Standardizing the Use of Mental Health Screening Instruments in Patients With Pain

Chronic pain is more prevalent in the US than diabetes mellitus, cancer, and cardiovascular disease combined, impacting about 100 million adults.¹ The annual cost of all that pain in the US is between $560 and $635 billion.¹

The high prevalence of chronic pain among active duty service members and veterans remains a pressing concern given its negative impact on military readiness, health care utilization, productivity, quality of life, and chronic disability rates.² Pain was found to be the leading complaint of service members returning from Operations Iraqi Freedom and Enduring Freedomand 44% of veterans returning from deployment suffered with chronic pain.^3,4

Chronic pain often occurs in the presence of comorbidities. In one study for example, 45% of primary care patients with chronic pain (N = 250) screened positive for ≥ 1 of the 5 types of common anxiety disorders, and those with anxiety disorder had higher pain scores.⁵ Another study involving almost 6000 participants found that anxiety disorders were present in 35% of people with chronic pain compared with 18% in the general population.⁶

In addition, military members are prone to depression with a rate of major depressive disorder that is 5% higher than that of civilians.⁷ Depression often is underdiagnosed and undertreated. According to a National Center for Health Statistics, only 35% of those with symptoms of severe depression in the US saw a mental health provider in the previous year.⁸ Comorbid depression, anxiety, and chronic pain are strongly associated with more severe pain, greater disability, and poorer health-related quality of life.⁹

As a result, there was a call for system-level interventions to increase access to, and continuity of, mental health care services for active duty service members and veterans.¹ It has been recommended that depression and anxiety screenings take place in primary and secondary care clinics.¹⁰ Standardized referral processes also are needed to enhance mental health diagnosis and referral techniques.¹¹ Although various screening tools are available that have excellent reliability and construct validity (eg, General Anxiety Disorder-7 [GAD-7], Patient Health Questionnaire-9 [PHQ-9]), they are underutilized.¹² I have witnessed a noticeable gap between clinical practice guidelines and current practice associated with chronic pain and screening for anxiety and depression within the Pain Management Clinic at Navy Medical Center of Camp Lejeune (NMCCL) in North Carolina.

Methods

The premise of this performance improvement (PI) project was to reduce missed opportunities of screening for anxiety and depression, and to examine the impact of the standardized use of the GAD-7 and PHQ-9 on the rate of mental health care referrals. The Theory of Unpleasant Symptoms was chosen as the underpinning of the project because it suggests that symptoms often cluster, and that the occurrence of multiple symptoms makes each of those, as well as other symptoms, worse.¹³ The PI model used the find, organize, clarify, understand, select (FOCUS), and plan, do, check, act (PDCA) models.¹⁴ The facility institutional review board ruled that this performance improvement project did not qualify as human research.

Inclusion and exclusion criteria

Patients were included if they were active duty service members aged 18 to 56 years at the initial patient encounter. Veterans and dependents were not part of the sample because of the high clinic volume. Patients who received mental health care services within the previous 90 days were excluded.