about the situation I’m in and I don’t really know how to get out of it" Patient 98, female, 43 years, low back pain

14. Somatic effects - pain “[The patient read about ADs analgesic properties] This is only on paper! Decrease pain threshold! I don't believe in that at all. I'd never run the risk of becoming dependent and of having all these adverse effects only to decrease pain threshold!" Patient 51, female, 57 years, fibromyalgia

15. Conclusions • Indication too much at odds with lay people’s representations? • Therapy judged as irrelevant • Perceived ‘delegitimation’ • What about the non-congruence between these representations and physicians’ models? • Contradiction indication ‘brain’ – indication ‘pain’ • Patient-therapist relationship may be at risk

16. Conclusions • Patients’ representations may influence their understanding of the physician’s prescription • Need to elicit these representations • Need to address the patient’s own model of pain • This may in turn hinder/favour patients’ adherence with treatment

17. Conclusions « If I were prescribed an antidepressant, it would be because I would be completely out of my mind... so I would no longer be able to know whether or not I need it.... because I would no longer be myself...» 37-year-old male; chronic LBP

18. The team of the multidisciplinary center mai 07

19. http://reseaudouleur.hug-ge.ch/ Pain network of the Geneva University Hospitals. President: Dr C. Luthy