Letters to the Editor / General Hospital Psychiatry 36 (2014) 228–229

Authors’ response to the letter to the editor: “Pain in primary care patients with bipolar disorder” To the Editor, In a recently published paper in General Hospital Psychiatry [1], we described the association between a diagnosis of a serious mental illness and a chronic pain condition. In a national sample of all patients who utilized services from the Veterans Health Administration within a given year, those individuals with schizophrenia and bipolar disorder were significantly more likely to have a chart diagnosis of chronic pain compared to those without these psychiatric diagnoses. We concluded that this line of research has important implications for understanding how chronic pain might impact mental health recovery. Cerimele et al. [2] extended these findings by presenting supporting data from a large study of primary care patients who were assessed using semi-structured interviews. Specifically, they reported that nearly half of the patients in the Washington State Mental Health Integration Program who were diagnosed with bipolar disorder were currently receiving treatment for pain or having difficulties due to pain interfering with their functioning. Additionally, the authors noted a high level of suicidal ideation in their sample of patients, and this may have been partially related to high level of comorbid pain as past research has established [3]. We thank Cerimele and colleagues for providing information to further highlight the importance of understanding the general association and consequences of co-occurring pain and serious mental illness. The data presented by Cerimele [2] are also very interesting, as they described the prevalence of pain conditions as perceived by the patient, above and beyond the chart diagnoses given by providers. In this study, 46% of patients with bipolar disorder were receiving pain treatment or endorsed pain interfering with daily functioning. Our study [1] reported slightly higher rates, with 61% of patients with bipolar disorder having a diagnosis of a chronic pain condition. There were some important demographic differences, such as our study consisting of 85% male (vs 66%) and exclusively patients being served in a VA hospital setting, which typically serve patients with greater medical and psychiatric severity than other healthcare settings. Across these two different samples, the convergence of findings regarding the generally elevated rate of pain and pain-related problems among those with bipolar disorder highlight that pain is a significant concern in many, and in some cases the majority, of patients with bipolar disorder. Chronic pain is common in the United States community [4] and clinical settings [5] and appears to have particularly problematic consequences for those individuals with a serious mental illness such as schizophrenia or bipolar disorder. Patients with serious mental illness may be less likely to know about and understand their medical difficulties [6], and this could limit their overall recovery and psychosocial functioning. Although we [1] and Cerimele and colleagues [2] have presented information regarding these comorbidities, there is much more to be known. For example, it is still unclear

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how the occurrence of chronic pain might impact treatment for psychiatric disorders, and whether providers might overlook comorbid conditions in lieu of treating over psychiatric symptoms. It is important for researchers to conduct further work to describe the longitudinal associations between pain and psychiatric symptoms as well as how treatment for one or both conditions influences their course and intensity over time. Denis G. Birgenheir Ph.D. Mark A. Ilgen Ph.D. Amy S.B. Bohnert Ph.D. Kristen M. Abraham Ph.D. Nicholas W. Bowersox Ph.D. Department of Veterans Affairs Healthcare System VA Serious Mental Illness Treatment Resource and Evaluation Center Ann Arbor, MI Department of Psychiatry University of Michigan Ann Arbor, MI E-mail address: [email protected] Karen Austin M.P.H. Department of Veterans Affairs Healthcare System VA Serious Mental Illness Treatment Resource and Evaluation Center Ann Arbor, MI Amy M. Kilbourne Ph.D., M.P.H. Department of Veterans Affairs Healthcare System VA Serious Mental Illness Treatment Resource and Evaluation Center Ann Arbor, MI Department of Psychiatry University of Michigan Ann Arbor, MI

http://dx.doi.org/10.1016/j.genhosppsych.2013.11.005

References [1] Birgenheir DG, Ilgen MA, Bohnert AS, Abraham KM, Bowersox NW, Austin K, et al. Pain conditions among veterans with schizophrenia or bipolar disorder. Gen Hosp Psychiatry 2013;35(5):480–4. [2] Cerimele JM, Chan Y, Chwastiak LA, Unutzer J. Pain in primary care patients with bipolar disorder. Gen Hosp Psychiatry 2013 [in press]. [3] Ilgen MA, Zivin K, McCammon RJ, Valenstein M. Pain and suicidal thoughts, plans and attempts in the United States. Gen Hosp Psychiatry 2008;30(6):521–7. [4] Krueger AB, Stone AA. Assessment of pain: a community-based diary survey in the USA. Lancet 2008;371(9623):1519–25. [5] Kerns RD, Otis J, Rosenberg R, Reid MC. Veterans' reports of pain and associations with ratings of health, health-risk behaviors, affective distress, and use of the healthcare system. J Rehabil Res Dev 2003;40(5):371–9. [6] Kilbourne AM, McCarthy JF, Welsh D, Blow F. Recognition of co-occurring medical conditions among patients with serious mental illness. J Nerv Ment Dis 2006; 194(8):598–602.

Authors' response to the letter to the editor: "Pain in primary care patients with bipolar disorder".

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