Coping With Depression in Chronic Pain Management

The Role of Depression When Living With Chronic Pain

Depression is the number one psychological (mood) disorder that causes the biggest problems for the most people living with chronic pain – and it often gets underdiagnosed and/or undertreated.

A variety of recent medical studies have drawn a strong association between chronic pain and a diagnosis of major depression. The two conditions seem to go hand-in-hand in a large percentage of unfortunate patients who suffer the debilitating effects of both chronically painful conditions and persistent mood problems.

Researchers still can not determine whether there is a cause-and-effect relationship between chronic pain and depression, and if there is, which condition causes the other. Some research suggests that insufficiently treated, ongoing pain may cause changes in the chemical environment of the brain, thereby increasing the likelihood of depression. Similarly, other research suggests that insufficiently treated, ongoing depression causes changes in the chemical environment of the brain, such that it increases an individual’s perception of painful sensations.  Regardless of the etiology, concurrent treatment is necessary for successful treatment outcomes.

Many people with chronic pain frequently become depressed due to living with under-treated or mistreated pain symptoms. When a person’s thinking and emotions become problematic, they become irrational or dysfunctional and mismanage their feelings. As a result, they have urges to indulge in self-defeating, impulsive or compulsive behaviors to cope with their depression, which affects all their relationships.

Common Causes of Depression

A clinical depression is typically caused by a combination of biological, genetic and psychological factors. Living with chronic pain, a recent death or loss, feelings of grief, family conflict or divorce, financial difficulties, major life transitions and other stressors can contribute to or exacerbate a depressive episode. It should also be emphasized that some depressive episodes can occur without readily identifiable causes.

There is some research evidence which indicates that consumption of alcohol and other drugs play a significant role in causing some depressive disorders. For some people, the consumption of alcohol and other drugs may mask the symptoms of depression, which discourages them from seeking proper treatment. It is important to remember that all of the depressive disorders are treatable conditions; they are not the result of laziness, weakness, personal failure, or a lack of willpower. Following are some common symptoms of depression.

Clinical depression results in disturbances in mood, concentration, self-confidence, sleep, appetite, activity and behavior as well as disruptions in friendships, family, work and/or school.  A clinical depression is different than the experiences of sadness, disappointment and grief familiar to everyone, which sometimes makes it difficult to determine when professional help is necessary.

Feeling Down Versus Being Depressed

A period of depressed mood that lasts for several days or a few weeks is often just a normal part of life and is not always a cause for concern. Although these feelings are often referred to as depression, they typically do not constitute clinical depression because the symptoms are relatively mild and only last for a short period of time. Moreover, milder periods of depression are often related to specific stressful life events and improvement frequently coincides with the reduction or elimination of the stressor.

If people are experiencing a clinical depression, however, there would be substantial changes in their mood, thinking, behaviors, activities and self-perceptions. If they are depressed they often have difficulty making decisions. Even the day-to-day tasks of paying bills, attending classes, reading assignments, and returning phone calls may seem overwhelming.

They may also dwell on negative thoughts, focus on unpleasant experiences, describe themselves as a failure, report that things are hopeless, and believe they are a burden to others. The changes in mood brought on by depression frequently result in feelings of sadness, irritability, anger, emptiness, and/or anxiety and may eventually lead to thoughts of suicide.

There are different types of depression, including Bipolar Disorder, in which depressive episodes alternate with mania (extremely elevated mood, energy, and unusual thought patterns) or hypomania (generally a less destructive state than full mania) episodes which may include feelings of agitation and euphoria. A severe or long-term depressive episode can substantially wear down self-esteem and may result in thoughts of death and even attempts at suicide.

The Depression Symptom Checklist

In the following section, you will see a depression checklist that includes many symptoms of clinical depression. However, only some of these symptoms are necessary for a diagnosis of depression. It is best for people to go over the results of this checklist with a qualified healthcare provider who can help determine if they are truly suffering from depression or just feeling blue or a little down and out.

