Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study: design and practical implications of an intervention for comorbid pain and depression.

OBJECTIVE: Depression and pain are common comorbid conditions that have reciprocal adverse effects on disability and treatment outcomes. The objective of this article is to describe a study that tests the effectiveness of a stepped-care approach using a combined medication-behavioral intervention.

METHOD: Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) is an NIMH-sponsored randomized clinical trial nested within a prospective cohort study. A total of 250 patients with clinically significant depression (PHQ-9 scores > or =10) and musculoskeletal pain of the lower back or legs (hip or knee) and 250 nondepressed patients with similar pain are enrolled, with baseline and serial follow-up assessments to be conducted over 12 months. The depressed patients are randomized to either a stepped-care intervention group or a usual-care control group. Stepped-care patients receive 12 weeks of optimized antidepressant management (Step 1) followed by six sessions of a pain self-management (PSM) program over the next 12 weeks (Step 2), all delivered by a nurse care manager who is supervised by a physician specialist. Approximately two thirds of the care manager contacts are by telephone.

RESULTS: The target sample of 500 subjects has been successfully enrolled, and randomization of the depressed patients has resulted in balanced groups of patients with moderately severe pain and depression. Mean SCL-20 depression severity in the clinical trial group is 1.9, with most meeting DSM-IV criteria for major depression (76.3%) and the rest having dysthymia only (18.4%) or minor depression (5.3%). Pain is about equally distributed between lower back (53%) and hip or knee (47%). A rational algorithmic approach to antidepressant selection and dosing, as well as an overview of the PSM program, is provided.

CONCLUSIONS: When completed, SCAMP will test whether optimized antidepressant management improves outcomes in patients with comorbid depression and pain and whether PSM produces additional benefits. The findings will be important for both primary care and mental health clinicians confronted by the prevalent depression-pain dyad.