geriatric psychosocial assessment of pain induced depression

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A Geriatric Psychosocial Assessment of Pain-induced Depression

James E. WilsonSchool of General Psychology

Oral Defense

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Personal Interest

• I chose this topic based on a personal interest in older adults and the socialization process in the United States that creates aging bias across many aspects of their lives.

• My interest include aging research focusing on: education that pain in just not a part of aging

• I provide continuing education for professionals on the perception of mental health and aging

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Background

• Beers and Jones (2009) reported the percentage of older adults in the United States suffering from chronic pain is 50%. In fact, chronic pain is so prevalent among older adults that leaders at the American Geriatric Society are recommending pain assessment become the fifth vital sign (Hunt, 2006).

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Literature Review• This literature review examines the body of research on pain-

induced depression among the geriatric population to include: • The unique experience of chronic pain in older adults, Depressive

symptoms in older• The connection between chronic pain and depression in older

adults• The Biopsychosocial theory, • Pain management for older adults• Age-specific considerations• The social consequences of chronic pain and depression in older

adults• Instrumentation /review of current measures

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Terms Specific to the Literature Review

• Older adults. This refers to the population or cohort of individuals based on age; the age requirement is 60 years of older (American Psychological Association of Aging, 2010).

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• Pain-induced depression. depression that has been onset by difficulties in dealing with pain. It shares many symptoms of major depression, including sleep disturbance, fatigue, and cognitive difficulties. It can be distinguished by exploring pain beliefs on two levels – catastrophizing and perceived helplessness behaviors related to pain (Lopez et al., 2008).

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• Chronic pain. This is pain that persist beyond six months and results in impaired physical functioning and emotional strain. There are three types of chronic pain: somatic (resulting from localized tissue damage in muscles, tendons, ligaments, bone, and joints, and includes such disorders as arthritis); visceral (viscera receptors are heightened in sensitivity to include stretching, infection, and inflammation, and includes such disorders as cancer); and neuropathic (caused by damage to peripheral nerves resulting in a burning, tingling, or electric-like shock. and includes such disorders as diabetic neuropathy) (Laird, 1999).

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Findings of the Literature Review

• According to Laforest, Gigna, and Gquvin (2004), chronic pain is a unique experience in older adults based on the following challenges: social beliefs on aging, multiple sources of pain, lack of support system, and the high cost of pain management.

• Schuler, Njoo, Hestermann, Oster, and Hauer (2004) identified physical comorbidities, such as vision, hearing loss, and cognitive decline, as additional factors that make pain perception a unique experience in older adulthood.

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• The social consequences of this unique experience for older adults are hopelessness, perceived disability, social isolation, decreased life satisfaction, and suicide attempts (Fiske, O’Riley, & Widoe, 2008).

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• A proper diagnosis of pain-induced depression, however, cannot be established unless pain and depression are examined together not through separate assessment tools (Montorio, Izal, & Velasco, 2008).

• Campbell, Clauw, and Keefe (2003) suggested that assessment development for pain-induced depression be centered around the Biopsychosocial theory (BPS) because both pain and depression in older adults are multifaceted concepts.

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• Peng, Fuchs, Peters, and Turk (2007) reviewed the use of BPS in the cognitive appraisal of pain in older adults and they suggested the following identified areas be applied to assessment development: appraisal, belief history and formation, catastrophizing, fear and avoidance beliefs, perceived control, and self-efficiency versus vulnerability

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• Montorio and Izal (2006) and Ferrel, Stein, and Beck (2000), which reviewed the development, validity, and reliability of the GDS and GPM, identifies that while neither are appropriate for measuring pain-induced depression, the formatting to include the simple yes/no responses should be carried forward when developing a BPS-based assessment.

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• The literature review in this study reveals a GAP in research in development of a multidimensional scale to detect pain-induced depression among geriatrics.

• A true assessment of pain-induced depression would measure how pain impacts daily living by focusing on the individual’s ideology of pain perception.

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Theoretical Base

• The Chosen theoretical base for this study is the Biopsychosocial (BPS) a theory that considers the chronic pain experience as one that is multifaceted.

• It was chosen because it acknowledges the medical/biological links to pain, emotional factors, cognitive processes, and the social consequences that result from the interactive process. In other words it’s holistic value in diagnostic development.

