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Chronic Pain and Depression: A Chicken or the Egg Story

A variety of recent medical studies have drawn a strong association between chronic pain and a diagnosis of major depression. The two conditions seem to go hand-in-hand in a large percentage of unfortunate patients, who suffer the debilitating effects of both chronically painful conditions and persistent mood problems. By Rosalyn Carson-DeWitt, MD

Do patients who are depressed perceive pain more acutely than people who aren’t depressed? Or does chronic pain have a debilitating effect on not just the body, but also the psyche, resulting in depression?

Researchers still don’t know whether there is a cause-and-effect relationship between chronic pain and depression, and if there is, which condition causes the other. Some research suggests that insufficiently treated, ongoing pain may cause changes in the chemical environment of the brain, thereby increasing the likelihood of depression. Similarly, other research suggests that insufficiently treated, ongoing depression causes changes in the chemical environment of the brain such that it increases an individual’s perception of painful sensations.
Who’s at Risk?

Some patients are at increased risk for both chronic pain and depression. For example, women and elderly patients are more likely to report both symptoms of chronic pain and symptoms of major depression. (Older adults, however, tend to report somatic or physical symptoms of depression rather than typical symptoms.) Researchers don’t fully understand why this is true.

Patients whose pain interferes with their independence, their mobility, or their ability to actively participate in their usual social activities are at a particularly high risk for depression.
Symptoms of Chronic Pain and Depression

Certain areas of the body are more likely to cause painful symptoms in patients with both chronic pain and depression. The types of chronic pain most commonly reported by depressed patients include:

* Headache
* Neck and back pain
* Pain in the musculoskeletal system (muscles, bones)
* Stomach pain
* Chest pain

The symptoms that lead to a diagnosis of depression include:

* Low or sad mood
* Inability to enjoy usual activities
* Irritability
* Under- or over-eating
* Difficulty sleeping or sleeping too much
* Difficulty concentrating
* Low energy
* Sense of guilt
* Negative thought patterns

Complications of Chronic Pain and Depression

Both chronic pain and depression interfere with daily functioning at school, at work, and within relationships.

The most serious complication of depression is suicide. Patients who have both chronic pain and depression have a much higher risk of feeling suicidal, acting on those suicidal feelings, and successfully committing suicide. Treatments that both improve depression and relieve chronic pain may decrease the risk of suicide in patients.
Diagnosis of Chronic Pain and Depression

Unfortunately, depression can be a slippery diagnosis. When someone is already suffering from chronic pain, it may seem obvious that some degree of depression is likely. Depression may even worsen the physical symptoms of chronic pain. Similarly, untreated chronic pain may cause a cycle of distress and depression. Diagnosing the presence of both chronic pain and depression may be the first step toward breaking this cycle and improving both pain and depression.

And yet, depression is not an inevitable result of every chronic pain condition. Nor is chronic pain an inevitable result of depression. However, until researchers unravel the complex interactions between depression and chronic pain, it is important that both healthcare providers and patients be aware that these two conditions frequently co-exist. Diagnosing and treating only one of them could result in serious complications, debilitation, or decreased functioning.

A thorough evaluation by your healthcare provider should always include an inquiry into the presence of any chronic pain, as well as screening questions designed to uncover the presence of a mood disorder. A questionnaire called the SF-36 Health Status Survey is particularly helpful at uncovering the dimensions of chronic pain and the presence of depressive symptoms.
Treatment of Chronic Pain and Depression

The good news is that there are medications available that treat both depression and chronic pain. Certain medications traditionally used for depression also have a significant effect on decreasing chronic pain. This association has been tested in individuals who suffer from chronic pain without depression; when these patients are asked to fill out rating scales that describe the intensity of their chronic pain, those patients who are given antidepressants rate their pain as significantly decreased. But these medications are prescribed by your doctor and can have side effects. Consult with your doctor about what would be best for you.

