Carl C. Bell

By Diana Mahoney, New England bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

In the war on drugs, methamphetamine is an insidious and tireless enemy.

According to statistics presented during a recent public Webcast addressing methamphetamine prevention sponsored by the U.S. Department of Justice (DOJ) Office of Community Oriented Policing Services, the Drug Enforcement Administration, and the Partnership for a Drug-Free America (PDFA), about 12 million Americans older than 12 years have tried methamphetamine, and 1.4 million Americans are addicted to it. Additionally, the results of a 2004 survey from the National Institute on Drug Abuse showed that more than 6% of high school seniors and more than 5% of 10th graders nationally reported lifetime use of the drug.

In a 2006 survey by the National Association of Counties (NAC), nearly half of the 500 participating counties reported that methamphetamine, or meth, is their primary drug problem. The results of separate NAC surveys reported in 2005 and 2006, respectively, showed that meth was the most commonly found drug in patients at public hospital emergency departments and demonstrated a significant increase in out-of-home placements for children because of parents' methamphetamine use or production.

Gains have been made on some battlefronts, but stubborn and unexpected obstacles hinder advances on others.

For example, the federal government has spent billions targeting the meth “super labs” in western states that are capable of producing huge quantities of the drug. Shutting down those facilities, however, has had little impact on the availability of meth. Rather, these actions pushed the large-scale production back into Mexico and have opened up more “business opportunities” for mom-and-pop meth labs that have been springing up across the country, particularly in the rural Midwest.

The super labs are a more important target. But the homespun labs, which account for more fires, explosions, child endangerment, and other problems, in many ways present a greater public health threat. Additionally, they make meth more accessible than ever to a wider range of people. And widespread access to the Internet has brought meth directly into people's living rooms by offering countless Web sites with detailed instructions for making meth.

The dangers of methamphetamine abuse extend beyond those associated with temporarily altering the consciousness of users. Meth stimulates central nervous system activity “by producing the mother of all dopamine releases,” according to Dr. Richard Rawson, associate director of the Integrated Substance Abuse Programs at the University of California, Los Angeles. Once the effect wears off, however, users “crash” and are often profoundly depressed, which triggers their desire for more meth to regain the high.

Side effects of the drug include irritability, insomnia, confusion, tremors, and aggressiveness. The increased dopamine production can induce psychosis, which may persist for months after the drug has been stopped. Meth also constricts blood vessels in the brain, leading to heart attacks, strokes, and potentially irreversible brain damage.

To put the brakes on meth abuse in the United States, the government recently passed a law called the Combat Methamphetamine Act, which provides legal pathways for targeting meth traffickers as well as a national standard for regulating meth precursors, including restrictions on the sale of over-the-counter medications containing pseudoephedrine.

Such efforts are positive, but community-level preventive interventions are needed that include local agencies, schools, parents, law enforcement, faith-based groups, and others with a vested interest in preventing meth use and intervening in meth abuse, according to Michael Townsend, director of the Methamphetamine Demand Reduction Program, a federally funded effort by the PDFA designed to reduce demand for the drug.

“Community partnerships are an effective approach to spreading this kind of word, and it's absolutely essential that the community get involved because [meth abuse] affects the whole community,” Mr. Townsend stated during the DOJ Webcast. Toward this end, the PDFA has developed a campaign called Meth 360, which has been piloted in several communities across the country. The approach relies on grassroots educational presentations delivered by teams made up of prevention, law enforcement, and treatment representatives.

“We call it Meth 360, because meth affects the whole community,” Mr. Townsend said. “It's important that everyone get involved at the local community level to give everyone a 360-degree view of the problem.”

After partnerships have been established, prevention approaches can be localized. The key is to “make sure that [the collaboration] is addressing your problem, and that the right people are at the table,” said Ron Glensor, deputy chief of the Reno, Nevada, police department, and one of the panelists participating in the DOJ Webcast. “And once you get to the table, be patient. Meth is not an easy problem to resolve, but you can make it better.”

Perspective

The “Just Say No” drug prevention strategy is not enough to keep at-risk teens from experimenting with drugs. And the dangers of experimentation are high, particularly with methamphetamine, which is reportedly so addictive that just a few “hits” have the capacity to addict the user.

Rather than a hit-and-run message, a good-quality intervention must incorporate psychological, social, and cultural strategies to take youth out of the context that would lead to experimentation in the first place. This involves creating a tight-knit social fabric around the youth with clear expectations.

Such an intervention also requires helping young people cultivate a sense of connectedness to people and places, a sense of power and belief in themselves, the confidence that they can handle challenges and make good decisions, and a sense of their uniqueness and value.

A good-quality intervention also helps youth develop social skills; provide close monitoring to protect them from risk situations; minimize trauma, which often leads to risky behaviors; and provide state-of-the-art treatment for those who become addicted.

Toward this end, one key strategy is to provide activities that prevent boredom. Doing so not only occupies youth, but it also offers an opportunity to monitor youth behavior in a subtle way and teaches social skills necessary to develop and sustain positive relationships.

In all cases, interventions should be customized to best serve the population being targeted. Kids share certain universal developmental aspects to their lives. But kids are also unique individuals with varying cultural, racial, and ethnic perspectives, not to mention class and regional styles. Universal approaches that will reach all youth should be considered, but we also need to tailor the approaches so the messages are culturally relevant, recognizable, and not offensive to the target culture.

Finally, encouraging law enforcement efforts aimed at stopping the drug distribution system early–before youth have an opportunity to get in trouble–is critically important.

Family-Focused Strategies Can Work

When thoughtfully designed and carefully implemented, the methamphetamine prevention message is well received, new research supported in part by the National Institutes of Health's institute on drug abuse shows.

