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
- 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
- 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
- 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.
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
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
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
- 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