Depression Management with the Chronic Pain Patient

Posted on Tuesday, June the 23rd at 5:26pm

By: Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

Challenges in the Treatment of Chronic Pain and Depression

In reality not everyone living with chronic pain develops depression; however it is one of the most common coexisting psychological disorders associated with someone facing the challenges of living with a chronic pain condition. One of the biggest problems in treating people with depression and chronic pain is a misdiagnosis. This occurs for two reasons: (1) a person living with chronic pain does not even realize they have a depressive disorder; and (2) healthcare providers are looking for it. People living with chronic pain will often define their problem strictly as a medical condition; that the various symptoms are only related to their pain. Therefore, it is important to be alert to the signs and symptoms of depression so an appropriate treatment strategy can be developed, which is a crucial component of an effective pain management plan.

Some people living with chronic pain and depression become isolated and believe they can handle life without any help, or they may go to the other extreme and become increasingly dependent on others to take care of them. Either style can worsen a depression. For example, the caretaking by others often enables the depressed person to persist in behaviors that enforce their belief they are a victim of their pain condition which can deepen their depression.

Researchers still cannot determine if there is a cause-and-effect relationship between chronic pain and depression, and if there is, which condition causes the other. Some research suggests that insufficiently treated, ongoing pain may cause changes in the chemical environment of the brain, thereby increasing the likelihood of depression. Similarly, other research suggests that insufficiently treated depression can cause changes in the chemical environment of the brain which increases an individual’s perception of painful sensations. Regardless of the etiology, concurrent treatment is necessary for successful treatment outcomes.

Currently, there are a variety of highly effective interventions available for the treatment of depression. The majority of depressive conditions can be treated with either psychotherapy (especially cognitive behavioral therapy) or medication, but research studies have indicated that a combination of these interventions is usually the most effective form of treatment for moderate to severe depression. There are also some types of depression that have a seasonal patterning; intensive Full Spectrum Lighting therapy is often effective in reducing symptoms. It should be emphasized that the majority of depressive conditions can be treated without hospitalization.

The Role of Antidepressant Medications

Not everyone living with chronic pain and depression will need antidepressant medications.  However, this class of medication may be indicated for people who have chronic pain disorders and have become clinically depressed. The Addiction-Free Pain Management® System recommends a full biopsychosocial evaluation to determine the severity of the problem before any medications are prescribed.

Situational depression responds best to cognitive behavioral therapy which would not need medications. Other types, i.e. bipolar, may need a medical intervention in addition to psychotherapy. There are many different types or classifications of antidepressants available and a specialist should be consulted to determine the most effective medication for each person.

A key factor to consider using an antidepressant for is pain reduction. For example, the use of tricyclic antidepressants has been an effective tool in pain management for years. The tricyclic medication Elavil (amitriptyline) is frequently used to treat and help prevent migraine headaches.  These antidepressants have been able to provide relief for nerve pain and often results in lowering the dose of opiate medications. Since sleep disturbances often accompany both chronic pain and depression some healthcare providers use this type of medication as a sleep aid.

Another class of newer antidepressants is the SSRIs (selective serotonin reuptake inhibitors) and SSNRIs (selective serotonin and norepenepherine reuptake inhibitors). Many pain management specialists utilize these types of medication for chronic pain treatment, particularly for people who live with constant debilitating chronic pain as their serotonin and norepenepherine system becomes depleted. This type of medication is good for both depression as well as improving pain management.

SSRIs like Prozac, Effexor, Lexapro, or Celexa, improve mood as well as help relieve pain, reduce fatigue and improve sleep problems. There have been reports that SSRIs are helpful for some types of neuropathic pain symptoms. Some studies also suggest that using an SSRI and a tricyclic antidepressant (such as amitriptyline) together may be more successful at breaking the cycle of pain, depression, and sleep problems caused by fibromyalgia than using just either one alone.

In addition, the following antidepressant medications can also be very helpful; Cymbalta and Effexor, which block the reuptake of serotonin and norepenepherine (SSNRI) and Wellbutrin, which alters the levels of norepenepherine and dopamine. Cymbalta is a versatile medication that is FDA approved to treat depression and certain types of neuropathic pain. Norepenepherine, serotonin, and dopamine are neurotransmitters that not only affect depression but also pain management. Many pain management specialists recognize that combining different medications creates a synergistic effect for both pain management and improving depression.

The good news is that there are many treatment options available for depression management. It is important to remember that overcoming depression takes time. Anyone living with chronic pain and depression will need to stay mentally strong and focused when faced with tough pain days. They must also learn how to reach out for support to reduce the risk of becoming isolated. One last thought: overcoming depression and implementing more effective pain management treatment is achievable with the right team and the right plan!