Kognitiv-behaviorales Training zur Depressionsbewältigung bei chronisch unspezifischen Rückenschmerzen und komorbider Depressivität: Einfluss von Depressivität und Chronifizierungsstadium auf den stationären orthopädishen Rehabilitationserfolg

Background. Chronic low back pain (CLBP) is frequently accompanied by additional psychiatric comorbidity (depression and anxiety). Although the frequent depressive comorbidity represents a risk factor for sustainably rehabilitation outcome, as a rule indication-specific psychological treatment components are missing for the targeted treatment of comorbid depression in previous orthopaedic multidimensional rehabilitation programmes (MDP). An indication-specific cognitive behavioural training for coping with depressive symptoms was developed and embedded in a standard MDP: it was finally crosschecked for its efficiency. Furthermore, differentiated therapy effects were investigated for different stages of chronicity (MPSS I-III). Objectives and Results. First of all, it could be demonstrated that patients with mid-, and high grade depression benefitted from a standard orthopaedic MDP only in the short term regarding their pain coping strategies. Moreover, the effect was more stable in women than in men. Post hoc analyses showed that men with severe depressive symptoms even worsened in respect of their functional capacity and somatization compared to beforehand (Publication I). A cognitive behavioural management training for coping with depressive symptoms was implemented in the MDP (Intervention group, IG) and compared to a standard MDP without any specific psychological components (Control group CG). Both treatment conditions were checked in a subgroup of patients with moderate to high level depression. The rehabilitation success was measured in dependency on the treatment conditions (CG vs. IG) and stage of chronicity for pain related and psychological parameters (Publications II-IV). After 6 months it was only possible to prove a stable rehabilitation outcome for the IG with regard to psychosocial characteristics (depression, somatization and mental health quality of life). Up to 12- and 24-month follow-up, a sustainable success could be observed in the intervention group for depression (Publication II, III). Patients of the IG with low chronicity exhibited a prolonged reduction in depression up to 2 years after rehabilitation (Publication III). Just as in the IG with high chronicity, anxiety and pain intensity were decreased up to 6-month follow-up. Finally, the changes of degree of severity according to Korff (1992) supported a superior cost-effectiveness of the IG (Publication IV). Conclusion. The investigations could prove a negative impact of depression as an important factor for the rehabilitation success and sustainability. In patients with unspecific CLBP and depressive comorbidity the newly implemented cognitive behavioural training for depression coping succeeded in sustainably ameliorating the rehabilitation outcome for psychological parameters compared to standard MDP. Moreover, patients in the IG with high chronicity benefited even more from the new treatment (anxiety and pain intensity). Furthermore comparisons with cost calculation of other studies indicate the cost-effectiveness of the examined treatment programmes. Therefore, a preceding psychological assessment and specific psychological treatment should be established in the MDP for patients with CLBP and comorbid psychiatric disorders at an early stage to delay and slow down chronic manifestation and to ameliorate the sustainability of rehabilitation.