Understanding the Bi-Directional Relationship Between Depression and Chronic Pain

Pain is something everyone occasionally experiences. You can cut your finger or develop arthritis or have a tooth go bad. Acute pain is part of a system that alerts the brain that the body’s been injured and needs healing. Once you address the source of the pain, the pain isn’t needed; the signal dissipates, and you return to normal.

Unfortunately, though, chronic pain, defined as pain lasting three months or more, can lead to mental health concerns such as anxiety and depression. In the same way, mental health conditions can lead to physical symptoms, including pain. These cases, where the problems become intertwined, can be some of the more difficult to treat.

The development of anxiety and/or depression is often comorbid with chronic pain syndromes like irritable bowel syndrome (IBS), fibromyalgia, low back pain, headache disorders, and neuropathic pain.

At the offices of Dr. Michael Kullman, in White Plains and Pleasant Valley, New York, the team diagnoses and treats chronic pain problems in their patients. They also treat the frequent anxiety and depression disorders that tend to come with the pain. Understanding the back-and-forth relationship between depression and chronic pain can ultimately lead to effective treatment of both.

More about the pain-anxiety-depression cycle

Scientists once believed that the relationship among pain, anxiety, and depression came mostly from psychological factors. However, as knowledge from new studies came in and correctly described how the brain functions, they discovered that pain shares some biological mechanisms with both anxiety and depression.

The brain region that interprets sensory information, called the somatosensory cortex, interacts with the amygdala, the hypothalamus, and the anterior cingulate gyrus (areas known to regulate both emotions and stress); together they create the mental and physical experience of pain. Interestingly, these same areas also play a role in creating the expression of anxiety and depression.

In addition, two neurotransmitters — serotonin and norepinephrine — contribute to pain signaling in the brain, and they’re both implicated in the manifestation of anxiety and depression.

Current theory holds that a psychological condition may drop the body’s threshold for pain tolerance. For example, people living with depression tend to experience more severe and longer-lasting pain than people without depression. Some 65% of patients seeking treatment for depression also report at least one type of pain symptom.

It also works in the other direction. Approximately two-thirds of patients with IBS develop symptoms of psychological distress, most often anxiety. Psychiatric disorders contribute not just to pain intensity but also to increased disability from the pain.

Stopping the cycle

When pain comes along with anxiety and/or depression, treatment can be a challenge. Focusing strictly on the pain can minimize the awareness that the patient also has a psychiatric disorder. And focusing strictly on the anxiety and/or depression overlooks the pain driving those conditions.

Fortunately, therapies are available that can help all three parts of the problem.

Cognitive behavioral therapy (CBT) is a type of psychotherapy. It isn’t only established for treating anxiety and depression, but it’s also the best-studied form of psychotherapy for treating pain. Our therapists use CBT to help you think about your symptoms in a more positive and healthier way so you can manage, rather than be at the mercy of, your conditions.

Exercise is another good option, boosting mood and alleviating anxiety, which may also help relieve pain.

A review of 34 peer-reviewed studies was undertaken by the Cochrane Collaboration in 2010; they compared various forms of exercise with different control conditions to treat fibromyalgia. The reviewers found that aerobic exercise improved overall well-being and physical function, and there was some evidence to suggest it might relieve pain. More limited evidence suggests that muscle strengthening may also help improve pain, overall functioning, and mood.

Medication can be an effective treatment modality, too, and some psychiatric medications also work as pain relievers. A number of antidepressants prescribed for both anxiety and depression relieve nerve pain, and the research most strongly supports using selective norepinephrine reuptake inhibitors (SNRIs) or tricyclic antidepressants for treatment. The findings are less robust for using the selective serotonin reuptake inhibitors (SSRIs) to alleviate pain.

Anticonvulsants not only control seizures, but they can also be used “off label” to stabilize mood. Primarily, they rein in the aberrant electrical activity and hyper-responsiveness in the brain that contribute to seizures. However, because pain also involves nerve hypersensitivity, some of these medications may prove helpful.

Most patients find that combining psychotherapy with medication therapy offers the most complete relief. The Stepped Care for Affective Disorders and Musculoskeletal Pain (SCAMP) study suggests such a combination approach might be effective.

Struggling with the trifecta of pain, anxiety, and depression? Dr. Kullman can help with that. Call the  office at 914-465-2882 to schedule your consultation, or visit our website for more options.