By Steven Booth, Founder and CEO, Elevation Behavioral Health
In my role as the owner of a residential mental health program I have witnessed firsthand the debilitating effects of chronic pain-related depression in clients. Visibly hurting, both physically and psychologically, these individuals are desperate for relief from the suffering.
It isn’t hard to understand how suffering from chronic pain might lead to depression. Chronic pain, the persistent physical pain that lasts three months or longer, is exhausting to the brain and the body. Pain places a tremendous burden on one’s energy reserves, wearing the person down over time. Is it any wonder that one of the symptoms of chronic pain is depression?
Chronic pain and depression appear to be intrinsically linked through brain functioning. According to an article published in Neural Plasticity, “The Link Between Depression and Chronic Pain: Neural Mechanisms in the Brain,” the authors conclude that both depression and chronic pain share common brain regions that are involved in mood regulation. In addition, they conclude that there are, “overlaps in the pain and depression-induced neuroplasticity changes and neurobiological mechanism changes.”
Indeed, chronic pain and depression can set up a vicious cycle, with each condition worsening the symptoms of the other. The result can be debilitating pain-induced depression that severely impairs daily functioning. Unfortunately, many who relay their symptoms of physical pain and discomfort with their physician do not mention their depression symptoms. Doctors are beginning to be more proactive in asking pointed questions of their patients regarding potential coexisting depression.
Treatment for a chronic pain patient with co-occurring depression should reflect both conditions. This will translate to the pain management program combined with psychiatric support, as well as other therapies or activities that will help alleviate suffering.
The Connection Between Chronic Pain and Depression
Chronic pain refers to the physical pain that results from an injury, a degenerative condition, or a disease that persists for more than three months. It is estimated that nearly half the population is living with chronic pain. Living with pain on a daily basis is disheartening and can result in other symptoms such as sleep problems, fatigue, and physical weakness. Chronic pain can also lead to depression as its limitations to fully enjoying life begin to accrue.
Individuals struggling with both comorbid depression and pain may suffer major impairment in daily functioning, only deepening the depressive disorder. Disruptions in relationships and work performance due to the coexisting disorders can lead to serious consequences. In fact, among those with both chronic abdominal pain and depression there is a 2 to 3 times higher likelihood of suicide ideation or suicide attempts.
Symptoms of Depression
While it may seem natural to focus primarily on the chronic pain and assume that any symptoms experienced are directly related to the pain, in many cases a co-occurring depressive disorder is the cause for many of the symptoms. By understanding what the symptoms of depression look like, individuals being treated for chronic pain are better prepared to identify them as attributable to depression and can then obtain necessary treatment for the depressive disorder.
The DSM-5 has identified nine basic symptoms of major depressive disorder. While it must be taken into considerations that some medications cause depressive symptoms, as do some illnesses, it is helpful to consider the diagnostic criteria for depression. When five or more of these symptoms occur over a two-week period, it is pointing to a co-occurring depression diagnosis:
Depressed mood most of the day, nearly every day, as indicated by either subjective report or observation made by others.
Markedly diminished interest or pleasure in all, or almost all, activities more of the day, nearly every day.
Significant weight loss when not dieting or weight gain or decrease or increase in appetite nearly every day.
Insomnia or hypersomnia nearly every day.
Psychomotor agitation or retardation nearly every day.
Fatigue or loss of energy nearly every day.
Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
Diminished ability to think or concentrate, or indecisiveness, nearly every day.
Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide.
Management of Co-Occurring Chronic Pain and Depression
Once a clinical diagnosis of depression is arrived at, it is essential for the individual to begin treatment for the depression in tandem with the pain management. Many doctors will refer the individual to a psychotherapist or a psychiatrist where the mental health disorder can be effectively managed.
To treat the depression, outpatient mental health services are usually the initial course of treatment. With the goal of improving overall quality of life, the prescribing doctor will likely include a combination strategy of psychotherapy and antidepressants. The most effective psychotherapy for depression patients is cognitive behavioral therapy (CBT), where negative thought patterns are challenged and reframed into more productive, positive self-messaging. CBT teaches patients how to shift out of negative territory when triggering thoughts occur, employing the newly acquired coping skills.
For those patients whose depression is spiraling, particularly those who have increasing thoughts about death or suicide, a residential depression program is appropriate. This higher level of care provides a more intensive approach to treating the depression within a safe, supportive, and healing environment. During the stay, patients focus on learning new helpful coping strategies and practice these skills. Psychotherapy is provided daily, with both individual and group therapy sessions. In addition to the conventional psychotherapies, holistic therapies are often integrated into a residential mental health program.
Holistic Therapies that Benefit Both Chronic Pain and Depression
There are multiple holistic or experiential activities that address the mind-body-spirit connection. Many of these are of eastern origin; some are even ancient. Other holistic methods have become popular in the past decade as a natural way to enhance the treatment effects of traditional therapy. Some holistic activities that help improve the symptoms of depression include:
● Mindfulness. Our minds can take us to dark places if we let them. Mindfulness helps teach individuals how to focus on the present moment, to acknowledge the emotions, and offer a sense of control.
● Regular exercise. Something as simple as a 20-minute daily walk can produce endorphins and increase serotonin levels, improving mood, sleep quality, and energy level.
● Yoga. Yoga utilizes purposeful poses that can increase strength and flexibility while calming the mind.
● Improve sleep. Sleep quality can greatly impact mood, one way or another. By committing to better pre-bedtime habits, such as no caffeine after mid-afternoon, avoiding heavy meals, and eliminating screen time one hour before bed, can improve mood, concentration, and cognitive functioning.
About the Author
My name is Steven Booth, the CEO and Founder of Elevation Behavioral Health in Agoura Hills, CA. I’ve earned my B.A. from the University of California, Santa Barbara in Economics. Before helping to co-found Elevation Behavioral Health I worked in both private and public accounting. Like many others, I have seen firsthand the destruction that addiction can inflict on family and friends. I have also witnessed the extraordinary changes that can be made when addicts receive the necessary treatment. My passion is providing outstanding mental health care through Elevation Behavioral Health.