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Depression Should Not Delay Appropriate Treatment for Pelvic Pain
Abstract & Commentary
By Frank W. Ling, MD, Clinical Professor, Department of Obstetrics and Gynecology, Vanderbilt University School of Medicine, Nashville, TN, is Associate Editor for OB/GYN Clinical Alert.
Dr. Ling reports no financial relationship to this field of study.
Synopsis:The presence of clinical depression in patients with chronic pelvic pain should not delay the appropriate treatment of the identified cause(s) of the pain.
Source: Learman LA, et al. Symptom resolution after hysterectomy and alternative treatments for chronic pelvic pain: Does depression make a difference? Am J Obstet Gynecol 2011;204:269.
Among 701 women with chronic pelvic pain (CPP), 22% were affected by clinical depression. After undergoing either surgery (including hysterectomy) or non-surgical alternatives, response to the therapy was found to be independent of the presence of depression. Besides hysterectomy in approximately 10% of subjects, other surgical interventions included removal/destruction of endometriosis and oophorectomy (without hysterectomy). Non-surgical treatments included GnRH agonist, narcotics, hormone therapy, acupuncture, neuropathic treatment, and physical therapy. Depression was not a predictor of symptom resolution in these patients with CPP; however, factors that were included age, being a college graduate, and the ability to enjoy sexual activity (which, to some extent, is a reflection of quality of life).
Do you remember the Lerner and Loewe Broadway play (and subsequent movie by the same name) "My Fair Lady"? More to the point, do you remember a song from that play titled "Wouldn't It Be Loverly"? It was sung by Eliza Doolittle expressing her wish for a life better than selling flowers on the streets of London. Have I lost you? I couldn't help but think of this song as I read this article and thought about its clinical implications. Why? Because it certainly would be "loverly," i.e., "lovely," if all patients with CPP were evaluated and followed as carefully as the population in this study by clinicians providing women's health care.
Much to the credit of these San Francisco Bay Area authors, they were able to study and follow a large number of patients with CPP as they underwent both surgical and non-surgical interventions. The primary focus of this presentation, which won an award at the annual meeting of the Central Association of Obstetricians and Gynecologists, was whether the presence of clinical depression had an effect on the outcome of those therapies. Previous research suggested that depressed patients had poorer outcomes after hysterectomy than those who were not depressed. In fact, this study, which was done in a prospective fashion (and therefore carries with it greater scientific validity) found that the presence or absence of depression did not significantly affect how much the patient improved.
This truly is a "lovely" study because it reminds us that patients with CPP do have depression, 22% in this study, with a range of 12% to 35% cited in the literature. It also tells us that we should use whatever treatment(s) is/are indicated with the understanding that treatment of depression is not to the exclusion of other modalities. Hopefully, this encourages all of us to be looking for the possibility of depression but not thinking that other treatments need to be delayed until depression is cured. In fact, we know from the psychiatric literature that initial antidepressant therapy is not always successful, and that even when it is, antidepressants may take 4 to 6 weeks or longer to have a significant effect. During that time, other treatments, both surgical and nonsurgical, can certainly be implemented. The range of treatments sought by the patients in this study hopefully reflects the type of considerations we look at when facing these challenging presentations.
So wouldn't it be "loverly" if all CPP patients received evaluations that included possible etiologies beyond just pelvic pathology while simultaneously being treated for depression? By no means am I calling for treatment for depression in all CPP patients. What I do suggest is that a better quality of life for these patients is possible if we evaluate all, and treat those who need it.