The WPA Educational Programme on the Management of Depressive Disorders Depressive Disorders and Pain Hayley Pessin, Ph.D., Wendy G. Lichtenthal, Ph.D.,
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• Reciprocal relationship between pain and depression– Ratings of pain intensity influenced by psychological factors – Mood is influenced by functional limitations associated with pain more than by
pain severity – Presence of pain influences onset and severity of depressive symptoms
(Mystakidou et al., 2006; Serlin et al., 1995)
• Pain is subjective and vulnerable to fluctuations in mood• Co-morbid depression and pain
– More resistant to treatment (Gallagher & Cariati, 2002)– May require multimodal intervention (Brietbart & Holland, 1990)
• Family stress• Reduced sexual activity• Reduced physical activity/exercise• Decreased self-esteem• Financial stress• Vocational issues• Legal concerns• Fear of injury
• No clear dominant causal or antecedent pattern despite established relationship between depression and pain
• Two possible frameworks (Von Korff & Simon, 1996)1. Genetic vulnerability to both physical and psychological symptoms amplifies
physical discomfort
2. Stress of pain exacerbates psychological symptoms
• “Gate control theory of pain” (Melzack & Wall, 1965)– non-nociception signals inhibit or enhance nociception signals from nerve fibers
• Neurobiological and biobehavioral processes– Prolonged pain leads to structural CNS changes (Gallagher, 1999)– Role of serotonin, norepinephrine in CNS pain-modulating circuit (Sawynok &
• Depression is underdiagnosed in primary care population– 50% of patients with major depression are not diagnosed by their primary care
physician (Simon & VonKorff, 1995)
• Somatic symptoms underrecognized as symptom of depressive disorders • Diagnostic interview is essential• Self-report measures/ Visual analog scales are helpful• Anhedonia is a key indicator of depression in medically ill
• Overreliance on somatic symptoms in reporting distress– Role of cultural stigma– More common in patients without primary care physician– Denial of psychological depressive symptoms (Simon et al., 1999)
• Recent findings challenge traditional view of cultural stigma surrounding depression
– Psychological and somatic symptoms reported at similar rate in non-Western communities (Simon et al. Ormel, 1999)
• Experience and expression of pain varies across racial, ethnic, and gender groups
• Healthcare providers can mediate cultural barriers to healthcare access (Bonham, 2001; Davidhizar et al., 2004)
• Psychiatric interventions are integral to a comprehensive clinical approach• Important to disentangle and address underlying physical and psychological
issues• Combination treatment approaches may have a reciprocal and/or interactive
effect• Psychological treatment has been found to impact nociception and
perception of pain• Physical therapies targeting pain detecting neurons have been found to
Treatment of Pain and Depression: Psychosocial Interventions
• Empirically-supported treatments for depression and pain– Cognitive-behavioral therapy– Acceptance and commitment therapy– Relaxation, guided imagery, self-hypnosis– Biofeedback– Supportive psychotherapy– Family interventions
• Common goals of treatments– Providing emotional support– Psychoeducation– Assistance with adaptation– Coping strategies– Problem solving– Communication skills
Treatment of Pain and Depression: Complementary Treatments
• Complimentary and Alternative Medicine (CAM) approaches are increasingly popular as primary interventions or in conjunction with traditional treatments, and may improve both pain and mood symptoms– Massage– Acupuncture– Homeopathic remedies
• St. John’s Wort, Arnicia, Sam-e
• Practitioners should interview patients regarding self-care practices to avoid the potential negative consequences associated with dietary supplements
Early Intervention:• Risk factors (presented earlier) can identify patients who may benefit from
early intervention• Treatments are more effective• Lower doses required to manage symptoms• Spares patients from increased suffering• Results in optimal treatment
Other Treatment Issues: Barriers to Adequate Treatment
• Lack of training in recognition, assessment, evaluation, and treatment of comorbidity of pain and depression
• Focus on prolonging life• Lack of patient-physician communication• Limited expectations for pain relief• Inadequate assessment due to impaired mental capacity• Lack of availability of narcotics• Physician fear of causing additional harm
– Side effects, respiratory depression, sedation
• Physician fear of increasing addiction/substance abuse
• Addiction is rare in individuals without a history of drug abuse that predates the physical illness
• Patients may experience tolerance or physical dependence, but not addiction• Increased use of opioids is often due to disease progression• Fear of addiction may lead to patient noncompliance and under-medicating• If patient has an active addiction, pain management is challenging and may
• Comorbid pain and depression is highly prevalent yet under-diagnosed and under-treated
• The reciprocal relationship between pain and depression is well established• Recognition and treatment of comorbid pain and depression are both
complicated and require additional training• Assessment and treatment of pain and depression are essential components
of quality patient care• Early detection and treatment improves patient outcomes• Adequate treatment of pain and depression will reduce suffering and improve