In an assessment of drug prevention interventions delivered to middle school students in rural Iowa, programs that relied on the development of strong partnerships among families, schools, and communities led to significant reductions in methamphetamine abuse in later years, according to Richard L. Spoth, Ph.D., and his colleagues at the Partnerships in Prevention Science Institute at Iowa State University, Ames (Arch. Ped. Adolesc. 2006;160:876–82).

In one of the studies, 667 families of rural Iowa sixth graders were randomly assigned to participate in one of two interventions–the Iowa Strengthening Families Project (ISFP) or the Preparing for the Drug Free Years (PDFY) program–or to a control group.

The ISFP is made up of seven 2-hour sessions, including 1 hour of separate, concurrent skills-building curricula for the child and the parents, and 1 hour of a joint family curricula. The goal of the project is to enhance family protective factors and to reduce family risk processes.

The PDFY program has a five-session design, only one of which requires the child's attendance. The goal of the program is enhance protective parent-child interactions.

At the 12th-grade follow-up, which included 457 of the original families, none of the students who had participated in the ISFP reported methamphetamine use within the past year, compared with 3.6% of the PDFY group and 3.2% of the controls.

In the second study, 679 families of seventh-grade students were randomly recruited to participate in one of three approaches: a school-based, goals-directed intervention called Life Skills Training (LST) combined with a modified version of the ISFP called the Strengthening Family Program for Parents and Youth; the LST program alone; or a minimal-contact control group. The LST program consisted of 15 sessions geared toward specific goals and taught to students during regular classroom periods, with five follow-up sessions 1 year later.

Of the initial study group, 597 families were available for 12th-grade follow-up evaluations, which showed that the adolescents who participated in the combined interventions had a relative reduction in lifetime methamphetamine abuse of 65%, compared with the controls.

In both studies, Dr. Spoth said, the most effective interventions were those that had strong family components and were delivered in a manner that was sensitive to local culture and conditions–factors that must be taken into consideration when designing prevention programs targeting at-risk adolescents.

By Diana Mahoney, New England bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

In the war on drugs, methamphetamine is an insidious and tireless enemy.

According to statistics presented during a recent public Webcast addressing methamphetamine prevention sponsored by the U.S. Department of Justice (DOJ) Office of Community Oriented Policing Services, the Drug Enforcement Administration, and the Partnership for a Drug-Free America (PDFA), about 12 million Americans older than 12 years have tried methamphetamine, and 1.4 million Americans are addicted to it. Additionally, the results of a 2004 survey from the National Institute on Drug Abuse showed that more than 6% of high school seniors and more than 5% of 10th graders nationally reported lifetime use of the drug.

In a 2006 survey by the National Association of Counties (NAC), nearly half of the 500 participating counties reported that methamphetamine, or meth, is their primary drug problem. The results of separate NAC surveys reported in 2005 and 2006, respectively, showed that meth was the most commonly found drug in patients at public hospital emergency departments and demonstrated a significant increase in out-of-home placements for children because of parents' methamphetamine use or production.

Gains have been made on some battlefronts, but stubborn and unexpected obstacles hinder advances on others.

For example, the federal government has spent billions targeting the meth “super labs” in western states that are capable of producing huge quantities of the drug. Shutting down those facilities, however, has had little impact on the availability of meth. Rather, these actions pushed the large-scale production back into Mexico and have opened up more “business opportunities” for mom-and-pop meth labs that have been springing up across the country, particularly in the rural Midwest.

The super labs are a more important target. But the homespun labs, which account for more fires, explosions, child endangerment, and other problems, in many ways present a greater public health threat. Additionally, they make meth more accessible than ever to a wider range of people. And widespread access to the Internet has brought meth directly into people's living rooms by offering countless Web sites with detailed instructions for making meth.

The dangers of methamphetamine abuse extend beyond those associated with temporarily altering the consciousness of users. Meth stimulates central nervous system activity “by producing the mother of all dopamine releases,” according to Dr. Richard Rawson, associate director of the Integrated Substance Abuse Programs at the University of California, Los Angeles. Once the effect wears off, however, users “crash” and are often profoundly depressed, which triggers their desire for more meth to regain the high.

Side effects of the drug include irritability, insomnia, confusion, tremors, and aggressiveness. The increased dopamine production can induce psychosis, which may persist for months after the drug has been stopped. Meth also constricts blood vessels in the brain, leading to heart attacks, strokes, and potentially irreversible brain damage.

To put the brakes on meth abuse in the United States, the government recently passed a law called the Combat Methamphetamine Act, which provides legal pathways for targeting meth traffickers as well as a national standard for regulating meth precursors, including restrictions on the sale of over-the-counter medications containing pseudoephedrine.

Such efforts are positive, but community-level preventive interventions are needed that include local agencies, schools, parents, law enforcement, faith-based groups, and others with a vested interest in preventing meth use and intervening in meth abuse, according to Michael Townsend, director of the Methamphetamine Demand Reduction Program, a federally funded effort by the PDFA designed to reduce demand for the drug.

“Community partnerships are an effective approach to spreading this kind of word, and it's absolutely essential that the community get involved because [meth abuse] affects the whole community,” Mr. Townsend stated during the DOJ Webcast. Toward this end, the PDFA has developed a campaign called Meth 360, which has been piloted in several communities across the country. The approach relies on grassroots educational presentations delivered by teams made up of prevention, law enforcement, and treatment representatives.

“We call it Meth 360, because meth affects the whole community,” Mr. Townsend said. “It's important that everyone get involved at the local community level to give everyone a 360-degree view of the problem.”

After partnerships have been established, prevention approaches can be localized. The key is to “make sure that [the collaboration] is addressing your problem, and that the right people are at the table,” said Ron Glensor, deputy chief of the Reno, Nevada, police department, and one of the panelists participating in the DOJ Webcast. “And once you get to the table, be patient. Meth is not an easy problem to resolve, but you can make it better.”

