Chronic Pain and Depression

Chronic Pain and Depression: Sorting Out Types of Mood Disorders

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 article will explore the importance of differentiating types of depression in the diagnosis and management of comorbid pain and depression, and presents case examples.

One-third to more than 50% of patients presenting to chronic pain clinics have a current major depression.

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)

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

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.

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.

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)

The physical symptoms occur because the brain is malfunctioning and suggesting pathology in the body.

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.

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.

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

Some circumstances overwhelm capacity and provoke a person’s vulnerability to distress.

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

Life story disorders emerge from the negative interpretations of life encounters

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.

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