The WPA Educational Programme on the Management of Depressive Disorders Depressive Disorders and...

Copyright © 2011. World Psychiatric Association

The WPA Educational Programme on the Management of Depressive Disorders

Depressive Disorders and Pain

Hayley Pessin, Ph.D., Wendy G. Lichtenthal, Ph.D., Emily Sachs, M.A., Elissa Kolva, M.A. and William Breitbart, M.D.


Relationship Between Depression & Pain

• 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)


Prevalence of Comorbid Pain & Depression

• Approximately 30% of patients suffering from persistent pain develop clinical depression (Gallagher & Cariati, 2002)

• Patients with chronic pain are 4x more likely to develop an anxiety or depressive disorder (Gureje et al., 1998)

• 50% of patients with depression report substantial pain (e.g., headache, abdominal, thoracic and pelvic pain)

• Medical illnesses characterized by painful symptoms (e.g., cancer, HIV, chronic back pain) increase risk of depression

• International estimates of depression-pain syndrome range from 22% - 87%


Symptoms Shared by Pain & Depression

Pain and depression share many symptoms (Turk et al. 2002)• Sleep disturbance• Mood symptoms

– anxiety, irritability, decreased pleasure, sadness

• Family stress• Reduced sexual activity• Reduced physical activity/exercise• Decreased self-esteem• Financial stress• Vocational issues• Legal concerns• Fear of injury


Common Etiologies & Pathways

• 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 &

Reid, 1996)


Assessment Issues & Risk Factors

• Assessment Issues– Poor adherence to treatment due to mood symptoms– Heightened risk of suicide

• Risk Factors– Personality disorders and maladaptive coping– Higher number of pain sites– Hopelessness – Impaired cognitive functioning– Desire for hastened death– Sleep disturbances– Poor occupational functioning– Decreased quality of life


Differentiating Mood Disorders & Pain

• 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


Cultural Considerations

• 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)


Treatment of Pain & Depression

• 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

improve psychological symptoms


Treatment of Pain & Depression: Pharmacological Interventions

First line treatment• Achieve adequate pain management with analgesics• Re-evaluate depressive symptoms, as mood symptoms may resolve with

adequate pain management

Second line treatment• Manage mood symptoms using antidepressants

– SSRIs initially recommended due to dosing simplicity

– TCSs, SNRIs and SSRIs may have antinocieptive effects (Raison & Miller, 2003)

– Serotonergic antidepressants (trazodone, mianserin) have been effective in relieving pain (Costa et al., 1985)

– MAOIs have adjuvant analgesic properties, but associated with myoclonus and delirium (Breitbart, 1988)


Treatment of Pain & Depression: Pharmacological Interventions continued

Additional Treatments• Psychostimulants

– As effective as antidepressants (Orr & Taylor, 2007)– Reduce excessive sedation secondary to opioid analgesics

• Benzodiazepines– Potent anxiolytics and anticonvulsants (Coda et al., 1992)– Limited evidence for analgesic effects

• Atypical antipsychotics – May have analgesic properties, particularly in cancer pain, chronic pain and

fibromyalgia (Khojanova, 2002; Freedenfeld et al., 2006; Gorski & Willis, 2003)– Reduce depressive symptoms, particularly sadness


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


Other Treatment Issues: Early Intervention

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


Other Treatment Issues: 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

require specialized substance abuse consultation


Conclusion

• 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

patient quality of life

The WPA Educational Programme on the Management of Depressive Disorders Depressive Disorders and...

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