Perspective

The “Just Say No” drug prevention strategy is not enough to keep at-risk teens from experimenting with drugs. And the dangers of experimentation are high, particularly with methamphetamine, which is reportedly so addictive that just a few “hits” have the capacity to addict the user.

Rather than a hit-and-run message, a good-quality intervention must incorporate psychological, social, and cultural strategies to take youth out of the context that would lead to experimentation in the first place. This involves creating a tight-knit social fabric around the youth with clear expectations.

Such an intervention also requires helping young people cultivate a sense of connectedness to people and places, a sense of power and belief in themselves, the confidence that they can handle challenges and make good decisions, and a sense of their uniqueness and value.

A good-quality intervention also helps youth develop social skills; provide close monitoring to protect them from risk situations; minimize trauma, which often leads to risky behaviors; and provide state-of-the-art treatment for those who become addicted.

Toward this end, one key strategy is to provide activities that prevent boredom. Doing so not only occupies youth, but it also offers an opportunity to monitor youth behavior in a subtle way and teaches social skills necessary to develop and sustain positive relationships.

In all cases, interventions should be customized to best serve the population being targeted. Kids share certain universal developmental aspects to their lives. But kids are also unique individuals with varying cultural, racial, and ethnic perspectives, not to mention class and regional styles. Universal approaches that will reach all youth should be considered, but we also need to tailor the approaches so the messages are culturally relevant, recognizable, and not offensive to the target culture.

Finally, encouraging law enforcement efforts aimed at stopping the drug distribution system early–before youth have an opportunity to get in trouble–is critically important.

Family-Focused Strategies Can Work

When thoughtfully designed and carefully implemented, the methamphetamine prevention message is well received, new research supported in part by the National Institutes of Health's institute on drug abuse shows.

In an assessment of drug prevention interventions delivered to middle school students in rural Iowa, programs that relied on the development of strong partnerships among families, schools, and communities led to significant reductions in methamphetamine abuse in later years, according to Richard L. Spoth, Ph.D., and his colleagues at the Partnerships in Prevention Science Institute at Iowa State University, Ames (Arch. Ped. Adolesc. 2006;160:876–82).

In one of the studies, 667 families of rural Iowa sixth graders were randomly assigned to participate in one of two interventions–the Iowa Strengthening Families Project (ISFP) or the Preparing for the Drug Free Years (PDFY) program–or to a control group.

The ISFP is made up of seven 2-hour sessions, including 1 hour of separate, concurrent skills-building curricula for the child and the parents, and 1 hour of a joint family curricula. The goal of the project is to enhance family protective factors and to reduce family risk processes.

The PDFY program has a five-session design, only one of which requires the child's attendance. The goal of the program is enhance protective parent-child interactions.

At the 12th-grade follow-up, which included 457 of the original families, none of the students who had participated in the ISFP reported methamphetamine use within the past year, compared with 3.6% of the PDFY group and 3.2% of the controls.

In the second study, 679 families of seventh-grade students were randomly recruited to participate in one of three approaches: a school-based, goals-directed intervention called Life Skills Training (LST) combined with a modified version of the ISFP called the Strengthening Family Program for Parents and Youth; the LST program alone; or a minimal-contact control group. The LST program consisted of 15 sessions geared toward specific goals and taught to students during regular classroom periods, with five follow-up sessions 1 year later.

Of the initial study group, 597 families were available for 12th-grade follow-up evaluations, which showed that the adolescents who participated in the combined interventions had a relative reduction in lifetime methamphetamine abuse of 65%, compared with the controls.

In both studies, Dr. Spoth said, the most effective interventions were those that had strong family components and were delivered in a manner that was sensitive to local culture and conditions–factors that must be taken into consideration when designing prevention programs targeting at-risk adolescents.

By Diana Mahoney, New England bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

In the war on drugs, methamphetamine is an insidious and tireless enemy.

According to statistics presented during a recent public Webcast addressing methamphetamine prevention sponsored by the U.S. Department of Justice (DOJ) Office of Community Oriented Policing Services, the Drug Enforcement Administration, and the Partnership for a Drug-Free America (PDFA), about 12 million Americans older than 12 years have tried methamphetamine, and 1.4 million Americans are addicted to it. Additionally, the results of a 2004 survey from the National Institute on Drug Abuse showed that more than 6% of high school seniors and more than 5% of 10th graders nationally reported lifetime use of the drug.

In a 2006 survey by the National Association of Counties (NAC), nearly half of the 500 participating counties reported that methamphetamine, or meth, is their primary drug problem. The results of separate NAC surveys reported in 2005 and 2006, respectively, showed that meth was the most commonly found drug in patients at public hospital emergency departments and demonstrated a significant increase in out-of-home placements for children because of parents' methamphetamine use or production.

Gains have been made on some battlefronts, but stubborn and unexpected obstacles hinder advances on others.

For example, the federal government has spent billions targeting the meth “super labs” in western states that are capable of producing huge quantities of the drug. Shutting down those facilities, however, has had little impact on the availability of meth. Rather, these actions pushed the large-scale production back into Mexico and have opened up more “business opportunities” for mom-and-pop meth labs that have been springing up across the country, particularly in the rural Midwest.

The super labs are a more important target. But the homespun labs, which account for more fires, explosions, child endangerment, and other problems, in many ways present a greater public health threat. Additionally, they make meth more accessible than ever to a wider range of people. And widespread access to the Internet has brought meth directly into people's living rooms by offering countless Web sites with detailed instructions for making meth.

The dangers of methamphetamine abuse extend beyond those associated with temporarily altering the consciousness of users. Meth stimulates central nervous system activity “by producing the mother of all dopamine releases,” according to Dr. Richard Rawson, associate director of the Integrated Substance Abuse Programs at the University of California, Los Angeles. Once the effect wears off, however, users “crash” and are often profoundly depressed, which triggers their desire for more meth to regain the high.

