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Managing Pain When You’re Depressed

June 16th, 2009 by admin Leave a reply »

Liv­ing with chronic pain should be enough of a bur­den for any­body. But pile on depres­sion — one of the most com­mon prob­lems faced by peo­ple with chronic pain — and that bur­den gets even heavier.

Depres­sion can mag­nify pain, and make it harder to cope. The good news is that chronic pain and depres­sion aren’t insep­a­ra­ble. Effec­tive treat­ments can relieve depres­sion and make chronic pain more tolerable.

Chronic Pain and Depres­sion: A Ter­ri­ble Twosome

If you have chronic pain and depres­sion, you’ve got plenty of com­pany. That’s because chronic pain and depres­sion are com­mon prob­lems that often over­lap. Depres­sion is one of the most com­mon psy­cho­log­i­cal issues fac­ing peo­ple who suf­fer from chronic pain, and it often com­pli­cates the patient’s con­di­tions and treat­ment. Con­sider these statistics:

  • Accord­ing to the Amer­i­can Pain Foun­da­tion, about 32 mil­lion peo­ple in the U.S. report pain last­ing longer than one year.
  • From one-quarter to more than half of patients who com­plain of pain to their physi­cians are depressed.
  • On aver­age, 65% of depressed peo­ple also com­plain of pain.
  • Peo­ple whose pain lim­its their inde­pen­dence are espe­cially likely to get depressed.

Because depres­sion in patients with chronic pain fre­quently goes undi­ag­nosed, it often goes untreated. Pain symp­toms and com­plaints take cen­ter stage on most doc­tors’ vis­its. The result is depres­sion, along with sleep dis­tur­bances, loss of appetite, lack of energy, and decreased phys­i­cal activ­ity which may make pain much worse.

“Chronic pain and depres­sion go hand in hand,” says Steven Fein­berg, MD, adjunct asso­ciate clin­i­cal pro­fes­sor at Stan­ford Uni­ver­sity School of Med­i­cine. “You almost have to assume a per­son with chronic pain is depressed and begin there.”

Chronic Pain and Depres­sion: A Vicious Cycle

Pain pro­vokes an emo­tional response in every­one. Anx­i­ety, irri­tabil­ity, and agi­ta­tion — all these are nor­mal feel­ings when we’re hurt­ing. Nor­mally, as pain sub­sides, so does the stress­ful response.

But what if the pain doesn’t go away? Over time, the con­stantly acti­vated stress response can cause mul­ti­ple prob­lems asso­ci­ated with depres­sion. Those prob­lems can include:

  • chronic anx­i­ety
  • con­fused thinking
  • fatigue
  • irri­tabil­ity
  • sleep dis­tur­bances
  • weight gain or loss

Some of the over­lap between depres­sion and chronic pain can be explained by biol­ogy. Depres­sion and chronic pain share some of the same neu­ro­trans­mit­ters — the chem­i­cal mes­sen­gers trav­el­ing between nerves.  They also share some of the same nerve pathways.

The impact of chronic pain on a person’s life over­all also con­tributes to depression.

“The real pain comes from the losses” caused by chronic pain, accord­ing to Fein­berg. “Los­ing a job, los­ing respect as a func­tional per­son, loss of sex­ual rela­tions, all these make peo­ple depressed.”

Once depres­sion sets in, it mag­ni­fies the pain that is already there. “Depres­sion adds a dou­ble whammy to chronic pain by reduc­ing the abil­ity to cope,” says Bev­erly E. Thorn, pro­fes­sor of psy­chol­ogy at the Uni­ver­sity of Alabama and author of the book Cog­ni­tive Ther­apy for Chronic Pain.

Research has com­pared peo­ple with chronic pain and depres­sion to those who only suf­fer chronic pain. Those with chronic pain and depression:

  • report more intense pain
  • feel less con­trol of their lives
  • use more unhealthy cop­ing strategies

Because chronic pain and depres­sion are so inter­twined, depres­sion and chronic pain are often treated together. In fact, some treat­ments can improve both chronic pain and depression.

Treat­ing Chronic Pain and Depres­sion: A “Whole-Life” Approach

Chronic pain and depres­sion can affect a person’s entire life. Con­se­quently, an ideal treat­ment approach addresses all the areas of one’s life affected by chronic pain and depression.

Because of the con­nec­tion between chronic pain and depres­sion, it makes sense that their treat­ments overlap.


The fact that chronic pain and depres­sion involve the same nerves and neu­ro­trans­mit­ters means that anti­de­pres­sants can be used to improve both chronic pain and depression.

“Peo­ple hate to hear, ‘it’s all in your head.’ But the real­ity is, the expe­ri­ence of pain is in your head,” says Fein­berg. “Anti­de­pres­sants work on the brain to reduce the per­cep­tion of pain.”

