There is a well-documented link between pain and depression that can make both of them harder to treat if they’re not dealt with quickly. Pain causes depression and depression causes pain in a vicious cycle that can get worse over time.
Pain causes depression
It’s not hard to see how pain causes depression. Being in pain makes you unable to do things – go out with friends, exercise, even do boring everyday chores like dishes and laundry. Even worse for many people, pain can also make you unable to sleep – and not getting enough sleep exacerbates almost every problem, physical and emotional. And if your pain is disabling, it can leave you unable to work, causing financial problems.
And all of those issues can lead to boredom and frustration, then to low self-esteem, and then into depression.
Depression causes pain
But it’s not a one-way street. Depression can also cause pain and for people who haven’t experienced it, that may be a harder link to grasp. Depression can induce headaches and back pain that have no other cause and depression is linked especially closely to migraine headaches. In fact, Harvard Medical School staff report that a person with major depression is three times more likely than other people to have a migraine attack sometime in the next two years.
Sometimes, a migraine is the first sign that a person has depression. Occasionally, it’s the only sign, and treating the depression can make the migraines stop.
The bottom line is that chronic pain is common in as many as 70% of the people who have depression or anxiety disorders. So it is vital that physicians consider that link when a patient complains of either pain or depression.
Warning signs of depression
As a pain management specialist, I see patients who have been referred due to pain, rather than depression. So in my office, the pain is obvious; it’s depression I have to look for.
Of course, many pain patients already know that they’re suffering from depression. Maybe they’ve been officially diagnosed and are being treated for depression, or maybe they just realize that in addition to feeling pain, they’re experiencing lethargy or are uninterested in friends, family, food or their normal activities. But maybe they don’t realize it at all and that’s something that physicians need to look for.
In recent years, primary care physicians have started asking routine questions about patients’ mental health. If you’ve been to a doctor recently, it’s likely that you filled out a form or were asked by a nurse: “How often in the last two weeks have you felt little interest or pleasure in doing things? Felt hopeless? Had trouble falling asleep or staying asleep? Slept too much? Felt tired or drained? Either had no appetite or were overeating? Felt bad about yourself or like you were a failure? Had trouble concentrating? Were either noticeably slow or noticeably fidgety? Thought about hurting yourself?”
The answers to those questions help primary care doctors decide whether a patient should be evaluated for depression and those are the same things I watch for when I’m treating a patient for pain.
Of course when people think of “pain,” they often think of injuries or surgery. However, much of the pain that we treat is chronic, due to fibromyalgia, migraines or irritable bowel syndrome. It can also be caused by heart disease, cancer or diabetes, and all of those issues are also linked to depression.
So what do we do?
As always, it depends on the patient, but there are a number of treatment options recognized by physicians as being effective for both pain and depression at the same time.
The most obvious is antidepressants. Most drugs used in psychiatric care are also effective as pain medications. A patient who is suffering from anxiety, depression, insomnia or fatigue can be treated with benzodiazepines, mood stabilizers or anticonvulsants, and all of those will also relieve any related pain.
Antidepressants are the most versatile of psychiatric drugs and they also relieve pain in a way that researchers believe is independent of their effect on mood. That is, while some drugs may help you sleep better and therefore take away the pain that comes from insomnia, antidepressants are different. A low dose of antidepressants can relieve pain and a higher dose can ease depression but those two things may not be entirely tied together – the antidepressant just does each thing separately.
The reason is that both classes of antidepressants: tricyclics and selective serotonin reuptake inhibitors (SSRIs), work on the brain pathways that regulate both mood and the perception of pain. So antidepressants are a good option for many people who have both pain and depression.
Antidepressants aren’t the only option though, and they’re not a miracle drug for pain. Exercise and physical therapy are very important, both for pain and for depression.
According to the Mayo Clinic, exercise is clinically proven to improve depression, anxiety and overall mood. And of course, it’s one of our key treatment plans in pain management. By “exercise” we don’t necessarily mean running laps or bench-pressing barbells, but for almost every patient, some type of exercise or physical therapy is part of the treatment. It may be walking to the mailbox and back every hour, or lifting a milk jug full of water while watching tv, or just bending and straightening a knee for 15 minutes several times a day – it depends on where the pain is and why. But in almost every case, some type of exercise or physical activity is required to relieve pain.
In our office, we deal with pain, but our patients who suffer from both pain depression may also be seeing some type of mental health specialist as well. Talk therapy (meeting with a social worker or psychologist for counseling) may be the most common type of therapy, but there are others.
Cognitive behavioral therapy is a type of talk therapy that pinpoints a specific problem. It’s based on the premise that physical and emotional issues are linked and it helps you become aware of negative thinking so you can view problems more clearly and then respond to them effectively.
Hypnosis is also a good treatment option that’s been gaining in popularity in recent years. In hypnosis, a specialist helps a patient achieve a trance-like state and then gives positive suggestions, like “I can manage my pain” and “I can feel good.” Harvard’s medical school reports that in a study, hypnosis lowered both depression and gastrointestinal pain in 71 percent of participants.
One of the important things to remember is that time matters. The vicious cycle between pain and depression can snowball over time as your mental state makes it hard to move or to sleep, and not moving or sleeping makes depression even worse.
Getting treatment by a pain specialist, mental health professional, or both, is important, and it’s important to start sooner rather than later. Of course, motivation and energy are both very difficult when you’re suffering from pain or depression. Even identifying the problem and recognizing that there is help can be difficult. Family and friends are often the people who step in to point out that it doesn’t have to be this way. If you think you’ve got a pain-depression link, or if you think someone you love might have a pain-depression link, get it checked out as soon as possible.
Amy Miller, MD, is a physician at Integrative Pain Specialists. After practicing more than 10 years as a family physician, Dr. Miller transitioned her skills and extensive training in integrative medicine to help patients understand and overcome chronic systemic pain. Dr. Miller earned a Bachelor of Science from Georgetown University and Doctor of Medicine from Medical College of Ohio.