October 2010
Reviewer: Jeff C. Huffman, MD

The impact of pain and depression on recovery after coronary artery bypass grafting

Morone NE, Weiner DK, Belnap BH, et al
Psychosom Med 2010; 72(7):620-625

Background:  Depression following coronary artery bypass graft (CABG) surgery is common and associated with substantial impairment of medical and functional recovery. Pain in depressed patients has been associated with poorer response to depression treatment and with poorer physical function compared to depressed patients without pain. The combined effects of pain and depression on post-CABG recovery, however, had not been examined.

Methods:  This was a secondary analysis of data from the Bypassing the Blues study, a randomized trial of collaborative care depression management for post-CABG patients (reviewed in a prior Articles of Interest). Briefly, this trial enrolled 352 patients who met depression criteria two weeks after hospitalization for CABG (and 150 nondepressed controls) and randomized the depressed patients to collaborative care or treatment as usual. For the purposes of this secondary analysis, key measures were pain (as measured by the SF-36 bodily pain score), depression (as measured by the Hamilton Rating Scale for Depression [HRS-D]), and function (as measured by the Duke Activity Status Index [DASI]). Standard regression and mixed effects models were used to examine several research questions on the relationship to pain, depression, and function in this cohort.

Results:  The authors examined the relationship between these three variables from multiple angles. To sum up:

• Patients with at least moderate pain at baseline had worse functional recovery after CABG throughout the next year versus those who reported less or no pain.
• Depressed post-CABG patients reported more pain than nondepressed post-CABG patients at baseline and throughout the one-year follow-up period.
• Depressed post-CABG patients with at least moderate pain at baseline had (a) significantly worse recovery from depression; and (b) inferior physical function/recovery over the one-year follow-up period, compared to depressed patients with less/no pain.
• The collaborative care intervention for depression was less likely to result in depression improvement for patients in moderate pain at baseline than for those in less/no pain.

Discussion:  In many ways, these results are not a surprise: pain and depression are associated with poor surgical recovery, and the presence of pain impedes recovery from depression. However, given the critical importance of functional recovery in post-CABG patients—and the fact that depression is associated with mortality in cardiac patients—finding ways to better treat depression and improve functional recovery in CABG patients with coexisting pain and depression is an important public health problem.

Unfortunately, managing depression alone does not appear to lead to excellent outcomes in these patients, as evidenced by the results in this study. However, a telephone-based care management approach by Kroenke and colleagues (JAMA 2010; 304(2):163-171) that included interventions for both pain and depression, did result in meaningful improvements in outcomes in patients with cancer, and such an approach that simultaneously addresses both conditions is very promising.

In sum, medically ill patients (in this case post-CABG patients) with both pain and depression are at high risk for persistent depression and poor functional recovery, and this is a major public health issue. However, treatment approaches that address both pain and depression do appear to have great promise in this important and complex population.

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