Side effects of the drug include irritability, insomnia, confusion, tremors, and aggressiveness. The increased dopamine production can induce psychosis, which may persist for months after the drug has been stopped. Meth also constricts blood vessels in the brain, leading to heart attacks, strokes, and potentially irreversible brain damage.

To put the brakes on meth abuse in the United States, the government recently passed a law called the Combat Methamphetamine Act, which provides legal pathways for targeting meth traffickers as well as a national standard for regulating meth precursors, including restrictions on the sale of over-the-counter medications containing pseudoephedrine.

Such efforts are positive, but community-level preventive interventions are needed that include local agencies, schools, parents, law enforcement, faith-based groups, and others with a vested interest in preventing meth use and intervening in meth abuse, according to Michael Townsend, director of the Methamphetamine Demand Reduction Program, a federally funded effort by the PDFA designed to reduce demand for the drug.

“Community partnerships are an effective approach to spreading this kind of word, and it's absolutely essential that the community get involved because [meth abuse] affects the whole community,” Mr. Townsend stated during the DOJ Webcast. Toward this end, the PDFA has developed a campaign called Meth 360, which has been piloted in several communities across the country. The approach relies on grassroots educational presentations delivered by teams made up of prevention, law enforcement, and treatment representatives.

“We call it Meth 360, because meth affects the whole community,” Mr. Townsend said. “It's important that everyone get involved at the local community level to give everyone a 360-degree view of the problem.”

After partnerships have been established, prevention approaches can be localized. The key is to “make sure that [the collaboration] is addressing your problem, and that the right people are at the table,” said Ron Glensor, deputy chief of the Reno, Nevada, police department, and one of the panelists participating in the DOJ Webcast. “And once you get to the table, be patient. Meth is not an easy problem to resolve, but you can make it better.”

Perspective

The “Just Say No” drug prevention strategy is not enough to keep at-risk teens from experimenting with drugs. And the dangers of experimentation are high, particularly with methamphetamine, which is reportedly so addictive that just a few “hits” have the capacity to addict the user.

Rather than a hit-and-run message, a good-quality intervention must incorporate psychological, social, and cultural strategies to take youth out of the context that would lead to experimentation in the first place. This involves creating a tight-knit social fabric around the youth with clear expectations.

Such an intervention also requires helping young people cultivate a sense of connectedness to people and places, a sense of power and belief in themselves, the confidence that they can handle challenges and make good decisions, and a sense of their uniqueness and value.

A good-quality intervention also helps youth develop social skills; provide close monitoring to protect them from risk situations; minimize trauma, which often leads to risky behaviors; and provide state-of-the-art treatment for those who become addicted.

Toward this end, one key strategy is to provide activities that prevent boredom. Doing so not only occupies youth, but it also offers an opportunity to monitor youth behavior in a subtle way and teaches social skills necessary to develop and sustain positive relationships.

In all cases, interventions should be customized to best serve the population being targeted. Kids share certain universal developmental aspects to their lives. But kids are also unique individuals with varying cultural, racial, and ethnic perspectives, not to mention class and regional styles. Universal approaches that will reach all youth should be considered, but we also need to tailor the approaches so the messages are culturally relevant, recognizable, and not offensive to the target culture.

Finally, encouraging law enforcement efforts aimed at stopping the drug distribution system early–before youth have an opportunity to get in trouble–is critically important.

Family-Focused Strategies Can Work

When thoughtfully designed and carefully implemented, the methamphetamine prevention message is well received, new research supported in part by the National Institutes of Health's institute on drug abuse shows.

In an assessment of drug prevention interventions delivered to middle school students in rural Iowa, programs that relied on the development of strong partnerships among families, schools, and communities led to significant reductions in methamphetamine abuse in later years, according to Richard L. Spoth, Ph.D., and his colleagues at the Partnerships in Prevention Science Institute at Iowa State University, Ames (Arch. Ped. Adolesc. 2006;160:876–82).

In one of the studies, 667 families of rural Iowa sixth graders were randomly assigned to participate in one of two interventions–the Iowa Strengthening Families Project (ISFP) or the Preparing for the Drug Free Years (PDFY) program–or to a control group.

The ISFP is made up of seven 2-hour sessions, including 1 hour of separate, concurrent skills-building curricula for the child and the parents, and 1 hour of a joint family curricula. The goal of the project is to enhance family protective factors and to reduce family risk processes.

The PDFY program has a five-session design, only one of which requires the child's attendance. The goal of the program is enhance protective parent-child interactions.

At the 12th-grade follow-up, which included 457 of the original families, none of the students who had participated in the ISFP reported methamphetamine use within the past year, compared with 3.6% of the PDFY group and 3.2% of the controls.

In the second study, 679 families of seventh-grade students were randomly recruited to participate in one of three approaches: a school-based, goals-directed intervention called Life Skills Training (LST) combined with a modified version of the ISFP called the Strengthening Family Program for Parents and Youth; the LST program alone; or a minimal-contact control group. The LST program consisted of 15 sessions geared toward specific goals and taught to students during regular classroom periods, with five follow-up sessions 1 year later.

Of the initial study group, 597 families were available for 12th-grade follow-up evaluations, which showed that the adolescents who participated in the combined interventions had a relative reduction in lifetime methamphetamine abuse of 65%, compared with the controls.

In both studies, Dr. Spoth said, the most effective interventions were those that had strong family components and were delivered in a manner that was sensitive to local culture and conditions–factors that must be taken into consideration when designing prevention programs targeting at-risk adolescents.

By Diana Mahoney, New England bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

Chronic pain cuts wide. One out of every five people lives with some sort of chronic pain. Of that 20%, one-third are not able or are only minimally able to maintain an independent lifestyle because of it, according to the International Association for the Study of Pain.

