Depression and pain often go hand-in-hand. Here’s why:
By John F. Greden, MD
Why do pains and depressions so often occur together?
Many people with depression routinely have physical pains. The more physical symptoms an individual has, the more likely it is that they also are struggling with a mood disorder. More than half of those with eight or more physical symptoms are found to have clinical depression.
It is often difficult to determine which unexplained pain symptoms are associated with depressions and which are due to other causes. The most common co-existing symptoms include fatigue, headache, muscle aches, joint discomfort, dizziness, weakness, and occasional chest or abdominal pains.
Research suggests that this profound overlap arises because pain and depression circuits are intertwined. Some of the same neurotransmitters and neuromodulators in the brain—including norepinephrine, serotonin, mu-opioids, neurotrophins, glutamate, substance P, adenosine, and GABA—are involved in both pain and depression.
Traditional stressors, such as deaths, divorce, or job loss, can trigger pains and commonly do so. For reasons that are beginning to be better understood as we learn more about so-called inflammatory depressions, chronic pain can be set off by some infections as well as by physical traumas. Hormonal alterations, such as hypothyroidism, also sometimes masquerade as and produce both depressive symptoms and such symptoms as fatigue, loss of energy, and joint stiffness.
Some groups of people may be more vulnerable to developing co-occurring pains and depressive symptoms. The prevalence of chronic pain among U.S. military service members, for example, recently was reported to be higher than 40 percent. Predictably, those with post-traumatic stress disorder (PTSD) and major depressive disorder were significantly more likely to experience chronic pain.
What are good treatments for co-occurring pains and depressions?
Both chronic pains and depressions are treatable illness syndromes, but treatments must be carefully selected, monitored, and integrated. Good communication among all the clinicians involved in treatment is vital.
Co-occurring syndromes need to be treated in tandem, and medications remain essential pillars for treating both pains and depressions. Not surprisingly, some antidepressants have strong evidence for improving both pain syndromes and depressions.
Over-the-counter pain relievers may be an option, with an important caveat: Pain medications must be used safely. Acetaminophen is effective for many, but use of alcohol at the same time is dangerous. Non-steroidal anti-inflammatory drugs (NSAIDs), a class that includes ibuprofen, may help overcome pain associated with inflammations; they should never be taken on an empty stomach, as they may cause gastrointestinal bleeding. Long-term use raises separate issues.
Most importantly, opioids merit special warnings. Opioids are dangerous when used for prolonged periods or with increasing doses; habituation and addiction are frightening risks. In addition, chronic opioid use may lead to depression.
The misuse of opioids is a national crisis. More than 42,000 Americans died of opioid overdoses last year alone. This is why it’s recommended that prescriptions be limited to truly small amounts, such as five tablets, for short time periods, and without routine refills. Such careful approaches may be life-saving.
In terms of non-pharmacological treatments, there is good evidence for the benefits of education about the common brain mechanisms for both syndromes, and about the fact that inactivity and withdrawal from regular pursuits may intensify rather than improve symptoms. Aerobic exercises and cognitive behavioral therapy have been shown to have positive impact. Ideally, family members should be included in education sessions.
When an individual has multiple unexplained pain symptoms, laboratory tests commonly fail to show “organic” findings, leading to consideration of less-well-understood diagnoses such as fibromyalgia or chronic fatigue syndrome. Often missing is a consideration of co-occurring clinical depression, thought of too little, too late, and thus remaining untreated.
Printed as “Ask The Doctor: Chronic Pain & Depression”, Winter 2018
via Esperanza – Hope To Cope
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