Multidisciplinary biopsychosocial rehabilitation for chronic low back pain: Cochrane systematic review and meta-analysis

Thank you for a well written review.

As psychiatrists we would like to advocate and highlight the need for the role of integrated mental health services in the multidisciplinary management of chronic conditions especially in pain management.

Chronic back pain is a common pain condition; it results in significant personal, social and occupational impairment, role disability and health care utilization.

Epidemiologic studies have found that chronic back pain is comorbid with psychiatric disorders, other chronic pain conditions (migraine, arthritis, headache) and chronic psychical conditions.1,2

Promoting a multidisciplinary biopsychosocial rehabilitation to manage chronic back pain is very much in keeping with the principles promoted by mental health rehabilitation.

Mental health rehabilitation services have always worked towards promoting ‘a whole systems approach to recovery from mental illness that maximises an individual’s quality of life and social inclusion by encouraging their skills, promoting independence and autonomy in order to give them hope for the future and leading to successful community living through appropriate support’3.

Back pain experienced beyond three month duration is defined as chronic and is often associated with both comorbid depression and anxiety. The combination of depression and pain is associated with worse outcomes than either condition alone, and it is important to recognize psychiatric disorders in clinical and primary care settings.4

Care providers should be aware of the co-occurrence of chronic back pain and psychiatric disorders, of the elevated risk patients with chronic back pain have of developing mood and anxiety disorders and of the elevated risk people with anxiety disorders have to develop chronic back pain. The simultaneous treatment of both chronic back pain and psychiatric disorders is needed to improve overall pain outcomes.

Consideration must also be given to medically unexplained symptoms which often go hand in hand with pain syndromes. Medically unexplained symptoms account for 20% of new presentations in primary care and 20–40% of medical out-patient referrals 5. Patients with medically unexplained symptoms often undergo potentially unnecessary, costly and sometimes damaging investigations and treatment 6. Adding liaison psychiatry to medical management offers a cost-effective and evidence-based approach to delivering integrated care for people with comorbid physical and mental disorders, particularly those with long-term conditions and medically unexplained symptoms.

References
1. Raspe A, Matthis C, Heon-Klin V eta al Chronic back pain: more than pain in the back. Findings of a regional survey among insurees of a workers pension insurance fund. Rehabilitation 42:195-203, 2003.
2. Hestbaek L. Leboef-Yde C, Manniche C. Is low back pain part of a general health pattern or is it a separate and distinct entity? A critical review of comorbidity with low back pain. Journal Manipul Physiol Ther 26:243-252, 2003.
3. Killaspy, H., Harden, C., Holloway, F., et al (2005) What do mental health rehabilitation services do and what are they for? A national survey in England. Journal of Mental Health, 14, 157–165.
4. Bair MJ, Robinson RL, Katon W, etal. Depression and pain comorbidity: a literature review. Arch Intern Med 163:2433-45, 2003.
5. Royal College of Psychiatrists & Academy of Medical Royal Colleges (2009) No Health without Mental Health: The ALERT Summary Report. AoMRC.
6. NHS Commissioning Support for London (2011) Medically Unexplained Symptoms (MUS): Project Implementation Report. NHS Commissioning Support for London.