And chronic pain cuts deep. Beneath the veneer of the physical symptoms lies the social, emotional, and psychological havoc caused by the associated disability, isolation, fear, and helplessness, which leads to a substantially diminished quality of life.

Unfortunately, chronic pain is also invisible. There's no gash to suture, no broken leg to set. Instead, there exists an amorphous condition that is difficult to measure and even more difficult to manage, particularly in a health care culture that values cut-and-dry diagnoses and magic pills. Adding to the complexity is the fact that chronic pain often coexists with a range of psychological disorders, including depression, anxiety, personality disorders, cognitive problems, and substance abuse.

In one study designed to assess the prevalence of chronic pain conditions and their relationship with major depressive disorder (MDD), investigators from Stanford (Calif.) University conducted a cross-sectional telephone survey of a random sample of nearly 19,000 subjects from the general population.

About 4% of the survey participants met the diagnostic criteria for MDD, and of those, 43.5% reported having at least one chronic pain condition–a number four times greater than reported by individuals in the study who did not have depression (Arch. Gen. Psychiatry 2003;60:39–47).

More recently, another Stanford study sought to evaluate the strength of the association between major depression and chronic pain and to examine the clinical burden associated with the two conditions. Of nearly 6,000 randomly sampled primary care patients who responded to a questionnaire, about 7% met criteria for MDD, and two-thirds of those with depression reported chronic pain. Among all of the subjects in the sample who reported chronic pain, the prevalence of MDD was significantly higher than in those without pain (Psychosom. Med. 2006;68:262–8).

The direction of the pain/depression connection has yet to be fully understood, but the degree of disability appears to play an important role, according to lead investigator Bruce A. Arnow, Ph.D. Among those respondents with chronic pain, the prevalence of MDD was 23% in people with disabling pain, compared with 5% in those who were not disabled by their pain. “It's possible that those who are disabled by pain become depressed, and it is possible that those who are depressed are more likely to become disabled,” he said.

Regardless of initial direction, the likelihood that one will coexist with the other warrants that both be addressed. Numerous studies have shown that depressed chronic pain patients report greater pain intensity, more malignant disease course, and poorer response to pain treatments. Additionally, depression can impede rehabilitation efforts because of low motivation, poor morale, low energy, and hopelessness.

In contrast, considering the physical and mental health components of chronic pain as symptoms of a single pain syndrome can improve patient outcome. A large, multisite investigation of depression care from the University of Washington, Seattle, showed that older adults with chronic arthritis pain who were screened and treated for depression had significant improvements in pain severity and functioning, compared with those patients who received standard arthritis care. The treatment group benefited from a multidisciplinary program that included medication, psychotherapy, and in-person and telephone follow-up (JAMA 2003;290:2428–9).

The multidisciplinary intervention “not only helped patients with arthritis feel less depressed but also helped them cope better with their pain, to be more active, and to have a higher quality of life,” according to lead investigator Dr. Elizabeth H.B. Lin of the Group Health Cooperative in Seattle. Treating patients' depression isn't going to take the pain away, she said, but treatment can change the experience of pain, which can lead to improved outcomes.

In addition to antidepressant medications when warranted, various nonpharmacologic strategies, including patient psychoeducation, and cognitive-behavioral interventions, can give chronic pain patients a sense of control over their pain and the tools needed to modify behaviors that contribute to emotional and physical distress.

The bottom line, according to chronic pain expert Robert D. Kerns, Ph.D., associate professor in the departments of psychiatry, neurology, and psychology at Yale University, New Haven, Conn., is that patients with chronic pain have to be viewed from a broad biopsychosocial perspective.

“For greatest effectiveness [in managing chronic pain], we should be treating the whole person, not fixing a 'broken' body part,” Dr. Kerns said.

Perspective

DR. BELL is chief executive officer and president of Community Mental Health Council Inc. in Chicago and serves as director of public and community psychiatry at the University of Illinoisat Chicago.

People who have chronic pain are extraordinarily clear about the devastating impact this problem has on their psychological balance. The resulting sense of helplessness often generates a great deal of grief, depression, stress, pessimism, and loneliness.

People who have never experienced severe, chronic pain, however, have no idea how disruptive it can be. Because of this, they may erroneously assume (and even suggest) that the pain is purely psychological or a sign of weakness of character or will–sentiments that further isolate and alienate the sufferers.

This isolation is exacerbated by the current health care culture. Although some understanding exists of the medical conundrum of pain, the psychiatric ramifications are very much an afterthought. The proactive approach of considering mind and body takes a back seat to the mechanistic approach of trying to heal the physical body while ignoring the mind.

This approach is rather typical of Western medicine and has its origins as far back as the Descartes doctrine of the distinction between the mind and body.

Because Western medicine focuses so intently on the mechanistic view of life and well-being, we don't have evidence of the efficacy of other, more esoteric forms of healing, such as acupuncture, meditation, prayer, and support group activities. We won't be able to collect such evidence until Western health care providers routinely begin to embrace non-Western approaches to health care that address issues of both the mind and the body.

Fortunately, science may be taking us in that direction. The mechanism of pain has been connected to the serotoninergic neurotransmitter system in the brain and body, which is also linked to depression. This connection suggests a potential route for therapeutic benefit of antidepressant medications for chronic pain.

Bridging the mind/body gap in our management of chronic pain is not impossible, but doing so does require a critical culture shift in which neither element takes a backseat to the other.

Pain Relief Is a Phone Call Away

Patients suffering from chronic, nonmalignant pain generally have to come to terms with the fact that finding a cure for their symptoms is an elusive goal. A more reasonable treatment target is pain management, often through some combination of analgesic medication and behavior modification.

In fact, numerous studies have shown that behavioral interventions–particularly cognitive-behavioral therapy (CBT) and self-regulatory techniques such as biofeedback and hypnosis–can significantly reduce pain intensity and improve emotional and physical functioning.

