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Freeport Integrated Health Center, Chiropractic Clinic in Freeport, ME

Depression & Pain

The link between Depression and Pain

By James Hendricks, D.C.

If you Googled the word “depression”, you find over 61 million search results, if you did the same for pain you find over 210 million.  When you link the 2 together you will get over 73 million links.  The over whelming thought in the medical research community if that there is a definite link between the two.  As a practitioner, the vital part is being able to recognize the symptoms of each, determine if the symptoms are linked in an effort to diagnose and treat your patient correctly.  Not all patients with chronic pain are depressed, but studies have shown that approximately one out of three people with chronic pain have significant depression. 

Clinical depression is the form of depression that is most often seen with pain and it is characterized and diagnosed with the list of symptoms below.  Doctors give a diagnosis of clinical depression to patients that suffer from at least five of these daily, for a minimum of two weeks.

  • Depressed mood for most of the day, nearly every day
  • Poor appetite or significant weight loss or increased appetite or weight gain
  • Loss of interest or pleasure in usual activities
  • Disrupted sleep: too much or too little
  • Agitation or restlessness
  • Low energy or fatigue 
  • Feelings of worthlessness and/or guilt
  • Lessened ability to think, concentrate, or make decisions
  • Frequent thoughts of death, suicide, or wishing to be dead

Researchers have determined that while depression is strongly linked to pain, “there is little understanding of how this link works or how it might be utilized in clinical settings.”  There is not a clear link that one precedes that other, however when both pain and depression are present in a patient the overall prognosis is significantly affected. As a doctor that treats musculoskeletal conditions, injuries and pain, while I have been trained to recognize the symptoms of depression, it is not my main clinical focus. I would expect the opposite to be true with a Psychiatrist or Psychologist, will they are able to recognize musculoskeletal pain or injuries, it is not their clinical focus, but depression would be. 

In the investigation of the treatment of depression and pain, it is noted in the research literature that clinicians in some cases are failing to assess both issues, resulting in a probable “under treatment of one or both of them.”  Clinical evidence has suggested that while treating the pain will not totally alleviate the symptoms of depression when both are present; it does result in significant early improvements in the depression as the musculoskeletal pain improves.  This would suggest that a course of action would be to combine both the treatment of the pain with the treatment of the depression to achieve the maximum amount of success.

 Researchers do agree on these four facts about pain and depression:

  • Pain occurs with depression as often as it occurs with anxiety.
  • The number of painful areas in the body, and how much pain interferes with daily life, can predict the risk of developing depression
  • Some symptoms of depression, like low energy, sleep problems, and worry, are common among pain patients, but other depression symptoms, like guilt and loneliness, are not
  • Depression often appears soon after a chronic pain condition starts

As a doctor that treats musculoskeletal pain every day, it makes perfect sense that depression is linked to ongoing chronic pain.  Pain in general limits what we in the medical world call the “Activities of Daily Living:” sleep, dressing, using the bathroom, sexual activity, driving the car, household chores and social activities to name a few.  Loss of even just one of these activities over time can lead to stress in family relationships, loss of pleasurable activities, fatigue, etc.  As person whom deals with chronic arthritis pain daily, on a personal level I can relate how loss of physical activity or physical strength can lead a diminished level of self esteem and self worth. As a poster I have seen frequently says,” Growing Old Is Not for Wimps.” I find as with all things one must always find happiness in things that we do have and retain an optimistic attitude; however it maybe hard to find the optimism when suffering from clinical depression.

Many researchers believe that neurotransmitters of the human brain form a link between chronic pain and depression.   Neurotransmitters are used to relay, amplify and modulate electrical signals between the brain, through its nerves and other cells of the body. The brain uses neurotransmitters to control everyday bodily activity: like heart beat, breathing or digestion.  They also affect mood, sleep, concentration, weight, and can cause adverse symptoms when they are out of balance or not working properly.  The neurotransmitters serotonin and norepinephrine have been found to influence both pain and mood (to name a few) and research suggests that they play a key role in depression and the mediation of pain. 

