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11 Articles in Volume 13, Issue #7
Ask the Expert: Which NSAIDs are Most Selective for COX-1 and COX-2?
Chronic Pain and Depression: Sorting Out Types of Mood Disorders
Chronic Pain and Depression—Why Antidepressants Treat Both
Editor's Memo: Fibromyalgia: Time To Be a Secondary Diagnosis?
Evaluation and Comparison of Online Equianalgesic Opioid Dose Conversion Calculators
History of Pain: A Brief Overview of the 19th and 20th Centuries
Letters To the Editor
Obesity and Pain Management
Pharmaceutical Treatment of Insomnia In Intractable Pain Patients
The Slipping Rib Syndrome: An Overlooked Cause of Abdominal Pain
You Ordered the Urine Drug Test: Now What?

Chronic Pain and Depression: Sorting Out Types of Mood Disorders

Chronic pain and depression often appear hand in hand. When dealing with patients with refractory or chronic pain and depression, it is important to identify the types of depression in order to properly treat both. In these cases, the role of the psychiatrist is key.

Depression is a common complaint of the patient suffering with chronic pain. And pain is a common complaint of patients with mood disorders and anxiety. The challenge for the practicing physician is sorting out the psychiatric syndromes from the underlying pain triggers. This requires a comprehensive evaluation of the underlying depression. Typically, however, the patient with chronic pain is “expected to be depressed” and multidisciplinary pain management simply treats the patient with a little bit of everything: antidepressants and cognitive-behavioral psychotherapy. Unfortunately, in this scenario the roles of psychiatrists (and the patient) are often misunderstood. This article will explore the importance of differentiating types of depression in the diagnosis and management of comorbid pain and depression, and presents case examples.

Depression and Chronic Pain: The Chicken or the Egg?

As noted, physical symptoms are common in patients suffering from major depression. Approximately 60% of patients with depression report pain symptoms at diagnosis.1 The reverse trajectory is also true, and in many conditions the relationship is bidirectional. Chronic pain, from a long-term medical condition, doubles the incidence of depression. One-third to more than 50% of patients presenting to chronic pain clinics have a current major depression.2,3 Depression in patients with chronic pain is associated with greater pain intensity, more pain persistence, and greater interference from pain including more pain behaviors observed by others. Pain severity, pain-related disability, and health-related quality of life were significantly worse in patients with chronic musculoskeletal pain and comorbid depression (Figure 1).4 Depression is a better predictor of disability than pain intensity and duration.

Moreover, patients suffering from chronic pain syndromes report increased rates of suicidal ideation, suicide attempts, and suicide completion. Although other psychosocial variables play a role, depression is the most consistent and strongest predictor of suicidal ideation and behaviors in patients with chronic pain.5

Lastly, depression in patients with chronic pain is more resistant to treatment.6 Pain often subsides with improvement in depressive symptoms. Because pain has a proven effect on the response of depression to treatment, recognizing and optimizing the management of comorbid pain that commonly coexists with depression may be important in enhancing depression response and remission rates (Table 1).5 In addition to having greater efficacy for the treatment of neuropathic pain, serotonin norepinephrine reuptake inhibitors and tricyclic antidepressants are associated with faster rates of improvement in depressive symptoms and lower rates of relapse of major depressive disorder.7

Case Formulation: The Differential Diagnosis of Depression

Patients with chronic pain are referred to a psychiatrist when their chief complaint is refractory to conventional pain management, disproportionate to objective findings, or accompanied by distress intense enough to suggest depression. In some way, the depression is understandable given that the patient is long suffering with a chronic pain syndrome. However, the search for the actual cause of depression must now extend to the domain of personal consciousness.8 This realm contains not only the diseases of the brain (cerebral faculties) but also the disruptions of the motivational rhythms of behavior, the psychological constitution of the individual, and the personal chronicle of desires and life encounters.

