Clinical Depression and Pain

Clinical Depression and Back Pain

Depression is by far the most common emotion associated with chronic back pain. The type of depression that often accompanies chronic pain is referred to as major depression or clinical depression. This type of depression goes beyond what would be considered normal sadness or feeling "down for a few days".

The symptoms of a major depression occur daily for at least two weeks and include at least 5 of the following (DSM-IV, 1994):

• A predominant mood that is depressed, sad, blue, hopeless, low, or irritable, which may include periodic crying spells
• Poor appetite or significant weight loss or increased appetite or weight gain
• Sleep problem of either too much (hypersomnia) or too little (hyposomnia) sleep
• Feeling agitated (restless) or sluggish (low energy or fatigue)
• Loss of interest or pleasure in usual activities
• Decreased sex drive
• Feeling of worthlessness and/or guilt
• Problems with concentration or memory
• Thoughts of death, suicide, or wishing to be dead

Chronic pain and depression are two of the most common health problems that health professionals encounter, yet only a handful of studies have investigated the relationship between these conditions in the general population (Currie and Wang, 2004).

Major depression is thought to be four times greater in people with chronic back pain than in the general population (Sullivan, Reesor, Mikail & Fisher, 1992). In research studies on depression in chronic low back pain patients seeking treatment at pain clinics, prevalence rates are even higher. 32 to 82 percent of patients show some type of depression or depressive problem, with an average of 62 percent (Sinel, Deardorff & Goldstein, 1996). In a recent study it was found that the rate of major depression increased in a linear fashion with greater pain severity (Currie and Wang, 2004). It was also found that the combination of chronic back pain and depression was associated with greater disability than either depression or chronic back pain alone.

Depression is common for those with chronic back pain

Depression is more commonly seen in patients with chronic back pain problems than in patients with pain that is of an acute, short-term nature. How does depression develop in these cases? This can be understood by looking at the host of symptoms often experienced by the person with chronic back pain or other spine-related pain.

• The pain often makes it difficult to sleep, leading to fatigue and irritability during the day.
• Then, during the day, because patients with back pain have difficulty with most movement they often move slowly and carefully, spending most of their time at home away from others. This leads to social isolation and a lack of enjoyable activities.
• Due to the inability to work, there may also be financial difficulties that begin to impact the entire family.
• Beyond the pain itself, there may be gastrointestinal distress caused by anti-inflammatory medication and a general feeling of mental dullness from the pain medications.
• The pain is distracting, leading to memory and concentration difficulties.
• Sexual activity is often the last thing on the person’s mind and this causes more stress in the patient’s relationships.
Understandably, these symptoms accompanying chronic back pain or neck pain may lead to feelings of despair, hopelessness and other symptoms of a major depression or clinical depression.

A recent study by Strunin and Boden (2004) investigated the family consequences of chronic back pain. Patients reported a wide range of limitations on family and social roles including: physical limitation that hampered patients’ ability to do household chores, take care of the children, and engage in leisure activities with their spouses.
Spouses and children often took over family responsibilities once carried out by the individual with back pain. These changes in the family often led to depression and anger among the back pain patients and to stress and strain in family relationships.

Psychological theories about depression

Several psychological theories about the development of depression in chronic back pain patients focus on the issue of control. As discussed previously, chronic back pain can lead to a diminished ability to engage in a variety of activities such as work, recreational pursuits, and interaction with family members and friends.

This situation leads to a downward physical and emotional spiral that has been termed "physical and mental deconditioning" (See Gatchel and Turk, 1999). As the spiral continues, the person with chronic back pain feels more and more loss of control over his or her life. The individual ultimately feels totally controlled by the pain, leading to major depression. Once in this depressed state, the person is generally unable to change the situation even if possible solutions to the situation exist.

Diagnosis of Depression and Chronic Back Pain

One of the biggest problems in treating major depression for the patient with chronic back pain is missing the diagnosis. This occurs for two reasons: the chronic back pain patients often do not realize they are also suffering from a major depression, and the doctor is not looking for depression.

Chronic back pain patients will often define their problem as strictly medical and related to the pain. This is supported by a recent study which found that individuals with chronic pain and depression went to their physicians 20% more often than a comparison group of non-depressed medical patients. In addition, depressed chronic back pain patients were 20% less likely to see a mental health specialist than medical patients without a pain problem (Bao, Sturm, & Croghan, 2003).

The depressive symptoms may be downplayed by the chronic back pain patient who believes that, “just get rid of this pain and I won’t feel depressed” or that acknowledging depression is a sign of weakness in dealing with the pain. When the diagnosis of major depression in the chronic back pain patient is missed or ignored, treatments strictly directed at the pain are much more likely to fail.

As concluded by Ohayon and Schatzberg (2003), the presence of a chronic pain physical condition increases the duration of depressive mood, and chronic pain patients seeking medical consultation should be routinely screened for a major depression.

Simultaneous treatment for depression and chronic back pain
Treatment of depression associated with chronic back pain requires a specialized approach. It is generally accepted that the pain and the depression should be treated simultaneously in a multidisciplinary fashion. The treatment of clinical depression most often includes psychological interventions (e.g. counseling, relaxation training, etc) and anti-depressant medication.

In a recent review of the research from 1980 though 2000 that looks at treatment of depression, it was found that the combined treatment approach of medication and psychotherapy yielded better outcomes than either of the interventions alone (Pampallona et al., 2004). Simultaneous treatment directed at the chronic back pain is critical. It has been found that chronic pain may interfere with depression improvement.

Treatment for the chronic pain might include such things as physical rehabilitation aimed at restoration of function, trying to “normalize” one’s life as much as possible even with the pain, appropriate medication management, among other things. Multidisciplinary treatment of the chronic back pain and major depression will ultimately give the patient more of a sense of control over the pain and start a “positive spiral” toward physical and mental re-conditioning.

Further Information about Chronic Pain and Depression can be found at
Click Link: Psychology Today