Clinical depression and chronic pain are strongly bidirectional and interrelated. In the general population, patients with chronic pain are more likely to have clinical depression and vice versa, and the same is true in patients with sickle cell disease (SCD).
Previous systematic reviews have reported a prevalence of clinically significant depression in patients with SCD at a rate of 29% to 34%, which is much higher than rates in the general population. In addition to acute pain from periodic vaso-occlusive crises, the majority of adult patients with SCD also experience varying levels of chronic pain, the etiology of which is less clear. Patients with SCD and elevated depressive symptoms tend to have increased intensity and frequency of pain attacks and more hospitalizations.1
Pat Carroll, MD, director of psychiatric services at the Sickle Center for Adults and an associate professor of psychiatry and behavioral sciences at Johns Hopkins Hospital in Baltimore, explained that although the association between depressive symptoms and chronic pain in SCD is well established, it’s been unclear how to best address this in terms of nondrug interventions that can be readily accessible to patients.
In the large national CaRISMA (Cognitive Behavioral Therapy and Real-Time Pain Management Intervention for Sickle Cell via Mobile Applications) study, Dr. Carroll and colleagues are exploring nondrug, affordable, easily accessible approaches to improve symptoms of both depression and chronic pain in SCD using a mobile phone app.
The team compared potential improvements with education on pain and the disease versus digitally delivered cognitive behavioral therapy in patients 18 years or older with SCD and chronic pain. Preliminary trial findings presented at the 2023 American Society of Hematology Annual Meeting and Exposition suggest that both interventions may benefit mental health and pain.2,3
A recently published analysis used additional initial blinded data and self-reported assessments from the trial. Almost 40% of participants (141 of 357) had high depressive symptoms, as identified on the Patient Health Questionnaire (PHQ ≥ 10). Patients with high depressive symptoms had increased maladaptive cognitive responses (i.e., catastrophizing), as well as increased pain frequency, severity, pain interference, and social and emotional impacts from their pain, as assessed by the Adult Sickle Cell Quality of Life Measurement system. Patients who had high depressive symptoms also had an increased risk of opioid misuse, as assessed by the Current Opioid Misuse Measure (COMM).1
Dr. Carroll pointed out that the COMM wasn’t developed or validated for patients with SCD, and it makes sense that patients living with repeated episodes of acute pain and high rates of depression would score higher on the measure. He emphasized that the finding should not be used to restrict access to opioids in patients with SCD, in whom acute episodes of pain are often not treated aggressively or quickly enough. “Ideally, we should have interdisciplinary teams that know SCD, know the patient, and who can then make appropriate clinical decisions,” he said.
Dr. Carroll stressed that mental health screening should be an important part of routine care for SCD, although this can be challenging because of the way general medicine and psychiatric care are often siloed. Another challenge is communication because many patients with SCD have had their experiences of pain unfairly doubted. When screening for depression in patients with SCD as part of overall care, it may be helpful for clinicians to emphasize to patients that they aren’t dismissing or diminishing their pain, but rather trying to find more ways to help.
Dr. Carroll also pointed out that no randomized trials of specific treatments for chronic pain and SCD have been performed, so that’s an important area for future research. Additionally, little is known about whether clinical depression in SCD responds to treatment in the same way as depression in the general population, including response to standard antidepressant medications. “You might need to treat pretty aggressively to get them to work in patients with SCD,” he added.
“We need to build better systems to treat depression and pain. These kinds of digital interventions may eventually be part of that,” Dr. Carroll said.
Any conflicts of interest declared by the authors can be found in the original article.
References
- Jonassaint CR, Parchuri E, O’Brien JA, et al. Mental health, pain and likelihood of opioid misuse among adults with sickle cell disease. Br J Haematol [published online ahead of print, 2024 Jan 3]. doi: 10.1111/bjh.19243.
- Badawy SM, Abebe KZ, Reichman CA, et al. Comparing the effectiveness of education versus digital cognitive behavioral therapy for adults with sickle cell disease: protocol for the Cognitive Behavioral Therapy and Real-time Pain Management Intervention for Sickle Cell via Mobile Applications (CaRISMA) study. JMIR Res Protoc. 2021;10(5):e29014.
- Jonassaint CR, Lalama CM, O’Brien JA, et al. A randomized clinical trial testing the effect of digital behavioral interventions on pain and mental health among adults with sickle cell disease. Blood. 2023;142(S1):789.