All mental disorders, even those in patients with chronic pain, are expressions of life under altered circumstances that affect characteristic mental capacities and generate particular expressions.9,10 Four perspectives (diseases, behaviors, dimensions, life stories) represent distinct classes of disorders that each have a common essence and logical implication for causation and treatment.11,12 In this approach to patient care, diseases are what people have; behaviors are what people do; dimensions are what people are; and life stories are what people encounter (Table 2). The formulation of a patient with chronic pain experiencing depression should address the contribution from any or all perspectives to the overall presentation and inform the design of a treatment plan that can address each element of the patient’s suffering.

Diseases

Diseases of the brain manifest psychologically. Abnormalities in the structures or functions of brain-based faculties such as consciousness, cognition, and affect produce mental diseases (eg, delirium, dementia, panic disorder, and major depression). However, the patient may describe deficits in these faculties with difficulty and rely on somatic symptoms (eg, pain) as incomplete proxies. The physical symptoms occur because the brain is malfunctioning and suggesting pathology in the body. The unifying feature of diseases is the presence of a broken part causing pathology.13,14 The pathology causes characteristic signs and symptoms typically manifested by the affliction.10 Finding a cure may repair the broken part, prevent the initial damage from progressing, or accommodate the pathology through secondary compensatory systems.

Case Example

A 62-year-old man presents with a 4-year history of chronic pain and depression. Originally, he experienced intermittent neck pain. He was prescribed ibuprofen 800 mg by mouth every 6 hours and hydrocodone/acetaminophen 5 mg/325 mg twice by mouth every 6 hours and told to rest. He benefited from physical therapy, aerobic conditioning, and structured classes in yoga. However, his episodes of pain became more chronic and the pain more widespread throughout his body. His function deteriorated and he eventually became disabled, taking early retirement. His mood was depressed and he believed his mood would improve if his pain was adequately treated and he could return to work. He also noted a lack of self-confidence in his abilities to be successful, inability to experience pleasure, a sense of hopelessness about his future, and frequent thoughts of wanting to die as a means of gaining relief from his suffering.

This patient was formulated as having classic symptoms of the affective disorder (diagnosis: major depressive disorder) with sustained low mood, impaired vital sense, and negative self-attitude with suicidality. He was started on duloxetine (Cymbalta) 30 mg by mouth every day, titrated to 90 mg by mouth every day, and began cognitive-behavioral psychotherapy specific to his negative automatic thoughts, noting the lack of evidence to support them, and production of positive reframing statements about himself and his future. As his depressive symptoms improved, he noted that the pain diminished in intensity and was less widespread. He regained the ability to engage in physical therapy exercises to stretch and strengthen core muscles in his lower back. He also engaged in relaxation and visual imagery to reduce muscle tension for what was more clearly his long-standing intermittent neck pain and was able to return to work as a consultant.

Behaviors

The perspective of behavior encompasses a wide range of actions and activities. The complex behaviors of human beings are designed with purpose to achieve goals. Internally, rhythmic alterations of attention and perception produce drives that increase a person’s motivation toward a particular action like eating when hungry.13,14 Afterwards, the drive is satisfied and a state of satiety emerges. Over time, drives re-emerge with subsequent effects on the individual’s perceptual attitude towards his setting and the need to achieve his goal. In concert, personal assumptions or external opportunities increase the likelihood of certain behaviors. Choices determine which action to take and consequences influence future actions. When aspects of choice and control over behavior become disrupted, psychiatrists will be asked to address the distorted goals, excessive demands, damaging consequences, and a lack of responsiveness to negative feedback.15 Treatment of behavioral disorders begins with regaining temporary control of the situation by stopping the behavior such as drinking alcohol to excess or consuming excessive amounts of prescribed opioids.16,17 Restricting the patient’s actions and preventing these problematic behaviors limits the chaos of destructive choices. This stable foundation is required for the patient to gain insight about and increase motivation toward appropriate choices that result in fewer negative consequences and more productive behaviors.18

