Functional Restoration for Chronic Pain and Depression in the Elderly: Pharmacotherapy and Beyond

Chronic pain and depression are both highly prevalent conditions and often are comorbid. According to a literature review and meta-analysis of 42 studies addressing depression and chronic pain symptoms, 65% of patients diagnosed with depression reported one or more pain symptoms, while 5% to 85% of patients with chronic pain reported symptoms of depression.¹ In a cohort of residents of continuing care retirement communities, 13% reported both comorbid activity-limiting pain and chronic high depressive symptoms.²

In a recent review, Peter Polatin, MD, MPH, and colleagues from the University of Texas Southwest Medical Center examined of the role of pharmacotherapy and functional restoration in the biopsychosocial treatment approach to comorbid pain and depression in elderly patients.  According to the authors, “Functional restoration is an integrated system of care that has proven efficacy in multiple randomized controlled trials for the treatment of chronic pain. It is typically interdisciplinary, with all the involved disciplines, including physical therapy, occupational therapy, case management, psychology, and the physician, within close proximity and communicating frequently about each individual patient.”³ George C. Chang Chien, DO, director of pain management at Ventura County Medical Center in California told Psychiatry Advisor that internationally recognized functional restoration programs are at the Rehabilitation Institute of Chicago, the Cleveland Clinic, the Mayo Clinic, and Stanford. 

In their review, Polatin and colleagues state that certain heterocyclic antidepressants— notably amitriptyline, desipramine, doxepin, imipramine, and clomipramine — have known analgesic qualities in chronic pain, particularly pain of neuropathic origin. They advocate for the initiation of both antidepressant medication and cognitive-behavioral therapy in older patients with chronic pain in whom depression is an important contributor to pathology. A multimodal approach to chronic pain and depression — including psychoeducation about pain, biofeedback, mindfulness training, physical and occupational therapy, and detoxification of narcotics — is also suggested as part of a functional restoration approach.³

To learn more about the potential utility of a functional restoration approach to chronic pain and depression in the elderly, Psychiatry Advisor interviewed Steven Feinberg MD, a Palo Alto-based physiatrist and pain medicine specialist whose multidisciplinary practice provides evaluation and treatment in the Workers’ Compensation arena.

Psychiatry Advisor: Why is a biopsychosocial approach incorporating functional restoration necessary and/or desirable for older patients with comorbid depression and chronic pain? How does it differ from a traditional approach to these problems?

Dr Feinberg: A traditional approach focuses on a biomedical model, which involves finding a cause of the pain or dysfunction and then fixing it with medication, therapy, injection, and intervention or surgery. This biomedical model fails miserably when it comes to individuals who have developed a chronic pain syndrome. The biopsychosocial model is basically a functional restoration model. The main concept is to look at the whole patient; assess not just the physical pathology but all the other drivers of ill health including social, mental, educational, and cultural factors. A biopsychosocial approach in the elderly is critical because focusing on the pathology can miss the drivers of pain and disability. One example would be a surgeon recommending surgery for an elderly patient complaining of low back pain and in whom rather significant abnormalities are found on imaging studies of the lumbar spine. It may be, however, that the individual is depressed, unhappy, and feeling the effects of getting older; therefore, the real problem is not the lumbar spine at all but rather psychosocial factors. Also, medications can be dangerous in the elderly population. In the depressed elderly individuals, an antidepressant might be prescribed but that might lead to cognitive dysfunction, falls, and further injury and disability. In the elderly individual complaining of pain, if you just focus on the pain and provide pain medication, that individual may have severe side effects that may lead to other injuries. Put very simply, the biopsychosocial functional restoration approach looks at the whole patient and provides both physical restorative services as well as psychological pain management. It looks at the home environment, finances, and other factors that may lead the elderly to decline in function.

Psychiatry Advisor: What is the current status of functional restoration as a treatment modality? Is it in current use for pain and/or depression?

Dr Feinberg: Functional restoration is not always an expensive full-time pain program but rather is an approach. It is in use, but it is not used enough. There could be problems coordinating between disciplines. Physical therapy or psychological care in isolation is problematic when there is not communication between the psychologist and the physical therapist. And that includes the physician, as well. A functional restoration approach can be managed separately but is best provided in a coordinated function by a physician, physical therapist, and a psychologist, all of whom are at a minimum knowledgeable about this approach and in constant communication but better yet, work in the same facility.

Psychiatry Advisor: How can community psychiatrists and other clinicians adopt a biopsychosocial/functional restoration approach to the treatment of depression and chronic pain?

Dr Feinberg: The first step could be to acknowledge the importance of this approach and to communicate regularly with each other. There are sometimes problems, though, with reimbursement for psychological or physical therapy services. Furthermore, in today’s healthcare environment, the busy physician is asked to see more patients in less time, as well as spending time on the computer working on electronic medical records. You asked about psychiatrists, but the reality is that patients are typically treated with this model by psychologists, not psychiatrists. Basically, the physician needs to lead the team and communicate regularly with the mental health provider, the physical therapist, and other specialist physicians. The patient needs to be treated as a whole person and not simply his or her body parts.

This interview was lightly edited for clarity.

References

1. Bair MJ, Robinson RL, Katon W, Kroenke K. Depression and pain comorbidity: a literature review. Arch Intern Med. 2003;163(20):2433-2445.
2. Mossey JM, Gallagher RM. The longitudinal occurrence and impact of comorbid chronic pain and chronic depression over two years in continuing care retirement community residents. Pain Med. 2004;5(4):335-348.
3. Polatin P, Bevers K, Gatchel RJ. Pharmacological treatment of depression in geriatric chronic pain patients: a biopsychosocial approach integrating functional restoration. Expert Rev Clin Pharmacol. 2017;10(9):957-963.