There are many challenging issues presented to a clinician when dealing with persons who have a primary report of chronic pain but who also present with depression and other comorbidities (see Table 17-1; Box 17-1). In this chapter we present an overview of epidemiology of pain and depression, discuss the biological basis for depression and pain, review commonly used assessment measures for depression in persons with chronic pain, and present treatment strategies for depression and chronic pain, including psychopharmacology and psychotherapy. We also include a brief discussion of somatization and suicidal ideation associated with pain and depression. Finally, we discuss future issues related to this topic.
|
BOX 17-1 CASE HISTORY
Mr. Jones is a 49-year-old disabled construction worker with a 4-year history of chronic back and left lower extremity pain. He was involved in an incident at work when he fell from a ladder and injured his back. He was seen by a number of providers and, despite receiving nerve blocks, physical therapy and many medications, still reported significant back and leg pain. He had evidence of a herniated disk in his lumbar spine and had back surgery. The surgery was unsuccessful and his symptoms worsened following the surgery. Over time his back and leg pain increased and he was prescribed oxycodone by his primary care physician. He became less inclined to leave his house and spent most of his days sitting on the couch watching television. He often became tearful when discussing his situation with others and was increasingly irritable with those around him. He preferred being by himself and became more socially isolated. He was angry that his coworkers no longer contacted him and he felt abandoned by his employer and friends. He had recurrent thoughts that life would not be worth living if he had to continue suffering in pain.
Eventually he was referred to a psychiatrist for an evaluation after reporting to his wife that he no longer wanted to live because of his pain. During the initial interview he described his back pain as very intense (8 to 10 on a 0–10 scale) and stated that the pain was burning, aching, pulling and sharp in nature and became much worse with any activity such as standing, walking, lifting, bending, or sitting for long periods. He had problems with his sleep since he could not get comfortable at night. He often felt fatigued and had problems with short-term memory and concentration. He had recurrent thoughts of suicide and of overdosing on his medication, although never acted on this plan.
During his initial evaluation it was learned that he had had a difficult childhood. He never knew his biological father and did not get along with his stepfather. He lived with his aunt and uncle during part of his adolescence and felt that they were abusive toward him. He proceeded to get into legal trouble with episodes of drug and alcohol abuse. His first marriage ended in divorce and he had a 16-year-old son from that marriage, who he rarely was able to see. His current wife had 2 children from her first marriage and there was considerable stress in their home. Mr. Jones stated that he had been sober for 3 years after a history of daily alcohol use and two DUIs. He continued to smoke a pack of cigarettes a day. He had a history of psychiatric hospitalization after attempting to overdose on prescription medication when he was 17. He has been treated for hypertension and borderline diabetes and had minimal perceived support from family members.
Complaints of pain are the most common reason for seeing a physician in the United States, and pain is now regarded as the fifth vital sign in medically hospitalized patients (see Table 17-2 and Fig. 17-1). According to the International Association for the Study of Pain, pain is defined as “an unpleasant sensory and emotional experience associated with actual or potential tissue damage or described in terms of such damage.”1 This definition describes pain as both an emotional and sensory phenomenon. Chronic pain is often classified into two broad categories of cancer pain (which includes cancer-related pain from chemotherapy, etc.) and noncancer pain (e.g., chronic low back pain). Chronic noncancer pain is an immense problem worldwide2,3: Approximately one out of every three individuals will experience chronic pain at some point in their lifetimes.4 Chronic pain accounts for 21% of emergency department visits and 25% of annual missed workdays in the United States. In fact, chronic pain imposes the greatest economic burden of any health condition.5,6 Persistent back pain in particular is one of the principal drivers of these costs, both in the United States7 and internationally,8 with indirect costs (e.g., lost or reduced work productivity) accounting for more than half of this economic burden.9 In addition, the presence of a long-lasting pain syndrome is a leading risk factor for suicide, and psychosocial variables are important risk factors for suicidality in patients with pain.10
|
Chronic pain, generally defined as pain persisting for more than 6 months, or past the normal healing time, influences every aspect of a person’s quality of life. It frequently interferes with sleep, employment, social functioning, and activities of daily living. Patients with persistent pain often report depression, anxiety, irritability, sexual dysfunction, and decreased energy.11,12 Family roles are altered and worries about financial limitations and the consequences of a restricted lifestyle are common.13,14,15,16,17 Studies suggest that most patients with chronic pain present with some psychiatric symptoms. Close to 50% of these patients have a comorbid psychiatric condition, and 35% of patients with chronic back and neck pain have a comorbid depressive or anxiety disorder (Box 17-2).18,19,20 In surveys of chronic pain clinic populations, between 50% and 70% of patients have significant psychopathology, and psychiatric comorbidity is the most prevalent comorbidity in patients with chronic noncancer pain.21,22,23 Many chronic pain patients have a history of physical or sexual abuse, or a past history of a mood disorder.24
BOX 17-2 ANXIETY AND PAIN
Anxiety and pain
Patients with chronic pain frequently present with anxiety and recurrent worried thoughts (1, 2)
Anxiety disorders are 2 to 3 times higher in chronic pain patients than comparable patients without pain (2, 3).
