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Chronic Pain and Depression

LukeNotes, Spring 2007

Ouch! One of my first experiences of pain as a young boy was when I reached up to touch the electric burner on the stove that my mother had just turned off. I quickly yanked my hand away from the hot coils. Although the color of the burner had changed from the fiery red that could boil water to its usual cold black, the coil had not lost its heat. Swelling, redness, and tenderness ensued on my left index finger. Immersion in cool water, followed by the application of a soothing salve eased the hurt. Within a span of minutes the pain dissipated. A cookie or two probably helped. Years later, only the memory of the incident remains.

This is an example of acute pain. In contrast, chronic pain persists for longer periods of time, sometimes indefinitely. Chronic pain tends to be more difficult to manage. It typically lingers, often waxing and waning in intensity. Chronic pain is also qualitatively different from acute pain. Consequently, our mind and body respond to it differently than acute pain. In some ways, chronic pain is actually more like depression. This comparison to depression occurs on both a psychological and a physiological level.

In acute pain, the sensory nerves in the affected area send off a signal that alerts us to physical discomfort. In an acute injury, these sensory nerves send the pain signal to our spinal cord, which in turn relays the message of the acute pain to the brain. Our brain then sends a return message to try to quiet and dampen the acute pain. During this process the body is trying to turn the pain off.

In chronic pain, this signal system is broken down. Instead of the signal going to and from the brain to dampen the sensation of pain, the damaged signal system is interrupted in its pathway. Alternatively, the nerve signal intensifies the pain rather than decreasing the pain. This process is known as “windup.” Imagine a “broken record” or CD that gets stuck in the middle of the song, and the repeated notes that drone on and on become louder than the original tune. An annoyance like this may eventually develop into aggravation. This is the experience of chronic pain. Instead of the body turning off the pain, it increases the sense of pain. As a result, chronic pain is more challenging for both the person and caregivers.

The psychological similarities between chronic pain and depression are remarkable. Those with chronic pain often describe it as relentless and unbearable, as do those who suffer from depression. The effects of chronic pain and depression are also noticeable in facial expressions, posture, and gait in the affected person. In addition, both chronic pain and depression frequently disrupt physical and psychological functioning. Chronic unremitting pain, like depression, can lead to self-destructive thoughts. Both persons with chronic pain and persons suffering from depression are at higher risk for suicide.

Research has shown that there is also a biological overlap in depression and chronic pain. Certain areas of the brain and spinal centers are affected in both conditions. Therefore, it is not so surprising that the two conditions are often found together. Almost seventy percent of people with chronic pain have a major depression at some point in their life. Conversely, approximately forty percent of people with chronic depression have some type of long-standing chronic pain condition.

A team of trained professionals, including psychiatrists, psychologists, psychotherapists, and primary care physicians, can best assess the effects of chronic pain and depression. Often consultations with neurologists, anesthesiologists, pain management specialists, and physical and massage therapists are sought for additional assistance with diagnosis and treatment. Optimally, both conditions should be treated together.

The four major categories of medications for pain are narcotics, anti-inflammatory, anti-depressants and mood stabilizers. Narcotics are sometimes necessary to control the pain, but can lead to addiction and may contribute to depression. Their long-term use should be carefully monitored by a physician who is experienced in treating chronic pain. Anti-inflammatory agents would include common medications such as Motrin(ibuprofen) and Advil (naproxen).

The use of antidepressants and mood stabilizers for treating depression and chronic pain reflects the biological overlap between these two conditions. Antidepressants include an older generation (Elavil and Pamelor) as well as a newer generation used for pain and depression (Effexor and Cymbalta.) Mood stabilizers used for pain include Lamictal, Neuronti, Trileptal, Depakote, Topamax, and Lithium.

In addition to antidepressants, psychotherapy and educational materials are used to treat depression and chronic pain. Supportive psychotherapy is important for learning to adjust to the discomfort of the chronic pain condition. Adjunctive therapies such as biofeedback and acupuncture may often be helpful. Massage will help to increase flexibility and mobility. In the treatment of chronic pain and depression, it is imperative to address both conditions simultaneously. Treating the pain without addressing the depression or treating the depression without attempting to alleviate the pain will impede the ability to achieve an ultimately successful treatment for the person suffering from both of these conditions. Treating both conditions together can offer more hope for the person in pain.