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Competing Theoretical Base

• Gate control theory of chronic pain• Focus on the medical model of pain only

briefly acknowledges that the T cells in the central nervous system that act as a gate heighten emotional sensitivity

• Little research on how this can be used in diagnosis of depression related to pain.

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Problem Statement

• The problem that this study is addressing is the absence of a psychological assessment that measures pain-induced depression among the geriatric population.

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Purpose of the Study

• The purpose of this research is to develop an evidenced-based assessment of pain-induced depression specific to the geriatric population.

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Nature of the Study

• This study will be used as a clinical trail to gain insight into a psychological new measure and it’s ability to detect pain-induced depression in older adults.

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Research Question and Hypotheses

• Research question. What differences would be found in the assessment of pain-induced depression using the GEAP in comparison to the GDS and GPM?

• Null hypothesis (H0). There will be no differences in item consistency/ internal reliability tested by item analysis between the GDS, GPM, and the GEAP in the assessment of pain-induced depression in geriatrics.

• Alternative hypothesis (H1). There are differences in item consistency/ internal reliability tested by item analysis between the GEAP, GDS, and GPM in the assessment of pain-induced depression in geriatrics.

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Research Question and Hypotheses

• Null hypothesis (H1). There will be no differences in the convergent and discriminate validity between the set of measures of the GEAP, GDS, and GPM in the assessment of pain-induced depression in geriatrics.

• Alternative hypothesis (H2). There will be differences in the convergent and discriminate validity between the set of measures of the GEAP, GDS, and GPM in the assessment of pain-induced depression in geriatrics.

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Limitations and Delimitations

• One limitation to this study was that a convenience sample of participants related to location

• Limitations also exist in test development of self-rating scales.

• Another limitation in brief self-report measures • This study was limited in scope to older adults

60 years or older

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Significance of the Study

• According to Karp, Rudy, and Weiner (2008), one of the most commonly overlooked symptoms of chronic pain is depression. They found that when depression is expressed in a generalized pain assessment by older adults, scales such as the GDS are accessed to obtain the level of depression. This becomes a social problem for this population because such scales were not developed for those suffering from chronic pain.

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Social Change Implications

• The positive social change implications include: the ability to aid in early detection and reducing the potential risk for suicide attempts and reduction in failed pain management and cost for older adults suffering from chronic pain and depression.

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Research Design and Approach

• This study uses a quantitative survey design approach

• A quantitative survey design approach is appropriate for this study because there are two or more quantitative variables, which include the GDS depression score, the GPM pain score, and the pain-induced depression score on the GEAP

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Research Design and Approach

• Campbell, Clauw, and Keefe (2003) research supported a quantitative survey research design in assessment development that focuses on social factors rather than etiological methods of diagnosis, which is currently used in scale development for depression and pain scales (Campbell, Clauw, & Keefe, 2003).

• Bennett, Walker, Moore, Lamberty, and O’Dwyer (2007) supported a quantitative survey design approach that focuses on the emotional consequences created through the socialization of pain in older adults. This study will develop questions around these suggestions using the quantitative survey design approach.

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Setting and sample/participants

• Participants that are being selected must meet the following criteria: (a) age, the client must be 60 years or older; (b) client would need to have experienced persistent pain (pain for six months or more); (c) be under the care of a pain management doctor; and (d) report depressed mood related to chronic pain.

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Procedures.

• Participants would be recruited through a general intake process from a network of 44 geriatric mental health outpatient clinics.

• participation would be voluntary • A pilot study will take place first (After IRB

approval) to assess the proposed data analysis techniques and gain additional participant feedbacks on the appropriateness of the questions develop for the scale.

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Pilot study

• Participants for the PILOT STUDY will be from one of the 44 sites and will not be assess again in the final study to prevent contamination.

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Procedures

• Standards for pilot studies in psychological research state that the sample size should range between 20% to 30% of your original calculated sample size for the full study (Daniel, 2002).

• The calculated sample size for the full study = 125 participants

• Pilot= 32 participants • The administration method for all three scales will

include the reading of the questions by the administrator

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Methods

• Item response theory (IRT) analysis for content analysis and exploratory factor analysis.

• An IRT provides internal consistency reliability assessing the consistency of results across items within a test.

• Exploratory factor analysis would be used to check for variations across the three scales or construct validity.

