For assessment of emotional distress in chronic pain, depression is a key target. The Beck Depression Inventory (BDI) has long been a standard and is a very good measure. It is very useful clinically, as its content is comprehensive, and in research where it appears sensitive to psychological differences.31 As each of the 21 items of the BDI potentially includes four statements to read, it may be too long for some applications. The BDI has been well studied in chronic pain samples.50,51 Concerns about the somatic item content of the BDI can be confusing. There is sometimes an assumption that these will contaminate or inflate judgments about the degree of depression present in an individual or sample.50 It seems likely, however, that these can be managed with an examination of endorsed item content in clinical contexts, testing of effects of content in research contexts, and a flexible use of standard cut-off scores. Results from extensive factor analysis of the BDI in patients with chronic pain suggest a robust factor structure that differs from nonchronic pain samples and again suggests the need for careful examination of the item content that contributes to high scores.51 A distinct advantage of the BDI in clinical assessment is the inclusion of an item assessing suicidal ideation. The Center for Epidemiolo-gical Studies-Depression Scale (CES-D)32 is another measure of depression that is well established and is perhaps somewhat shorter to administer than the BDI. We have also used a less well-known measure called the British Columbia Major Depression Inventory.52 It includes 20 items, requires an examination of separate symptom types for scoring and interpretation, rather than a straight interpretation of the total score, and includes assessment of both symptom severity and impact of symptoms.
For years, the standard assessment method for anxiety in relation to chronic pain included use of instruments such as the Spielberger State-Trait Anxiety Inventory (STAI).53 We questioned the utility of the STAI in a study demonstrating that instruments assessing more pain-specific fear and anxiety responses appear more useful, and are stronger predictors than general measures, like the STAI, of patient functioning.54 General measures of anxiety tend to be highly correlated with measure of depression and, thus, do not provide additional information in most clinical assessments. They also do not take into account the source of the distress and, thus, are not as helpful in the design or selection of treatment methods as they could be. As an alternative for measuring pain-related fear and avoidance, clinicians or researchers might use the Pain Anxiety Symptoms Scale (PASS).33,34 The distinction between the PASS and other measures related to fear of pain, such as the Fear Avoidance Beliefs Questionnaire (FABQ)55 and the Tampa Scale for Kinesio-phobia (TSK),56 is that the latter scales appear to almost exclusively focus on beliefs, while the PASS focuses on a range of cognitive and physiological anxiety responses in addition to avoidance. Again, beliefs may be considered more as contributors to the experience of pain-related suffering and disability, rather than effects of it.
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