Case Example

A 24-year-old woman was referred for excessive depressive symptoms in the context of chronic headaches and shoulder pain that was precipitated by a whiplash injury sustained in a motor vehicle accident 2 years ago. The patient had failed multiple modalities of treatment including naproxen 500 mg by mouth twice daily, oxycodone 10 mg by mouth every 6 hours, and tramadol (Ultram) 50 mg by mouth every 6 hours. In addition, she failed physical therapy; biofeedback; and epidural steroid injections in the cervical spine every 3 months, trigger point injections in the muscles of the neck and shoulders every month, and occipital nerve blocks once without relief. She had pursued multiple consultations to find the cause of her pain, which she believed was some specific abnormality that had been missed on examination and imaging studies. She was insistent that until the broken part—like a nerve impingement—was found, she could not be cured of the multiple symptoms she was experiencing including pain, poor concentration, fatigue, visual blurring, and a sense of pressure in her head and neck. In addition, she was consuming oxycodone 10 mg by mouth, up to 10 tablets, and Flexeril (cyclobenzaprine) 10 mg by mouth, up to 6 tablets, over the course of a few hours during severe headaches.

The patient was formulated as having a depressive disorder that was a manifestation of 1) analgesic-induced headache coupled with intermittent opioid withdrawal (diagnosis: opioid and muscle relaxant abuse) and 2) her belief that doctors had missed the cause of her problems and that she now could not benefit from treatment unless she found that cause and had it repaired (diagnosis: somatoform pain disorder). As a result, her depression increased with each “normal” examination and diagnostic test, which only increased her drive to seek out the next consultation and derailed her from engaging in the appropriate rehabilitative treatments for a common musculoskeletal or myofascial pain syndrome. Her continued medication use was rationalized as the only means by which her marginal functioning could be maintained.

Behavioral psychotherapy directed at limiting further consultations and focusing the patient on making more productive choices about her medical care, including slowly tapering her from medications, allowed her to regain a sense of control over her care and feel positively reinforced by functional gains rather than the negative reinforcement she would experience when a physician would tell her that nothing was wrong and pain continued without abatement. All medications were tapered and discontinued.

Dimensions

Another form of depressive disorder arises not from a disease of the brain or some form of inappropriate behavior but by a patient’s personal affective or cognitive constitution.13,14 Each individual possesses a set of personal dimensions such as intelligence and temperament. These traits describe who a person is and are carried into the world as a set of innate capabilities within their psychological makeup. Which traits are relied upon and how much of them a person possesses will determine his potential to cope with different contextual demands. Some circumstances overwhelm capacity and provoke a person’s vulnerability to distress. Treatment for disorders of the dimensional type focuses on acquiring new skills with remediation of specific deficiencies and guidance about overcoming potential vulnerabilities through adaptations such as education about, assistance with, or modification of the particular situational stressors.16,17

Case Example

A 35-year-old man presented with severe depression in the context of shoulder pain of approximately 2 years duration. The patient could not identify a precipitant for his pain, and all examinations had been negative. A physical exam was normal, plain x-rays of the shoulder were negative, and an MRI of the shoulder showed mild degenerative changes and scarring without structural effects suggestive of an old rotator cuff injury. The patient provided an extremely detailed history, however, filled with nuances of his course, specific symptoms, and those movements and other factors associated with exacerbation of his condition. All previous consultations were catalogued along with extensive personal research about the anatomy, mechanics, and disorders of the back. Previously, the patient had been described as a conscientious, introverted person who had a degree in computer engineering and worked for an aeronautics contractor at the time his symptoms began. He was exhausted and overwhelmed with the mystery of his pain and how it had completely consumed his life and interrupted his work. He had seen multiple physicians and been treated with multiple analgesics, but could not remember their names or doses. He usually stopped taking medications after a few days because of intolerable side effects and no obvious benefits.

