Depression and pain: Break the cycle

Written by: Jonas I. Bromberg, Psy.D.
Published: July 29, 2008
Reviewed by: Evelyn Corsini, MSW, January 2010

It’s common for people with chronic pain to have depression. Depression can worsen and prolong the pain. Pain and depression can take over a person’s thoughts and feelings with more pain leading to more depression, creating a cycle that is difficult to break. Not everyone with chronic pain is depressed, but about one out of three people with pain have significant depression. People with pain, especially the elderly, are at greater risk for developing depression than others without pain.

Major depression

The type of depression that often occurs with chronic pain is referred to as major depression or clinical depression. Usually this means feelings of sadness that are much greater than considered normal, lasting for a longer than normal period of time. If five of these symptoms happen daily, for at least two weeks, experts consider this a major depression:

• Depressed mood for most of the day, nearly every day
• Poor appetite or significant weight loss or increased appetite or weight gain
• Loss of interest or pleasure in usual activities
• Disrupted sleep: too much or too little
• Agitation or restlessness
• Low energy or fatigue 
• Feelings of worthlessness and/or guilt
• Lessened ability to think,concentrate, or make decisions
• Frequent thoughts of death, suicide, or wishing to be dead

The relationship between chronic pain and depression

In the scientific literature, researchers agree on four facts about pain and depression:

• Pain occurs with depression as often as it occurs with anxiety.
• The number of painful body parts, and how much pain interferes with daily life, can predict the risk of developing depression.
  
• Some symptoms of depression, like low energy, sleep problems, and worry, are common among pain patients, but other depression symptoms, like guilt and loneliness, are not.
• Depression often appears soon after a chronic pain condition starts.
  

It makes sense that depression might occur in people with chronic pain. Pain can make it difficult to sleep, causing fatigue and daytime irritability. Limited physical activity can result in fewer social events, more isolation, and the loss of pleasurable activities. There may be financial problems. Pain medications can cause fatigue or mental dullness. Pain can be distracting, cause memory loss, and increase difficulty doing normal activities, especially work. Interest in sex may decrease leading to stress or unhappiness in an important relationship.

Pain also affects the family as roles and responsibilities may change. Physical limitations may limit someone from doing household chores, participating in family activities, or caring for children. Domestic partners and children often take on responsibilities that were once performed by the person with pain. These adjustments can cause stress and strain in family relationships.

Recognizing and managing depression

Tackling depression head-on is difficult for many people, but is too important to ignore. Two out of every three people who commit suicide are depressed. A person with major depression faces a risk of suicide twenty times greater than someone who is not depressed. Recognizing when you have depression is a key step in figuring out how to deal with your everyday life.

Strategies such as these may help a person with pain to prevent or manage depression:

• Talk to health care providers early in treatment if there are symptoms or a history of depression. The more the provider knows about the patient, the better he/she can care for the patient. 
• Advise the provider if any of these common symptoms of depression occur:
  1. changes in sleep patterns,
  2. changes in appetite
  3. feelings of anxiety or stress.
• Both pain and depression can become worse without enough physical activity. Participating in an appropriate exercise plan can lessen or prevent symptoms
  Identify and avoid stresses that can increase pain and depression
• Obtain health care from a physician and a mental health professional.
• Pain-related depression is common. It can result in more problems and a worsening of pain symptoms. Many negative consequences result from not managing the depression that may come with pain. Aggressive treatment of depression can improve the outcome of pain treatment and reduce pain-related disability.

Antidepressant medications for pain

There are some antidepressant medications that treat both pain and depression at the same time. It’s important to know that these medications are also often prescribed to people with pain who do not have depression. For example, many antidepressants are effective for migraine pain and for other types of pain as well. The antidepressants that are prescribed for pain are typically not given in the same dosage that is used to treat depression. There are many good reasons why a patient with chronic pain may be prescribed an antidepressant. It does not mean your doctor thinks you are crazy, or that your pain is all “in your head.”

Depression can be hard to diagnose. Some symptoms, such as fatigue, can come from depression, pain, or medications used to treat pain. Though pain may occur with depression, it should be treated separately and differently than depression. Patients often believe that if their pain gets better, their mood will improve. While this may happen, pain patients experiencing depression should see their healthcare provider to be sure they are getting the best treatment.