Ideally, after participating in a behavioral intervention, patients will regularly access and employ the various coping strategies they've acquired. Realistically, the likelihood that they will do so diminishes over time.

Although it may not be feasible to conduct open-ended behavioral intervention groups, pain specialists at the University of Vermont in Burlington may have developed the next best thing. Therapeutic Interactive Voice Response (TIVR) was developed to enhance the therapeutic outcome of patients who have completed a course of group CBT for chronic pain and to minimize their reliance on pharmacologic painkillers.

The first component of the TIVR enhancement is a daily self-monitoring questionnaire. Patients access the computerized interactive telephone system and respond by touch-pad to a series of questions that measure coping, perceived pain control, mood, medication, and stress. The objective is to improve self-monitoring of pain behavior, coping skills, and medication use, said TIVR principal investigator Dr. Magdalena R. Naylor, director of the university's MindBody Medicine Clinic.

If patients desire a coping skills “refresher,” they can access a didactic review that provides a verbal review of the various pain management skills learned during the CBT intervention, such as relaxation response, positive self-talk, cognitive restructuring, and distraction techniques.

The final component is a monthly feedback message: A therapist analyzes computer-collated, patient-specific data from the telephone response system and records a personalized message for participants summarizing the daily reports and offering insight into potential problem areas. This element is critical to the efficacy of the system, according to Dr. Naylor, as it is a vehicle for valuable feedback and an ongoing positive connection with the therapist.

In a pilot test of TIVR in a group of 10 middle-aged patients with severe, chronic musculoskeletal pain, regular use of the TIVR both maintained and strengthened the therapeutic gains associated with the CBT intervention (J. Pain 2002;3:429–38).

The Vermont investigators are currently replicating the TIVR study in a randomized, controlled trial.

By Diana Mahoney, New England bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

Chronic pain cuts wide. One out of every five people lives with some sort of chronic pain. Of that 20%, one-third are not able or are only minimally able to maintain an independent lifestyle because of it, according to the International Association for the Study of Pain.

And chronic pain cuts deep. Beneath the veneer of the physical symptoms lies the social, emotional, and psychological havoc caused by the associated disability, isolation, fear, and helplessness, which leads to a substantially diminished quality of life.

Unfortunately, chronic pain is also invisible. There's no gash to suture, no broken leg to set. Instead, there exists an amorphous condition that is difficult to measure and even more difficult to manage, particularly in a health care culture that values cut-and-dry diagnoses and magic pills. Adding to the complexity is the fact that chronic pain often coexists with a range of psychological disorders, including depression, anxiety, personality disorders, cognitive problems, and substance abuse.

In one study designed to assess the prevalence of chronic pain conditions and their relationship with major depressive disorder (MDD), investigators from Stanford (Calif.) University conducted a cross-sectional telephone survey of a random sample of nearly 19,000 subjects from the general population.

About 4% of the survey participants met the diagnostic criteria for MDD, and of those, 43.5% reported having at least one chronic pain condition–a number four times greater than reported by individuals in the study who did not have depression (Arch. Gen. Psychiatry 2003;60:39–47).

More recently, another Stanford study sought to evaluate the strength of the association between major depression and chronic pain and to examine the clinical burden associated with the two conditions. Of nearly 6,000 randomly sampled primary care patients who responded to a questionnaire, about 7% met criteria for MDD, and two-thirds of those with depression reported chronic pain. Among all of the subjects in the sample who reported chronic pain, the prevalence of MDD was significantly higher than in those without pain (Psychosom. Med. 2006;68:262–8).

The direction of the pain/depression connection has yet to be fully understood, but the degree of disability appears to play an important role, according to lead investigator Bruce A. Arnow, Ph.D. Among those respondents with chronic pain, the prevalence of MDD was 23% in people with disabling pain, compared with 5% in those who were not disabled by their pain. “It's possible that those who are disabled by pain become depressed, and it is possible that those who are depressed are more likely to become disabled,” he said.

Regardless of initial direction, the likelihood that one will coexist with the other warrants that both be addressed. Numerous studies have shown that depressed chronic pain patients report greater pain intensity, more malignant disease course, and poorer response to pain treatments. Additionally, depression can impede rehabilitation efforts because of low motivation, poor morale, low energy, and hopelessness.

In contrast, considering the physical and mental health components of chronic pain as symptoms of a single pain syndrome can improve patient outcome. A large, multisite investigation of depression care from the University of Washington, Seattle, showed that older adults with chronic arthritis pain who were screened and treated for depression had significant improvements in pain severity and functioning, compared with those patients who received standard arthritis care. The treatment group benefited from a multidisciplinary program that included medication, psychotherapy, and in-person and telephone follow-up (JAMA 2003;290:2428–9).

The multidisciplinary intervention “not only helped patients with arthritis feel less depressed but also helped them cope better with their pain, to be more active, and to have a higher quality of life,” according to lead investigator Dr. Elizabeth H.B. Lin of the Group Health Cooperative in Seattle. Treating patients' depression isn't going to take the pain away, she said, but treatment can change the experience of pain, which can lead to improved outcomes.

In addition to antidepressant medications when warranted, various nonpharmacologic strategies, including patient psychoeducation, and cognitive-behavioral interventions, can give chronic pain patients a sense of control over their pain and the tools needed to modify behaviors that contribute to emotional and physical distress.

The bottom line, according to chronic pain expert Robert D. Kerns, Ph.D., associate professor in the departments of psychiatry, neurology, and psychology at Yale University, New Haven, Conn., is that patients with chronic pain have to be viewed from a broad biopsychosocial perspective.

“For greatest effectiveness [in managing chronic pain], we should be treating the whole person, not fixing a 'broken' body part,” Dr. Kerns said.

Perspective

DR. BELL is chief executive officer and president of Community Mental Health Council Inc. in Chicago and serves as director of public and community psychiatry at the University of Illinoisat Chicago.