The patient was formulated as having a secondary depressive disorder that was the result of his temperamental vulnerabilities that predisposed him to becoming focused on minute details and collecting more information when confronted with the lack of an adequate “mechanical” explanation for his physical symptoms such as pain with certain movements and the relief of pain when he placed his arm in very specific positions (diagnoses: adjustment disorder with depressed mood; obsessive-compulsive personality traits with a rule out for obsessive-compulsive personality disorder). His depression had only increased as he sought to chronicle his course of illness in more detail and collect more and more information that he hoped would help doctors figure out what was wrong.

Treatment was directed at helping the patient gain insight into his trait composition and personality. Specifically, he was helped to appreciate that what were strengths in situations like engineering—where attention to detail and explaining cause and effect relationships were critical to success—had now become a liability in an illness situation that required accepting the doctors’ more vague reassurance given their failure to find an abnormality. As the patient was trained with biofeedback to ignore certain bodily sensations and minimize his anxiety as he began directing his attention to outside interests rather than bodily sensations, his function returned and his symptoms were no longer intrusive limitations.

Life Stories

The life story perspective uses a narrative composed of a series of events that a person encounters and determines to be personally meaningful.13,14 These self-reflections are the means by which a person judges the value of his life as a whole. They impart a sense of self both as the agent of a life plan unfolding in a social setting and as the reflective subject experiencing and interpreting the outcome of plans and commitments. If events unfold as planned, the person feels successful. However, if the sequence of events ends in a disappointing outcome, the person feels distress about this failure. Life story disorders emerge from the negative interpretations of life encounters (eg, grief from loss).19 Treatment forges a new understanding of settings and sequences that highlight the role of the patient in his life and illuminates the troubled state of mind as the outcome of that role and course of events.16,17 The effective treatment requires reframing and reinterpretation to remoralize the patient by transforming the story into one with the potential for future success and fulfillment.

Case Example

A 53-year-old woman was referred for chronic abdominal and pelvic pain complicated by depression. The patient had a history of multiple surgical procedures for inflammatory bowel disease (IBD). While pain had initially been acute and then episodic, now after 20 years of illness, she was never pain free and had developed multiple adhesions. She was discouraged about her constant physical symptoms and overwhelmed by the threat of recurrent exacerbations and the possibility of needing future surgeries that were likely to be complicated by long recovery periods. She noted that despite her depressed mood, she was able to distract herself at times such as when she was engaged with grandchildren or her hobbies. She was hopeful about new medications being found to control IBD and appreciative of her family’s support during times of symptom exacerbation.

The patient was formulated with having a depressed mood that was an understandable reaction to her chronic illness and stress (diagnosis: bereavement). She lacked the stereotypical features of a major depressive disorder such as anhedonia, hopelessness, and suicidality. Treatment focused on interpersonal psychotherapy to address her relationships with close friends and family to develop a healthy balance of deriving support without losing a sense of independence and being able to reciprocate. In addition, the patient entered into group psychotherapy with other patients with IBD to discuss shared experiences and successful coping strategies. As the patient developed more effective stress management and problem-solving skills, she felt like her life had a greater sense of accomplishment and satisfaction rather than a belief that she was a victim of her illness and a burden to significant others. The patient did not require any medical management, and was treated with psychotherapy and counseling to help her make sense of what she was going through and how she will overcome it.

Summary

All physicians have a role to play in the care of patients with chronic pain; however, psychiatrists, psychologists, and psychotherapists should take the lead in their care when depression is a prominent complaint. Each perspective of an interdisciplinary formulation has a unique logic that defines specific methods for designing treatment for the patient with chronic pain and depression. The patient’s treatment is based on a practical formulation and rational recommendations. The perspectives of psychiatry identify the patient as a person who is a composite of vulnerabilities and strengths but afflicted with diseases, struggling through life events, and motivated toward a variety of goals. A comprehensive approach to each patient offers hope for the refractory case. Knowing the type of depression a patient suffers from maximizes the patient’s opportunities for recovery.

Last updated on: April 12, 2017
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