The following primary hypotheses will be tested:
1. During Step 1: Major Depressive Disorder (MDD) or Chronic Low Back Pain (CLBP) in < 40%
of the initial 60 subjects treated with duloxetine (DUL) + Clinical Management(CM)
during the first 8 weeks will respond (response is defined as a Montgomery Asberg
Depression Rating Scale (MADRS) score </=9 and at least a 30% improvement in back pain
as measured with the 20-point numeric rating scale.
2. During Step 2: More DUL+Problem Solving Therapy for Depression and Pain (PST-DP) than
DUL+CM treated subjects will achieve response during the second 8 weeks, defined as a
MADRS score </=9 and at least a 30% improvement in back pain as measured with the
2-point numeric rating scale.
3. Improvement in depression scores will be correlated with improvement in CLBP scores.
The exploratory hypotheses to be tested are that:
During Step 2: Compared to subjects treated with DUL+CM, subjects treated with DUL+PST-DP
will have improved outcomes in: 1) disability, 2) sleep, 2) functioning/quality of life, 3)
caregiver burden/depression, and 5) analgesic use.
This is a two-part study. Step 1 is an 8-week long open-label trial of duloxetine (DUL) +
clinical management (CM), titrated up to 90 mg/day, for older adults with comorbid major
depressive disorder (MDD) and chronic low back pain (CLBP). At week 8, if subjects have not
responded, the dose of duloxetine is increased to 120 mg/day. Duloxetine will be increased
and continued at 120 mg/day (or highest tolerated dose) for both randomized study groups
(during step 2) to assure medication parity.
Step two starts at week 9 and includes those subjects whose MDD and/or CLBP has not met
criteria for response during Step 1. At week 9 subjects will be randomized to receive
treatment with either: 1) DUL 120 mg/day (or the highest tolerated dose)+ Problem Solving
for Depression and Pain (PST-DP) or 2) DUL 120 mg/day (or highest tolerated dose) + CM. Step
2 will be delivered over the course of 8-10 sessions.
NOTE ADDED 1/5/16: THIS WAS TREATMENT DEVELOPMENT WORK CONDUCTED AS PART OF A CAREER
DEVELOPMENT AWARD. ONLY THE FIRST OPEN-LABEL PART OF THE STUDY WAS COMPLETED, AND THESE
RESULTS HAVE BEEN PUBLISHED AND WILL BE REPORTED HERE ON CLINICALTRIALS.GOV
- Age >/= 60
- Current episode of MDD per SCID DSM-IV criteria
- Must score >/= 16 on the CES-D assessment
- Serum sodium >/=130 mEq/ml
- CLBP of at least moderate severity for more days than not for >/= 3 months
- MADRS score >/= 15
- Sufficiently medically stable to be able to participate in a depression treatment
- Willingness and ability to speak English Access to translators is limited. It would
be unsafe to treat an older adult who does not speak English with an antidepressant
and not be able to effectively communicate with them about their progress and any
side effects. We provide a 24/7 on-call service for all subjects enrolled in this
study. The on-call clinicians and physicians are not bilingual, and if a problem
arose, it may be impossible to effectively interpret and manage the emergent
situation. Finally, many of the assessments used in the study are self-reports. At
the present time, we do not have the ability to translate these instruments into
other languages. If the subject cannot read and understand English, this would
interfere with their ability to complete the self-report assessments
- Willingness to discontinue other antidepressants and anxiolytics, except for
lorazepam up to 2 mg/day
- Mini Mental State Exam > 20
- Willingness to provide informed consent
- Corrected visual ability that enables reading of newspaper headlines and hearing
capacity that is adequate to respond to a raised conversational voice.
- Meet DSM-IV criteria for dementia
- History of bipolar, schizophrenia, schizoaffective, or other psychotic disorder
- Alcohol or other drug abuse (including abuse of prescription medications) within the
past 6 months
- History of treatment non-adherence in other protocols run by the Mid-Life or
- Acute pain superimposed on chronic pain. For example, subjects who report "red flags"
which suggest a herniated disk, vertebral fracture, infection, cauda equina syndrome,
or other medical emergency will be excluded
- Wheelchair bound
- History of documented non-response to duloxetine
- Concurrent use of thioridazine
- Active suicidal ideation with plan
- Uncontrolled narrow angle glaucoma