This article is from nurse.com.
Suffering from pain, especially chronic pain, often goes hand in hand with depression. And depression itself can be physically painful. But, in individuals inflicted by both, how is it determined what came first — the physical or the mental turmoil?
“The myth has been that being in pain is depressing, so logically, clinical depression will follow,” says Linda Stone, RNC, APNP, PhD, FAAPM, a fellow of the American Academy of Pain Management and a specialist in pain management, anxiety, and depression in Brookfield, Wis. “Although there is a significant connection between the two conditions, it’s not exactly a chicken and the egg situation.”
The mind/body scuffle
The current understanding of the pain/depression connection is that it’s not an issue over which condition comes first, but rather a wrestling match between mood and sensation over limited amounts of shared stores of neurochemicals.
Neurochemicals, including serotonin and norepinephrine, which regulate mood and depression, play a key role in mediating pain response. Endorphins also are part of the picture because these neurochemicals act as a natural pain reliever and pick-me-up by producing analgesia and a sense of well-being.
“Any condition that extensively uses serotonin, norepinephrine, and endorphins will result in less availability of those neurochemicals for other needs in the body,” says Stone. “Because of this link, pain and depression are intimately related. Both conditions intensify the other.”
Clinical depression is an accompanying diagnosis in about 30% of patients with chronic pain, and anyone in pain can experience some level of mood change, according to the National Pain Foundation.
Although the pain/depression phenomenon can accompany any pain condition, common examples include chronic back pain, joint pain, fibromyalgia, and migraine headaches.
“People who are depressed have three times the chance that they will begin having chronic migraine headaches, and people with migraine headaches are at least three times as likely to develop depression,” says Stone.
Compounding the pain/depression connection is the fact that the mood and pain perception centers are both located in the same areas of the brain. It also is believed people with a family history of depression may be more vulnerable to the pain-intensifying and mood-altering effects of neurochemical depletion.
Cultural influences can impact how pain/depression presents. Seventy-five percent of patients with clinical depression arrive on the doorstep of their primary care providers with complaints of physical symptoms, especially pain, according to the National Pain Foundation. It’s important that nurses and other providers recognize that pain can be a symptom of depression, and depression commonly accompanies pain.
“In primary care in particular, you will see a lot of depression converted into pain symptoms because culturally, it’s more acceptable to complain about pain than about depression,” says Stone. “In reality, both conditions are pushing each other’s buttons.”
The goal of treatment for pain/depression is to improve overall function because when pain is coupled with depression, it results in even higher levels of disability.
Treatment for pain can include the use of antidepressants and other adjunctive therapies such as exercise, physical therapy, self-hypnosis, relaxation techniques, meditation, and cognitive/behavioral therapy or psychotherapy, as well as antidepressants. “It’s not just about taking pain pills,” says Stone. “It’s about getting people with pain/depression to sleep and eat better and to focus on life, and you can’t do that with just pain pills.”
Antidepressants, especially the tricyclic amitriptyline (Elavil), venlafaxine (Effexor), and duloxetine (Cymbalta) can treat pain/depression because they inhibit reuptake of serotonin and norepinephrine, increasing their concentration and availability in the central nervous system.
Antidepressants can improve appetite, sleep, and pain tolerance, reducing the need for pain medications. They also can help patients to be more social and less withdrawn from their families and friends.
Antidepressants also minimize suffering, which is different than the physical sensation of pain. Suffering is the result of cognitive recognition of what has happened in the past because of pain, such as missing work or a family function, and anticipating it will happen again.
“Suffering is due to our ability to remember the past and project it into the future,” says Stone.
Implications for the boomer generation
Nurses need to be aware that as the baby boomer generation ages, they will encounter greater numbers of patients with pain/depression because of painful conditions associated with aging, such as osteoarthritis.
“We won’t be doing these patients justice with long-term use of nonsteroidal anti-inflammatory drugs, acetaminophen, or narcotics. Their systems can’t tolerate the side effects, such as liver damage, gastrointestinal bleeding, sedation, and drug tolerance,” says Stone. “We are going to have to open our minds to helping people stay active and functional by addressing all the components of pain/depression with the use of adjunctive treatments.”
Catherine Spader, RN, is a contributing writer for Nursing Spectrum/NurseWeek.