People who have chronic pain are extraordinarily clear about the devastating impact this problem has on their psychological balance. The resulting sense of helplessness often generates a great deal of grief, depression, stress, pessimism, and loneliness.

People who have never experienced severe, chronic pain, however, have no idea how disruptive it can be. Because of this, they may erroneously assume (and even suggest) that the pain is purely psychological or a sign of weakness of character or will–sentiments that further isolate and alienate the sufferers.

This isolation is exacerbated by the current health care culture. Although some understanding exists of the medical conundrum of pain, the psychiatric ramifications are very much an afterthought. The proactive approach of considering mind and body takes a back seat to the mechanistic approach of trying to heal the physical body while ignoring the mind.

This approach is rather typical of Western medicine and has its origins as far back as the Descartes doctrine of the distinction between the mind and body.

Because Western medicine focuses so intently on the mechanistic view of life and well-being, we don't have evidence of the efficacy of other, more esoteric forms of healing, such as acupuncture, meditation, prayer, and support group activities. We won't be able to collect such evidence until Western health care providers routinely begin to embrace non-Western approaches to health care that address issues of both the mind and the body.

Fortunately, science may be taking us in that direction. The mechanism of pain has been connected to the serotoninergic neurotransmitter system in the brain and body, which is also linked to depression. This connection suggests a potential route for therapeutic benefit of antidepressant medications for chronic pain.

Bridging the mind/body gap in our management of chronic pain is not impossible, but doing so does require a critical culture shift in which neither element takes a backseat to the other.

Pain Relief Is a Phone Call Away

Patients suffering from chronic, nonmalignant pain generally have to come to terms with the fact that finding a cure for their symptoms is an elusive goal. A more reasonable treatment target is pain management, often through some combination of analgesic medication and behavior modification.

In fact, numerous studies have shown that behavioral interventions–particularly cognitive-behavioral therapy (CBT) and self-regulatory techniques such as biofeedback and hypnosis–can significantly reduce pain intensity and improve emotional and physical functioning.

Ideally, after participating in a behavioral intervention, patients will regularly access and employ the various coping strategies they've acquired. Realistically, the likelihood that they will do so diminishes over time.

Although it may not be feasible to conduct open-ended behavioral intervention groups, pain specialists at the University of Vermont in Burlington may have developed the next best thing. Therapeutic Interactive Voice Response (TIVR) was developed to enhance the therapeutic outcome of patients who have completed a course of group CBT for chronic pain and to minimize their reliance on pharmacologic painkillers.

The first component of the TIVR enhancement is a daily self-monitoring questionnaire. Patients access the computerized interactive telephone system and respond by touch-pad to a series of questions that measure coping, perceived pain control, mood, medication, and stress. The objective is to improve self-monitoring of pain behavior, coping skills, and medication use, said TIVR principal investigator Dr. Magdalena R. Naylor, director of the university's MindBody Medicine Clinic.

If patients desire a coping skills “refresher,” they can access a didactic review that provides a verbal review of the various pain management skills learned during the CBT intervention, such as relaxation response, positive self-talk, cognitive restructuring, and distraction techniques.

The final component is a monthly feedback message: A therapist analyzes computer-collated, patient-specific data from the telephone response system and records a personalized message for participants summarizing the daily reports and offering insight into potential problem areas. This element is critical to the efficacy of the system, according to Dr. Naylor, as it is a vehicle for valuable feedback and an ongoing positive connection with the therapist.

In a pilot test of TIVR in a group of 10 middle-aged patients with severe, chronic musculoskeletal pain, regular use of the TIVR both maintained and strengthened the therapeutic gains associated with the CBT intervention (J. Pain 2002;3:429–38).

The Vermont investigators are currently replicating the TIVR study in a randomized, controlled trial.

By Diana Mahoney, New England bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com

Chronic pain cuts wide. One out of every five people lives with some sort of chronic pain. Of that 20%, one-third are not able or are only minimally able to maintain an independent lifestyle because of it, according to the International Association for the Study of Pain.

And chronic pain cuts deep. Beneath the veneer of the physical symptoms lies the social, emotional, and psychological havoc caused by the associated disability, isolation, fear, and helplessness, which leads to a substantially diminished quality of life.

Unfortunately, chronic pain is also invisible. There's no gash to suture, no broken leg to set. Instead, there exists an amorphous condition that is difficult to measure and even more difficult to manage, particularly in a health care culture that values cut-and-dry diagnoses and magic pills. Adding to the complexity is the fact that chronic pain often coexists with a range of psychological disorders, including depression, anxiety, personality disorders, cognitive problems, and substance abuse.

In one study designed to assess the prevalence of chronic pain conditions and their relationship with major depressive disorder (MDD), investigators from Stanford (Calif.) University conducted a cross-sectional telephone survey of a random sample of nearly 19,000 subjects from the general population.

About 4% of the survey participants met the diagnostic criteria for MDD, and of those, 43.5% reported having at least one chronic pain condition–a number four times greater than reported by individuals in the study who did not have depression (Arch. Gen. Psychiatry 2003;60:39–47).

More recently, another Stanford study sought to evaluate the strength of the association between major depression and chronic pain and to examine the clinical burden associated with the two conditions. Of nearly 6,000 randomly sampled primary care patients who responded to a questionnaire, about 7% met criteria for MDD, and two-thirds of those with depression reported chronic pain. Among all of the subjects in the sample who reported chronic pain, the prevalence of MDD was significantly higher than in those without pain (Psychosom. Med. 2006;68:262–8).

The direction of the pain/depression connection has yet to be fully understood, but the degree of disability appears to play an important role, according to lead investigator Bruce A. Arnow, Ph.D. Among those respondents with chronic pain, the prevalence of MDD was 23% in people with disabling pain, compared with 5% in those who were not disabled by their pain. “It's possible that those who are disabled by pain become depressed, and it is possible that those who are depressed are more likely to become disabled,” he said.

