ADAPT: Addressing Pain and Depression Together

The ADAPT trial assessed the utility of a stepped-care approach for older patients presenting in primary care settings with depression and CLBP for whom previous treatment failed.6


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The primary aim of the study was to compare combined high-dose venlafaxine with problem-solving therapy for depression and pain (PST-DP) with high-dose venlafaxine with supportive management (SM) to determine outcomes on depression, pain, and disability scales.

The study involved 250 patients assigned to 6-week treatment with lower-dose venlafaxine (up to 150 mg/d) with SM. Those who responded to treatment as defined as a score less than 5 on the 9-item Patient Health Questionnaire (PHQ-9) and a greater than 30% improvement on the Numeric Rating Scale for Pain (NRS) left the study.

In phase 2, patients whose depression did not respond to treatment were assigned to either 14-week treatment with higher-dose venlafaxine (up to 300 mg/d) and SM (n = 71) or 14-week treatment with higher-dose venlafaxine (up to 300 mg/d) and PST-DP (n = 68). The median venlafaxine dosage was 244 mg/d. On average patients in the PST-DP group received 8.4 sessions and those in the SM group received 9.2 sessions.

Remission was defined as a positive response as demonstrated by a PHQ-9 score less than 5 and a greater than 30% reduction on the NRS on two sequential visits.

Comparing the PST-DP group vs the SM group, final remission rates were 31% vs 18% on both pain and depression outcomes (P = .11); 44% vs 33% on depression outcomes (P = .17); and 43% vs 47% on pain (P = .73), respectively.

“In older adults, no significant difference in depression was seen when comparing medication and psychotherapy, but combined treatment is significantly better than medication alone,” Dr. Karp said. “Combined treatment seems to be the best treatment option in this group.”

Disclosures: Pfizer and Reckitt Benckiser provided medication for the trials reported.

References

1. Lebowitz BD, Pearson JL, Schneider LS, et al. Diagnosis and treatment of depression in late life.  Consensus statement update. JAMA. 1997;278:1186-1190.

2. Lenze EJ, Mulsant BH, Shear MK, et al. Comorbid anxiety in depressed elderly patients. Am J Psychiatry. 2000;157:722-728.

3. Blazer DG. Depression in late life: review and commentary.  J Gerontol. 2003; 58A(3):3249-265.

4. Lyness JM, Caine ED, King DA, Cox C, Yoediono Z. Psychiatric disorders in older primary care patients.  J Gen Intern Med. 1999;14(4):249-254.

5. Brown SC, Glass JM, Park DC. The relationship of pain and depression to cognitive function in rheumatoid arthritis patients. Pain. 2002;96(3):279-284.

6. Karp JF, Rollman BL, Reynolds CF III, et al. Addressing both depression and pain in late-life: the methodology of the ADAPT study. Pain Med. 2012;13(3):405-418.