Psychosocial assessment in chronic pain

Screen every chronic pain patient for psychosocial risk with brief validated tools, then match care to risk: high-risk back pain needs psychologically informed physiotherapy, and low recovery expectations are a modifiable target.

1. Stratify back pain by prognosis. STarT Back assigned low-risk patients a single advice session, medium-risk patients physiotherapy, and high-risk patients psychologically informed physiotherapy addressing psychosocial obstacles to recovery ¹.
2. Stratified care beat best usual care. Roland Morris disability improved more with stratification at 4 months (difference 1.81 points) and 12 months (1.06 points), with QALY gains and cost savings ¹.
3. Screen for depression with PHQ-9. Each of nine DSM-IV criteria scores 0–3; a score of 10 or more had 88% sensitivity and 88% specificity for major depression ².
4. Screen for anxiety with GAD-7. The seven-item scale had good reliability and validity, and its optimal cut point gave 89% sensitivity and 82% specificity for generalized anxiety disorder ³.
5. Ask about expectations. In workers with low back pain, positive return-to-work expectations doubled the adjusted odds of returning; low expectations marked higher risk of long-term work disability ⁴.
6. Use professional interpreters. Compared with ad hoc interpreters such as family members, professional interpreters improved communication, use of services, outcomes and satisfaction for patients with limited English proficiency ⁵.

A family member, especially a child, is not an adequate interpreter for history-taking, risk discussion or consent; professional interpreters reduce communication errors and improve comprehension ⁵.

• PHQ-9 scores of 5, 10, 15 and 20 mark mild, moderate, moderately severe and severe depression ².
• Anxiety and depression co-occur but are distinct dimensions with independent effects on disability ³.
• High-risk STarT Back patients had the highest fear-avoidance and HADS anxiety and depression scores at baseline ¹.
• Physiotherapists delivering the high-risk pathway received 6 days of extra training; medium-risk, 3 days ¹.
• With professional interpreters, care quality for limited English proficiency patients approached or equaled that for patients without language barriers ⁵.
• The PHQ-9 was validated in 6000 primary care and obstetrics-gynecology patients, with similar results in both settings ².
• GAD-7 scores track impairment across all six Short-Form General Health Survey scales and disability days ³.
• Rising PHQ-9 severity tracks falling function, more sick days and more health care use ².

• Giving every back pain patient the same pathway regardless of risk ¹.
• Expecting the stratified-care benefit to stay constant; the effect size fell from 0.32 at 4 months to 0.19 at 12 months ¹.
• Letting a relative interpret consent discussions ⁵.