Mental Health & Vocational Rehabilitation: Information for Pain Management
Numerous studies have found a strong relationship between chronic pain and mental health disorders.1 Previous research has shown that chronic pain is most often associated with depression, anxiety, post-traumatic stress disorder (PTSD), personality disorders, and substance use disorders.2 Furthermore, past research has found that the presence of the comorbidity between mental health disorders and chronic pain is associated with an increase in suicidal behaviors and mortality.3
The diathesis-stress model purports that pre-existing characteristics of the patient (genetics) are activated by the onset of chronic pain (environment) and then exacerbated by stress of this chronic condition, eventually resulting in a mental health disorder.1 The stress may result from the physical sensation of pain as well as the secondary losses (financial, physical ability, self-esteem, etc) associated with pain.4
This cycle, known as chronic pain syndrome, is best treated with an interdisciplinary approach.5 Interdisciplinary pain rehabilitation programs are based on a functional restoration approach, involving the use of multiple disciplines, including vocational rehabilitation. Vocational rehabilitation is a process that enables persons with functional, psychological, developmental, cognitive, and emotional impairments to overcome barriers to accessing, maintaining, or returning to employment.6 The following is a review of mental health disorders that are commonly found in patients who suffer with chronic pain—depression, anxiety, and PTSD—and the role of vocational rehabilitation in treatment (see Table 1).
What Is Depression?
The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) contains several depressive disorders, including major depressive disorder (including bereavement), persistent depressive disorder, disruptive mood dysregulation disorder, and premenstrual dysphoric disorder.7
Depression is a state of low mood and aversion to activity that can affect a patient’s thoughts, behaviors, feelings, and physical well-being for a duration of at least 2 weeks. A patient can experience changes in thinking, including problems with concentration, decision-making, and even forgetfulness. Negative thinking leads to pessimism, poor self-esteem, excessive guilt, and self-criticism, which are characteristic of depression.
Some patients who suffer from chronic pain may have suicidal thoughts during a more serious depression. In fact, a review of past studies concluded that suicide ideation, suicide attempts, and suicide completions are commonly found in chronic pain patient populations.8
There are several warning signs that a patient may be suicidal (see Table 2). The role of the provider in these cases is simple—plan for the patient’s safety! A suicide prevention safety plan may include calling the mental health professional with whom the patient is working, referring the patient to the local hospital or emergency room, calling 911 and reporting that the patient is having suicidal thoughts and needs assistance (with the patient’s permission), completing a working and portable safety plan document, and/or giving the patient the telephone number for the national suicide hotline, 1-800-273-TALK (8255).
Changes in behavior may also occur, including excessive crying, temper outbursts, decreases in sexual libido, social discomfort and isolation, neglect of personal hygiene, loss in productivity, and dysania, or difficulty getting out of bed.
Changes in behavior during depression are reflective of the feelings being experienced, such as sadness, irritability, anhedonia (loss of pleasure in activities), lack of motivation, fatigue, helplessness, and hopelessness. Patients who suffer from depression may also experience changes in physical well-being, such as variations in sleep, fluctuations in appetite, deceleration/acceleration in activities, escalation in aches, and increased pain.
Research has shown that depression in patients who suffer from pain is associated with more pain complaints and greater impairment. According to Bair et al, “depression and pain share biological pathways and neurotransmitters, which has implications for the treatment of both concurrently.”9 In addition, when elevated, many of the same neurotransmitters (serotonin, norepinephrine, and dopamine) are associated with both pain and psychosocial disorders.10-14 Numerous clinical trials have revealed a correlation between decreased serotonin functioning and lowered pain thresholds.15-17
What Is Anxiety?
The new DSM-5 contains several anxiety disorders, including panic disorder, agoraphobia, specific phobia, social anxiety disorder, separation anxiety disorder, and selective mutism.7 Anxiety is an emotion characterized by feeling apprehensive and worried (possibly without knowing why), and is accompanied by several physical symptoms, which may include tense muscles, trembling, churning stomach, nausea, diarrhea, headache, backache, heart palpitations, numbness, and/or sweating/flushing. It is easy to mistake symptoms of anxiety for physical illness and become concerned about suffering a heart attack or stroke, which in turn increases anxiety.
Negative thinking is the cornerstone of an anxiety disorder. Pain catastrophizing is a type of irrational thought. Pain catastrophizing is the tendency to describe a pain experience in more exaggerated terms than the average person, to ruminate on it more (eg, “My pain is terrible’”), or to feel more hopeless about the experience (“My pain is never going to get better”). Research on pain catastrophizing has found that catastrophic thinking is associated with a more intense experience of pain, which in turn leads to increased use of health care and longer hospital stays. Simple screening tools are available to identify patients with pain catastrophizing, and treatments that improve outcomes are available.
The DSM-5 chapter on anxiety disorder no longer includes obsessive-compulsive disorder (OCD) or PTSD. However, the sequential order of these chapters in DSM-5 reflects the close relationships among them. The relationship of the neuroendocrine system, especially the hypothalamic–pituitary–adrenal (HPA) axis, to both psychosocial and pain disorders has been well established. The HPA axis is the body’s primary stress pathway, and it is activated by corticotropin-releasing factors from the hypothalamus, which stimulate the release of cortisol from the adrenal glands. Cortisol modulates the metabolism of serotonin, norepinephrine, and dopamine.18
One investigation—which found strong associations between chronic pain and anxiety disorders, such as panic disorder—raised the possibility that improved efforts in detecting and treating anxiety disorders may be required in pain treatment.19