CHRONIC PAIN: PAIN AND DEPRESSION

The Link Between Pain and Depression
Pain and depression are inexorably linked in a complex way. Pain causes depression — depression causes pain. About 30 percent of patients with persistent pain conditions suffer from clinical depression related to their pain, and almost all persons will experience some mood changes; 75 percent of patients with clinical depression present to their doctors because of physical symptoms, including pain.1 People in pain who have symptoms of depression experience more impairment associated with pain than those who do not have depressive symptoms.2

To successfully treat your chronic pain, you and your physician need to examine the emotional factors that may influence your pain level and physical disability. One of the first steps to treating pain is recognizing that depression often accompanies pain and that increases in pain or widespread pain (i.e., pain in many areas of your body) can be a symptom of depression. Understanding this aspect of your pain experience may help you identify your own symptoms and seek the care you need to lessen your pain.

The Pervasiveness of Pain

Chronic pain affects all aspects of life. It affects your quality of life as it limits your physical functioning, your ability to perform activities of daily living, and your ability to work. It has social consequences for your marital and family relationships, it may limit intimacy with your partner, and it may prevent interaction with friends. Chronic pain has societal consequences in terms of increased health care costs, increased disability costs and lost productivity that is a consequence of missed workdays.

Given the pervasiveness of pain, it's no wonder that chronic pain affects your psychological well-being as well.3 Research indicates that as the number and severity of a patient's physical symptoms increase, the number and severity of psychological complaints increase.4 In other words, the more places you feel pain and the more severe the pain, the more likely you are to have a depression or problems such as difficulty sleeping or anxiety and the more severe these symptoms are. Some of the signs and symptoms related to depression reported by chronic pain patients treated at pain clinics include:

· Physical deconditioning

· Sleep disturbance

· Reduced sexual activities

· Family stress

· Work issues

· Legal issues

· Financial concerns

· Decreased self-esteem

· Fear of injury

· Altered mood, including irritability, anxiety and depression5

Why do pain and depression co-exist so often? Scientists have been studying this relationship through neurosciences and epidemiology and have made important discoveries. First of all, both depression and the suffering of pain are located in the same area of the brain.6 Second, the same chemical messengers are involved in regulating pain and mood.7 What are the mechanisms that affect these parts of the brain and these chemical systems? We find that depression runs in families, so that the stress of having pain may trigger the chemical changes in the brain leading to depression in persons who may be vulnerable because of a family tendency (genetic) to depressive illness. More commonly, however, a person has no family vulnerability to depression, but may get "worn down" by all the stress, losses and problems encountered by having pain over many months.8 Either way, this "wearing down" is biochemical, such that certain important chemicals (similar to vitamins) that are responsible for regulating both pain and mood appear to be functionally depleted. This is why the same medications that are helpful in depression also may effectively treat pain — because they enhance the pain and mood regulating effects of these chemical systems in your brain.

Approximately 40 percent to 60 percent of patients being treated at pain clinics report experiencing symptoms of depression.9 Unfortunately, people experiencing pain do not always receive the treatment they need to combat their depression and their pain, especially if they do not see physicians with the training and background to treat both together (e.g., pain medicine specialists, psychiatrists or primary care physicians with this training). Given the nature of today's health care system, most Americans receive mental health care by visiting their primary care physician, but research studies indicate that 50 percent of patients who are clinically depressed are not diagnosed by their primary care physicians.10 So be on the lookout for depression in yourself and loved ones and seek treatment before the negative effects occur.

Treating Depression and Pain

Seeking help and advocating for yourself are the first steps to treating your pain. Your physician's goals in treating you are to reduce your pain, improve your physical functioning, reduce your psychological distress and improve your overall quality of life.11 There are many different ways to treat depression and anxiety related to pain. Your physician may suggest one or more of the following therapies to reduce your psychological distress:

· Medication

· Cognitive-behavioral therapy

· Stress management (e.g., relaxation techniques, hypnosis, biofeedback)

· Supportive counseling

· Family counseling12

It's important to remember that being depressed is not a sign of personal weakness — depression and anxiety are related to chemical imbalances in your brain.13 Depressive and anxiety disorders are illnesses that can be treated. Taking medication and going to therapy to treat your depression is the same as taking antibiotics to treat an infection — the necessary steps you take to get better.