When you “prick your finger” on a needle, the nerves of sensation in your skin send signals to you brain in response to the stimulus.  The stimulus is moderated in the brain by serotonin and norepinephrine.  In some patients with depression, with an imbalance of serotonin and norepinephrine, could affect how they perceive the pain response, possibly making it exacerbated.  This is a possible explanation of the connection between pain and depression.   In a study done by University of Oxford researcher Dr. Chantal Berna, the findings revealed that inducing a depressed mood disrupted the neurotransmitters that regulate emotion, causing an enhanced perception of pain. “In other words,” as explained by Dr. Berna, “when the healthy people were made sad by negative thoughts and depressing music, we found that their brains processed pain more emotionally, which lead to them finding the pain more unpleasant."

While it all makes sense to me, as a doctor you have to try to distinguish if it is the depression causing the heightened pain response, the chronic pain which has lead to depression, or the depression causing symptoms of pain?  Further investigation into the later has postulated that the more severe the physical symptoms, the more severe the depression can be. Statistically, it has been shown that people with depression have three times the risk of incurring chronic pain.   Additionally, for many patients who are diagnosed with depression over a long period of time, many will develop chronic pain problems as well, without any clear injury to explain that pain.  A study published in the journal Psychosomatic Medicine found that 2/3 of all people beginning treatment for depression additionally reported being in physical pain, with the most commonly symptoms being frequent headaches, back pain, joint pain, and abdominal pain.  From these studies it might be easy to conclude that the depression induces the pain, but lets’ take look at some research coming from down under.

In research done in Australia on depression and low back pain suffers; patients with depressive symptoms at the time of consultation had higher back pain scores at the three week follow-up. Patients with back pain after three weeks in turn were more likely to suffer from depressive symptoms at six weeks.   The study, which was in collaboration with the University of Berne in Switzerland, tested 300 patients who went to their general practitioner with a new episode of back pain. They were followed up over a six week period.  As mentioned above, it has been determined that people with depression are more likely develop and maintain back pain.  The reason given is that due to the imbalance of the brain neurotransmitters, people with depression have a diminished ability to cope with an episode of pain. On the other hand, this research has found that people with back and neck pain suffer from depression more often.

Physical symptoms are common in major depression and may lead to chronic pain. Pain symptoms associated with depression include joint pain, limb pain, back pain, gastrointestinal problems, fatigue, psychomotor activity changes, and appetite changes.  In regards to chronic pain here are some statistics:

  • According to the American Pain Foundation, about 32 million people in the U.S. report have had pain lasting longer than one year.
  • From one-quarter to more than half of the population that complains of pain to their doctors are depressed.
  • On average, 65% of depressed people also complain of pain.
  • People whose pain limits their independence are especially likely to get depressed.

The treatment of depression needs to be such that is addresses all the areas of the patient’s life; diet & nutrition, the psychological aspect, stress and the physical aspect as well. Chiropractic health care is a well suited holistic approach to treating the musculoskeletal pain that may be associated with depression or in fact be the issue that is root cause of the disease.  Simply put, Chiropractors use joint manipulation or “adjustments” to restore joint and muscle mechanics and reduce pain. My doctors like myself, take a total approach to patient treatment in an effort to reduce pain but also to prevent it from reoccurring.  Addressing nutrition, sleep habits, workplace ergonomics, stretching and exercise are just a few ways.  Coordinating this type of care with that of the councilor, psychologist or psychiatrist could be the solution to reducing the symptoms patients suffering from both pain and depression deal with. Whether or not you choose Chiropractic, massage therapy or acupuncture, physical therapy, etc. the most important thing is that you choose to deal with any type of chronic pain, especially when associated with depression, rather ignore it or choose to believe that it is something you have to deal with or might “just go away on its own.”

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