The antidepressant medications that have been successfully used to decrease chronic pain include:

* Tricyclic antidepressants
o Amitryptiline (Elavil)
o Desiprimaine (Norpramin)
o Imipramine (Tofranil)
o Doxepin (Sinequan)
o Nortiptyline (Pamelor)
* Selective serotonin reuptake inhibitors
o Fluoxetine (Prozac)
o Sertraline(Zoloft)
o Paroxetine (Paxil)
o Fluvoxamine (Luvox)
o Citalopram (Celexa)

***Please Note: On March 22, 2004, the Food and Drug Administration (FDA) issued a Public Health Advisory that cautions physicians, patients, families and caregivers of patients with depression to closely monitor both adults and children receiving certain antidepressant medications. The FDA is concerned about the possibility of worsening depression and/or the emergence of suicidal thoughts, especially among children and adolescents at the beginning of treatment, or when there is an increase or decrease in the dose. The medications of concern ­- mostly SSRIs (Selective Serotonin Re-uptake Inhibitors) – are: Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (fluvoxamine), Celexa (citalopram); Lexapro (escitalopram), Wellbutrin (bupropion), Effexor (venlafaxine), Serzone (nefazodone), and Remeron (mirtazapine). Of these, only Prozac (fluoxetine) is approved for use in children and adolescents for the treatment of major depressive disorder. Prozac (fluoxetine), Zoloft (sertraline), and Luvox (fluvoxamine) are approved for use in children and adolescents for the treatment of obsessive compulsive disorder. For more information, please visit http://www.fda.gov/cder/drug/antidepressants.
* Atypical antidepressants
o Venlafaxine (Effexor)
o Nafazodone (Serzone)
o Trazodone (Desyrel)
o Bupropion (Wellbutrin)
o Mirtazepine (Remeron)

What Else Can I Do?

Psychotherapy, referred to commonly as therapy, in which a person with depression talks to a licensed and trained mental healthcare professional, can also be helpful for patients who are struggling with both chronic pain and depression.

In addition, a variety of other treatments are available that may improve pain and lessen depression, such as:

* Behavioral therapy
* Biofeedback
* Massage
* Occupational therapy
* Yoga
* Stretching
* Relaxation techniques
* Hypnosis

Finally, keeping a pain diary might also help you recognize which interventions help and which situations exacerbate your pain and/or depression. Or, you can try getting involved with a support group, which can put you into contact with other people who are meeting similar challenges. It may also give you an opportunity to learn from the experiences of others, and to share your own coping strategies with people who could use your support.

RESOURCES:

American Academy of Pain Management

http://www.aapainmanage.org

American Pain Foundation

http://www.painfoundation.org

American Pain Society

http://www.ampainsoc.org

References:

Clark, M. Chronic pain, depression and antidepressants: Issues and relationships.

Available at: http://www.hopkins-arthritis.som.jhmi.edu/mngmnt/depression.html

Accessed June 3, 2003.

Gallagher, R. The pain-depression conundrum: Bridging the body and mind. Medscape CME program. Available at: http://www.medscape.com/viewprogram/2030

Accessed June 3, 2003.

Ohayon, MM, Schatzberg, AF. Using chronic pain to predict depressive morbidity in the general population. Arch Gen Psychiatry. 2003;60:39-47.

Accessed June 3, 2003.

Rosack, J. New antidepressants target aches and pains, too. Psychiatric News. 2003:38(8):39.

Accessed June 3, 2003.

Sylvester, B. AAPM: widely used questionnaire spots depression in chronic pain patients.

Available at: http://www.pslgroup.com/dg/22cba6.htm

Accessed June 3, 2003.

Last reviewed January 2006 by Steven Bratman, MD

Please be aware that this information is provided to supplement the care provided by your physician. It is neither intended nor implied to be a substitute for professional medical advice. CALL YOUR HEALTHCARE PROVIDER IMMEDIATELY IF YOU THINK YOU MAY HAVE A MEDICAL EMERGENCY. Always seek the advice of your physician or other qualified health provider prior to starting any new treatment or with any questions you may have regarding a medical condition.

© 2006EBSCO Publishing. All rights reserved.

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