Regardless of initial direction, the likelihood that one will coexist with the other warrants that both be addressed. Numerous studies have shown that depressed chronic pain patients report greater pain intensity, more malignant disease course, and poorer response to pain treatments. Additionally, depression can impede rehabilitation efforts because of low motivation, poor morale, low energy, and hopelessness.

In contrast, considering the physical and mental health components of chronic pain as symptoms of a single pain syndrome can improve patient outcome. A large, multisite investigation of depression care from the University of Washington, Seattle, showed that older adults with chronic arthritis pain who were screened and treated for depression had significant improvements in pain severity and functioning, compared with those patients who received standard arthritis care. The treatment group benefited from a multidisciplinary program that included medication, psychotherapy, and in-person and telephone follow-up (JAMA 2003;290:2428–9).

The multidisciplinary intervention “not only helped patients with arthritis feel less depressed but also helped them cope better with their pain, to be more active, and to have a higher quality of life,” according to lead investigator Dr. Elizabeth H.B. Lin of the Group Health Cooperative in Seattle. Treating patients' depression isn't going to take the pain away, she said, but treatment can change the experience of pain, which can lead to improved outcomes.

In addition to antidepressant medications when warranted, various nonpharmacologic strategies, including patient psychoeducation, and cognitive-behavioral interventions, can give chronic pain patients a sense of control over their pain and the tools needed to modify behaviors that contribute to emotional and physical distress.

The bottom line, according to chronic pain expert Robert D. Kerns, Ph.D., associate professor in the departments of psychiatry, neurology, and psychology at Yale University, New Haven, Conn., is that patients with chronic pain have to be viewed from a broad biopsychosocial perspective.

“For greatest effectiveness [in managing chronic pain], we should be treating the whole person, not fixing a 'broken' body part,” Dr. Kerns said.

Perspective

DR. BELL is chief executive officer and president of Community Mental Health Council Inc. in Chicago and serves as director of public and community psychiatry at the University of Illinoisat Chicago.

People who have chronic pain are extraordinarily clear about the devastating impact this problem has on their psychological balance. The resulting sense of helplessness often generates a great deal of grief, depression, stress, pessimism, and loneliness.

People who have never experienced severe, chronic pain, however, have no idea how disruptive it can be. Because of this, they may erroneously assume (and even suggest) that the pain is purely psychological or a sign of weakness of character or will–sentiments that further isolate and alienate the sufferers.

This isolation is exacerbated by the current health care culture. Although some understanding exists of the medical conundrum of pain, the psychiatric ramifications are very much an afterthought. The proactive approach of considering mind and body takes a back seat to the mechanistic approach of trying to heal the physical body while ignoring the mind.

This approach is rather typical of Western medicine and has its origins as far back as the Descartes doctrine of the distinction between the mind and body.

Because Western medicine focuses so intently on the mechanistic view of life and well-being, we don't have evidence of the efficacy of other, more esoteric forms of healing, such as acupuncture, meditation, prayer, and support group activities. We won't be able to collect such evidence until Western health care providers routinely begin to embrace non-Western approaches to health care that address issues of both the mind and the body.

Fortunately, science may be taking us in that direction. The mechanism of pain has been connected to the serotoninergic neurotransmitter system in the brain and body, which is also linked to depression. This connection suggests a potential route for therapeutic benefit of antidepressant medications for chronic pain.

Bridging the mind/body gap in our management of chronic pain is not impossible, but doing so does require a critical culture shift in which neither element takes a backseat to the other.

Pain Relief Is a Phone Call Away

Patients suffering from chronic, nonmalignant pain generally have to come to terms with the fact that finding a cure for their symptoms is an elusive goal. A more reasonable treatment target is pain management, often through some combination of analgesic medication and behavior modification.

In fact, numerous studies have shown that behavioral interventions–particularly cognitive-behavioral therapy (CBT) and self-regulatory techniques such as biofeedback and hypnosis–can significantly reduce pain intensity and improve emotional and physical functioning.

Ideally, after participating in a behavioral intervention, patients will regularly access and employ the various coping strategies they've acquired. Realistically, the likelihood that they will do so diminishes over time.

Although it may not be feasible to conduct open-ended behavioral intervention groups, pain specialists at the University of Vermont in Burlington may have developed the next best thing. Therapeutic Interactive Voice Response (TIVR) was developed to enhance the therapeutic outcome of patients who have completed a course of group CBT for chronic pain and to minimize their reliance on pharmacologic painkillers.

The first component of the TIVR enhancement is a daily self-monitoring questionnaire. Patients access the computerized interactive telephone system and respond by touch-pad to a series of questions that measure coping, perceived pain control, mood, medication, and stress. The objective is to improve self-monitoring of pain behavior, coping skills, and medication use, said TIVR principal investigator Dr. Magdalena R. Naylor, director of the university's MindBody Medicine Clinic.

If patients desire a coping skills “refresher,” they can access a didactic review that provides a verbal review of the various pain management skills learned during the CBT intervention, such as relaxation response, positive self-talk, cognitive restructuring, and distraction techniques.

The final component is a monthly feedback message: A therapist analyzes computer-collated, patient-specific data from the telephone response system and records a personalized message for participants summarizing the daily reports and offering insight into potential problem areas. This element is critical to the efficacy of the system, according to Dr. Naylor, as it is a vehicle for valuable feedback and an ongoing positive connection with the therapist.

In a pilot test of TIVR in a group of 10 middle-aged patients with severe, chronic musculoskeletal pain, regular use of the TIVR both maintained and strengthened the therapeutic gains associated with the CBT intervention (J. Pain 2002;3:429–38).

The Vermont investigators are currently replicating the TIVR study in a randomized, controlled trial.