It's also important to keep in mind that not every medication or therapy works immediately or even works in every person. Medications used to treat depression often take up to six weeks to be effective. If you and your physician decide a particular therapy isn't effective for you, you may need to try different medications or different combinations of therapies to find the right ones for you. Try not to become frustrated or give up — you and your physician need to work together to achieve results.

Counseling and behavioral therapy — alone or combined with medication — are effective and important techniques in treating depression and pain.14 They also require your active participation in your care and recovery. Following are some suggestions for actively participating in your care and helping you and your physician work together to treat your pain and your depression:

· Keep a diary and record changes in your pain and emotions. Visit the My Pain section of www.nationalpainfoundation.org and keep pain journal online. You can print it out and bring it with you to your doctors' appointments to remind yourself of how you were feeling and when you were feeling better or worse.

· Identify a support network. Support persons could include family members, friends and support groups. The National Pain Foundation's My Community area is an online support group for persons in pain.

· Educate yourself through books, reputable Web sites and organizations.

· Set realistic treatment goals.

· Stay active — with your doctor's advice and approval, begin an exercise program, try yoga or other stretching activities.

· Try the stress management techniques you learn in counseling and use them regularly. Guided imagery, hypnosis, biofeedback and relaxation techniques really can work if you work at using them.

Depression is an illness, and ignoring it will not make it go away. Seek the treatment you need to get better and be involved in your care.

"When you do nothing, you feel overwhelmed and powerless. But when you get involved, you feel the sense of hope and accomplishment that comes from knowing you are working to make things better." —Pauline R. Kezer

1. R M Gallagher, S Cariati, "The pain-depression conundrum: Bridging the body and mind," Oct 2, 2002. Available from Medscape.com.

2. Mossey J, Gallagher RM, Tirumalasetti F. Pain and depression reduce physical functioning functioning in elderly residents of a continuing care retirement community residents: Implications for health management. Pain Medicine 1(4):340-350,2000

3. D C Turk, "Beyond the symptoms: The painful manifestations of depression." Presented at Pain and Depression: Navigating the Intersection of Body and Mind Symposium, San Diego, 20 August 2002."

4. Kroenke K, Jackson JL, Chamberlin J. Depressive and anxiety disorders in patients presenting with physical complaints: clinical predictors and outcome. Am J Med. 1997;103:339-347; Kroenke K, Spitzer RL, deGruy FV III, Swindle R. A symptom checklist to screen for somatoform disorders in primary care. Psychosomatics. 1998;39:263-272; Watson D, Pennebaker JW. Health complaints, stress, and distress: exploring the central role of negative affectivity. Psychol Rev. 1989;96:234-254.

5. D C Turk, "Beyond the symptoms: The painful manifestations of depression." Presented at Pain and Depression: Navigating the Intersection of Body and Mind Symposium, San Diego, 20 August 2002."

6. Rome and Rome, Pain Medicine 2000.

7. Rome and Rome, Pain Medicine 2000; Gallagher and Verma 1999).

8. Dohrenwend, B., Marbach, J. , Raphael, K., Gallagher, R.M.: Why is depression co-morbid with chronic facial pain? A family study test of alternative hypotheses. Pain 83:183-192, 1999.

9. D C Turk, "Beyond the symptoms: The painful manifestations of depression." Presented at Pain and Depression: Navigating the Intersection of Body and Mind Symposium, San Diego, 20 August 2002.

10. Depression Guideline Panel. Depression in Primary Care: Volume 1. Detection and Diagnosis. Clinical Practice Guideline, Number 5. Rockville, Md: U.S. Department of Health and Human Services; 1993. AHCPR Publication No. 93-0550. Simon GE, VonKorff M. Recognition, management, and outcomes of depression in primary care. Arch Fam Med. 1995;4:99-105. R M Gallagher, S Cariati, "The pain-depression conundrum: Bridging the body and mind," Oct 2, 2002. Available from Medscape.com.

11. D C Turk, "Beyond the symptoms: The painful manifestations of depression." Presented at Pain and Depression: Navigating the Intersection of Body and Mind Symposium, San Diego, 20 August 2002."

12. Ibid.

13. R M Gallagher, S Cariati, "The pain-depression conundrum: Bridging the body and mind," Oct 2, 2002. Available from Medscape.com.