Pain and Depression are Unfortunate Bedfellows

New research is bolstering the case for prescribing antidepressants to people with chronic pain to help them better deal with their discomfort. It’s also shedding new light on the relationship between pain and depression.

Indeed, what medicine is increasingly coming to understand is that pain and depression are linked and that it is possible that one condition may cause the other. Moreover, it is highly probable that pain can worsen the symptoms of depression and vice versa.

"A person who has been suffering from chronic pain for more than five years, and can’t work, has lost the desire for socialization, has no opportunities for recreation and no sex life will get pretty depressed," says pain specialist Edward C. Covington, M.D., director of the Cleveland Clinic Chronic Pain Rehabilitation Program.

Conversely, one who deals with melancholy by withdrawing from physical and social activities is likely to develop aches and pains. "If your life is empty, pain will fill it up," says Dr. Covington. "Don’t stay home and sit in the recliner and watch TV all day, because that’s guaranteed to lead to a life of pain and depression."

Painful facts
Clinical depression produces many symptoms—sleep loss, irritability, dietary changes, reduced productivity; but its primary effects include intense sadness and significant loss of enjoyment for life that persist for more than two weeks. Untreated, an episode of depression typically lasts approximately 6 months, but it can also last years. Depression affects relationships, energy levels and the desire to perform normal daily activities. And a growing body of evidence is demonstrating the unfortunate and often complicated link between depression and pain.

• In a 2004 study of more than 118,000 household residents, Canadian researchers showed that when compared with individuals who have no back pain, those who did were more likely to experience depression. The researchers also showed that the rate of major depression was related to the level of pain experienced—the greater the severity, the greater the likelihood of depression symptoms.
• In 2003, researchers from Stanford, California showed that compared with individuals who have no symptoms of depression, those with major depression are more than twice as likely to have a chronic painful physical condition, for instance persistent headache or low back pain.
• A 1992 report from The Journal of Gerontology reported that the onset of depression was significantly higher in patients whose chronic pain caused a loss of independence or mobility and thereby decreased participation in social activities.
• According to a report released in 1997 by the Academy of General Dentistry, "the 50 million people in America who suffer from chronic facial pain, including temporomandibular disorders (TMD), are likely to suffer depression as well and should be screened for depressive symptoms during their health evaluation."

Dr. Covington says that in addition to demonstrating the many different ways pain and depression can be linked, these and other studies serve as a reminder for patients and physicians of the importance of investigating whether one or the other condition is present in patients who complain of pain or in whom depression has been diagnosed.

Chicken or the egg? Pain or the depression?
Although research underscores the link between chronic pain and depression, no one really knows why one condition gives rise to the other. Dr. Covington believes that people with chronic pain are either unaware that they may be depressed, or they choose not to seek treatment for their depression. But those patients, he says, should not be expected to deal with either condition by keeping a stiff upper lip. Ideally, they should seek professional medical treatment—therapy, medication or both—for both conditions. "Going to see a pain doctor for pain without seeing a psychiatrist for depression won’t work," says Dr. Covington. "You’ve got to pay attention to both diseases."

Psychiatrist Donald Malone, M.D., section head of Cleveland Clinic adult psychiatric services, says depression can amplify pain; greater pain intensity then leads to the feeling that the individual has less control of life, which then leads to a deeper depression. "It’s a vicious cycle," says Dr. Malone. "Pain can feed on deep, deep feelings of sadness, remorse or the like."

New hope
Antidepressant drugs can help correct chemical imbalances in the brain caused by abnormal levels or actions of the neurotransmitters (brain chemicals) serotonin and norepinephrine. Thus antidepressants can help improve mood and outlook in people feeling "blue" or depressed. But research has also shown that some antidepressants can help reduce the severity of physical pain, which suggests a role in the treatment of depression associated with pain. Drs. Covington and Malone suggest that antidepressant medication can be used to treat both depression and chronic pain.

For instance, the antidepressant venlafaxine (brand name, Effexor) has been shown to provide relief for people experiencing chronic pain, says Dr. Malone. Drugs such as Effexor increase levels of serotonin, which can dull pain receptors. Just taking drugs, however, will not help a person overcome issues that have arisen due to long-term suffering from chronic pain, such as low self-esteem, loss of sex drive and retreating from social and recreational activities. Getting back on track should involve key lifestyle changes (e.g., starting an exercise regimen, getting involved in a social activity at least once per week, etc.) combined with "talk" therapy to help guide, counsel and motivate patients and to document their progress.

Getting mobile, in fact, is key. "It may seem hard at first, but a person must try to become as active as possible," says Dr. Malone. "Exercise is the best antidepressant I know of." He says that exercise—from lifting weights to water aerobics to walking—can increase the release of endorphins, neurotransmitters believed to have pain-relieving and mood elevating properties. Dr. Covington agrees that exercise can play a role in helping people manage depression: "Exercise is one of the most powerful forms of psychotherapy for anyone, including people with chronic pain." Both physicians recommend consulting first with a physician before embarking on an exercise regimen.

Dr. Covington also says that meditation, yoga and biofeedback can help a person dealing with pain and depression regain a sense of control over life. "I’ve seen significant pain reduction among a number of patients with fibromyalgia, a musculoskeletal disease that causes stiffness in joints," he says. "These patients go to Target, buy a yoga videotape and start doing the exercises at home."

Dr. Malone agrees that exercise is beneficial to pain sufferers because it helps elevate mood. But the first step toward physical wellness, he believes, is mental wellness. "A patient must have some self-motivation," he says. To break the downward spiral of a depression that causes or is caused by pain—which can create further pain or depression—a combination of therapy and antidepressants may be the boost that can help a patient overcome a painful existence.