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Competing Research Design • qualitative phenomenological approach using structured interview.• problem lies in the analysis process. • Thematic content analysis which is most often used when reviewing

data from the phenomenological approach generates a spectrum: one that is too broad to develop into a standardized assessment

• another criticism of thematic content analysis stating that the coding system developed fragments segments of statements to create a whole which distorts the context of the original meaning.

• Austrian and Kern (2008) believe that qualitative research is helpful in finding the contextual meaning associated with chronic pain in older adults but not in assessment development.

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Instrumentation

• The GDS in this study will be used to gather a generalized depression rating among participants.

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Instrumentation

• The GPM will be used in this study to measure the physical consequences of pain. The questions when scored fall under five unique subscales: disengagement of pain (the only items on the measure formed around depression)(items 9, 10, 11, 12, 15, 18, 24), pain intensity (items 13, 17, 19, 20, 21, 22, 23), pain with ambulation (items 4, 5, 6, 7), pain with strenuous activities (items 1, 2, 3) and pain with other activities (items 8, 13, 14, 15, 16). (Ferrell, Stein, & Beck, 2000).

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Instrumentation GEAP

• GEAP. • This scale was developed to measure pain-induced

depression, which is defined by Lopez, Montorio, Izal, and Velasco (2008) as depression that is onset by chronic pain.

• Questions were formed on two primary levels catastrophizing and perceived helplessness. Each primary level was then broken into three secondary: appraisal and beliefs, perceived helplessness and cognitive interference based on Gatchel, Peng, Fuchs, Peters, & Turk (2007).

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• Original version had 35 questions , this version of the scale was given to 10 psychiatrists with specialization in geriatrics for review of appropriateness of questions.

• The original 35 questions were then narrowed down to 25 questions based on their feedback.

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• Those questions which received a 1 or 2 were eliminated from the scale the total number dropped equals 10 and included the following questions 9, 10, 11, 21, 22, 28, 29, 30, 31, and 35.

• The finalized version consist of 25 yes or no questions

• The rating scale would be as follows: 0-5 – no to little pain-induced depression, 5-9 – moderate pain-induced depression, and 10 and above – severe pain-induced depression.

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References

• Campbell, L., Clauw, D., & Keefe, F. (2003). Persistent pain and depression: A Biopsychosocial perspective. Society of Biological Psychiatry, 18(2), 399-409.

• Ferell, B., Stein, W., & Beck, J. (2000). The geriatric pain measure: Validity, reliability and factor analysis. The Journal of the American Geriatric Society, 48(12), 1669-1673.

• Hunt, T. (2006). Treating pain in the older person. Journal of Pain and Palliative Care, 20(4), 55-57.

• Lopez, A., Montorio, I., Izal, M., & Velasco, L. (2008). The role of psychological variables in explaining depression in older people with chronic pain. Aging and Mental Health, 12(6), 735-745.

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References• Lopez, A., Montorio, I., Izal, M., & Velasco, L. (2008). The role of

psychological variables in explaining depression in older people with chronic pain. Aging and Mental Health, 12(6), 735-745.

• Marwijk, H., Wallace, P., DeBrock, G., & Hermans, J. (2005). Evaluation of the feasibility, reliability and diagnostic value of shortened versions of the geriatric depression scale. British Journal of General Practice, 45(2), 195-199.

• Mavandadi, S., & Katz, I. (2007). Effects of depression treatment on depressive symptoms in older adulthood: The moderating role of pain. The Journal of American Geriatrics, 55(2), 202-211.

• Meeks, T. W., Dunn, L.B., Daniel, K. S., Shahrokh, G., Sewell, J. H., & Lebowitz, B. D. (2008). Chronic pain and depression among geriatric psychiatry inpatients. International Journal of Geriatric Psychiatry, 23(4), 637-642.

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References

• Peng, R., Fuchs, P., Peters, M., & Turk, D. (2007). The Biopsychosocial approach to chronic pain: Scientific advances and future directions. Psychological Bulletin, 133(4), 581-624.

• Schuler, M., Njoo, N., Hestermann, M., Oster, P., & Hauer, K. (2004). Acute and chronic pain in geriatrics: Clinical characteristics of pain and the influence of cognition. Pain Medicine, 5(3), 253-262.

geriatric psychosocial assessment of pain induced depression

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