Fear of pain, anxiety, and negative affect contribute to higher pain intensity ratings (4, 5)
Anxiety and mood disorders increase the disability associated with chronic pain (6)
Highly anxious patients with pain have: (1) a greater number of repeat surgeries, (2) higher medical expenses, and (3) higher compensation expenses compared with those with pain and lower levels of anxiety (7)
Negative beliefs about the inevitability of pain, fear of hurting, and perceived disability are significantly associated with absenteeism and lower successful rates of return to work (6,8)
Presurgical anxiety and depression are the best predictors of poor response from surgery (9,10)
Anxiety and catastrophic thinking predict lower benefit from opioids and higher risk for prescription opioid misuse among chronic pain patients (11–13)
Patients with chronic pain and a comorbid psychiatric disorder are more likely to report greater pain intensity, more pain-related disability, and a larger affective component to their pain than those without psychiatric comorbidity.25,26 Patients with chronic pain and psychopathology, especially those with chronic low back pain, also typically have poorer pain and disability outcomes with treatment.27,28,29,30 There is a significantly poorer return-to-work rate 1 year after injury among patients with both chronic pain and anxiety and/or depression compared to those without any psychopathology.31,32 Physicians are more likely to prescribe opioids for noncancer pain on the basis of increased affective distress and pain behavior, rather than the patient’s pain severity or objective physical pathology.33 Moreover, there is some evidence that opioids may be less effective in patients with both chronic pain and psychiatric comorbidity. In one study, patients with chronic low back pain and high negative affective symptoms had 40% less analgesia with IV morphine than those in a low negative affect group.34 In sum, psychiatric comorbidity, primarily major depression and anxiety disorders, is associated with greater levels of chronic pain, more disability, a worse response to treatment, and a greater likelihood of receiving prescription opioids.
Many pain patients with affective disorders also have co-occurring substance use disorders. Treating the affective disorder may result in decreased substance abuse behaviors, although these patients remain at risk of relapse.35,36,37,38,39 Hasin et al. found some patients abuse opioid pain medication in an attempt to alleviate their psychiatric symptoms.40 Thus comorbid depression and/or anxiety disorders are associated with greater opioid misuse, even in those with no history of a substance use disorder. Wasan et al. also found that increased craving for prescription opioids was associated with a greater urge to self-medicate the anxiety and depression that precede the sensations of craving.41 These individuals with a mood disorder who self-medicate negative affective symptoms are at increased risk for substance abuse.42 Since many patients with chronic pain frequently report mood swings and prominent anxiety and depressive symptoms, it remains important to carefully monitor all patients for psychiatric comorbidity. Individuals self-medicating their dysphoria with analgesics will then have a greater chance of receiving appropriate antidepressant and behavioral treatment instead of ineffective and potentially dangerous opioid analgesics.
The rate of depression among patients in pain centers has varied widely from 10% to 100% depending on the method of assessment.43 Most studies report depression in more than 50% of chronic pain patients24,44 and there is a direct relationship between the duration of pain and the incidence of major depression. Persons with fibromyalgia, chronic daily headache, and chronic pelvic pain have the highest rates of depression compared to patients with other chronic pain conditions.45,46,47 Patients with two or more pain complaints are more likely to be depressed than those with a single pain complaint, and the number of pain conditions is a better predictor of major depression than pain severity or pain duration.48 In a study of back pain patients within primary care, those whose back pain improved over time also showed significant improvement in depression and overall mood.49 Taken together these studies provide solid support for the association between chronic pain and depression.
Prospective studies of patients with chronic noncancer pain have suggested that chronic pain can cause depression,50 that depression can increase chronic pain,51 and that they exist in a mutually negative reinforcing relationship in a vicious cycle52,53 (see Fig. 17-2). In the majority of cases, the depressive episode began after the onset of the pain problem,54 although many patients with chronic pain have had early childhood trauma and depressive episodes that predated their pain problem.55 It may be useful when initiating depression treatment to embrace the notion that the pain contributed to depression rather than the other way around. This formulation avoids concerns by the patient that the pain is perceived to be “all in my head” and there is considerable empirical support for the directionality of this relationship based on epidemiologic evidence.56
Regardless of the directionality of the relationship, psychological symptoms and ineffective coping styles are prognostic indicators of poor outcomes (Box 17-3). Patients who present with poor coping skills often remain bed-bound and inactive because they mistakenly assume that chronic pain is indicative of ongoing tissue damage. Patients with poor coping skills tend not to use active self-management strategies. Pain catastrophizing, which is a cognitive distortion centered around pain and low self-efficacy, has been linked to higher levels of pain and disability and worse quality of life (Fig. 17-3).57,58 Psychiatric comorbidity and pain duration are each independent predictors of pain intensity and disability.10 High levels of anger also explains a significant portion of the variance in pain severity.59,60
BOX 17-3 IMPORTANT RISK FACTORS FOR DEPRESSION IN PAIN DISORDERS
Pain chronicity and heightened pain sensitivity
Pre-existing personality traits including high negative affect
Poor coping and pain catastrophizing
Neurovegetative symptoms and somatic preoccupation
Low self-image
Early childhood trauma, abuse history, and chaotic family background
Substance use disorder and opioid craving
Three core symptoms of major depression in patients with pain are low mood, impaired self-attitude, and neurovegetative signs.61,62 For many of these patients, poor sleep, poor concentration, and lack of enjoyment are attributed to pain rather than depression. Patients with major depression have more prominent pain complaints than those without depression. Thirty percent to 60% of depressed patients complain of pain.63 Depressed patients may in fact have a greater sensitivity to noxious stimuli and reduced pain tolerance.64,65 Thus, patients with temporamandibular (TMJ) disorder and depression symptoms have lower pain thresholds and greater sensitivity to noxious stimuli than those with TMJ pain alone.66,67
Related posts:
Assessment of Depression in Patients with Medical Illnesses
Depression and Gynecologic Conditions
Depression in Pulmonary Disease
Depression in Chronic Kidney Disease, Hypertension, and Nutritional Deficiencies
Depression in Medical Illness: Future Directions
Delivering Depression Care: Services and Settings
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