Tri­cyclic anti­de­pres­sants (Elavil, Dox­epin) have abun­dant evi­dence of effec­tive­ness. How­ever, because of side effects their use is often lim­ited. Newer anti­de­pres­sants known as sero­tonin and nor­ep­i­neph­rine reup­take inhibitors (Cym­balta, Effexor), on the other hand, seem to work well with fewer side effects.

Phys­i­cal Activity

Many peo­ple with chronic pain avoid exer­cise. “They can’t dif­fer­en­ti­ate chronic pain from the ‘good hurt’ of exer­cise,” says Fein­berg. But, the less you do, the more out of shape you become. That means you have a higher risk of injury and wors­ened pain.

The key is to break this cycle. “We now know that gen­tle, reg­u­lar phys­i­cal activ­ity is a cru­cial part of man­ag­ing chronic pain,” says Thorn. Every­one with chronic pain can and should do some kind of exer­cise. Con­sult with a physi­cian to design an exer­cise plan that’s safe and effec­tive for you.

Exer­cise is also proven to help depres­sion. “Phys­i­cal activ­ity releases the same kind of brain chem­i­cals that anti­de­pres­sant med­ica­tions release — [it’s] a nat­ural anti­de­pres­sant,” says Thorn.

Men­tal and Spir­i­tual Health

Chronic pain affects your abil­ity to live, work, and play the way you’re used to. This can change how you see your­self — some­times for the worse.

“When some­body begins to take on the iden­tity of a ‘dis­abled chronic pain patient,’ there is a real con­cern that they have sunk into the pain and become a vic­tim,” says Thorn.

Fight­ing this process is a crit­i­cal aspect of treat­ment. “Peo­ple with chronic pain end up sit­ting around,” which leads to feel­ing pas­sive, says Fein­berg. “The best thing is for peo­ple to get busy, take control.”

Work­ing with a health care provider who refuses to see you as a help­less vic­tim is part of the for­mula for suc­cess. The goal is to replace the vic­tim iden­tity with one of a “well per­son with pain,” accord­ing to Thorn.

Treat­ing Chronic Pain and Depres­sion: Cog­ni­tive Ther­apy for Chronic Pain

Is there such a thing as “mind over mat­ter”? Can you “think” your way out of feel­ing pain?

It may be hard to believe, but research clearly shows that for ordi­nary peo­ple, cer­tain kinds of men­tal train­ing truly improve chronic pain.

One approach is cog­ni­tive ther­apy. In cog­ni­tive ther­apy, a per­son learns to notice the neg­a­tive “auto­matic thoughts” that sur­round the expe­ri­ence of chronic pain. These thoughts are often dis­tor­tions of real­ity. Cog­ni­tive ther­apy can teach a per­son how to change these thought pat­terns and improve the expe­ri­ence of pain.

“The whole idea is that your thoughts and emo­tions have a pro­found impact on how you cope” with chronic pain, says Thorn. “There’s very good evi­dence that cog­ni­tive ther­apy can reduce the over­all expe­ri­ence of pain.”

Cog­ni­tive ther­apy is also a proven treat­ment for depres­sion. Accord­ing to Thorn, cog­ni­tive ther­apy “reduces symp­toms of depres­sion and anx­i­ety” in chronic pain patients.

In one study Thorn con­ducted, at the end of a 10-week cog­ni­tive ther­apy pro­gram, “95% of patients felt their lives were improved, and 50% said they had less pain.” She also says, “Many par­tic­i­pants also reduced their need for medications.”

Treat­ing Chronic Pain and Depres­sion: How to Get Started

The best way to approach man­ag­ing chronic pain is to team up with a physi­cian to cre­ate a treat­ment plan. When chronic pain and depres­sion are com­bined, the need to work with a physi­cian is even greater. Here’s how to get started.

  • See your pri­mary care physi­cian and tell her you’re inter­ested in gain­ing con­trol over your chronic pain. As you develop a plan, keep in mind that the ideal pain man­age­ment plan will be mul­ti­dis­ci­pli­nary. That means it will address all the areas of your life affected by pain. If your physi­cian is not trained in pain man­age­ment her­self, ask her to refer you to a pain specialist.
  • Empower your­self by tap­ping into avail­able resources. Sev­eral rep­utable national orga­ni­za­tions are devoted to help­ing peo­ple live full lives despite pain. See the list below for their websites.
  • Find a cog­ni­tive ther­a­pist near you with expe­ri­ence in the treat­ment of chronic pain. You can locate one by con­tact­ing the national pain orga­ni­za­tions or cog­ni­tive ther­a­pists’ pro­fes­sional groups listed below.
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