• A significantly depressed mood or general absence of mood: You may sometimes find yourself feeling overly negative and down or at other times emotionally cut off.
• Inability to experience pleasure or feel interest in daily life: Things that used to excite or interest you now hold no attraction at all. Sometimes it hardly seems worth getting up.
• Inexplicable crying spells, sadness and/or irritability: You may find yourself crying for no reason or having a temper tantrum and lashing out without any provocation.
• Insomnia (difficulty sleeping) or hypersomnia (oversleeping) nearly every day: You either can’t get to sleep or stay asleep and/or find yourself spending most of your time sleeping to the point of missing important events in your life.
• A substantial change in appetite, eating patterns or weight: You find that you have no appetite and nothing sounds good so you just don’t eat, or in an effort to feel better you discover that eating certain types of foods seems to sooth you. You either lose or gain a significant amount of weight.
• Fatigue or energy loss: You seem to be always tired or don’t seem to have enough energy to accomplish even simple tasks of daily living.
• Diminished ability to concentrate: You find that paying attention is very difficult you may even find yourself reading the same page over and over or forgetting the plot of a movie you are watching.
• Difficulty making decisions: You can’t seem to decide what to do even in simple areas that used to be easy for you. You tend to procrastinate or put off having to decide.
• Feelings of hopelessness or worthlessness: At times you feel like your life is always going to be unbearable or that you don’t deserve to be happy or successful.
• Inappropriate feelings of guilt or self-criticism: You find yourself putting yourself down for little things and feel bad about things that might not even really be your fault.
• A lack of sexual desire: You have lost your interest and passion for being a sexual being. It either seems like too much of a hassle or you just don’t care anymore.
• Suicidal thoughts, feelings or behaviors: You start having thoughts like “maybe I’d be better off dead,” or “I feel that life isn’t worth living.” You may even start thinking about ways you could kill yourself and even start developing a plan.

The Complexities of Managing Depression

One of the biggest problems in managing depression in people with chronic pain is a misdiagnosis or a missed diagnosis. It’s difficult for someone who is depressed to realize it, as well as family or friends. This occurs for two reasons:

(1) When people have chronic pain, they don’t make the connection between their pain and experiencing depression

(2) Peoples’ healthcare providers are not looking for it

People living with chronic pain will often define their problem as strictly a medical issue related to their pain. Therefore, it is important to notice if depression is present and then become willing to develop a treatment strategy, which is a crucial component of an effective pain management treatment plan.

There are currently a variety of highly effective interventions available for the treatment of depression. The majority of depressive conditions can be treated with either psychotherapy (especially cognitive behavioral therapy) or medication, but research studies have indicated that a combination of these interventions is usually the most effective form of treatment for moderate to severe depression.

There are also some types of depression that have a seasonal patterning where intensive Full Spectrum Lighting therapy is often effective in reducing symptoms. It should be emphasized that the majority of depressive conditions can be treated without hospitalization.

Things People with Chronic Pain Should Do When They’re Depressed

• Eliminate the use of alcohol and other drugs (other than appropriate prescriptions)
• Exercise or engage in some form of physical activity every day, such as walking, or whatever is possible given your physical limitations
• Eat a proper, well-balanced diet – also, use a good multivitamin daily
• Obtain an adequate amount of sleep – if sleep is a problem discuss this with your doctor/therapist
• Reach out for emotional support from friends and family
• Focus on the positive aspects of your life
• Pace yourself, modify your schedule and set realistic goals
• Eliminate or reduce unnecessary tasks so that your schedule is more manageable
• Reduce or eliminate the use of nicotine, caffeine, and sugar
• Consult with a physician if you are experiencing any medical problems
• Seek early intervention which may modify the severity of your depression

Things People with Chronic Pain Should Avoid When They’re Depressed

• Isolating behavior
• Making long-term commitments or important decisions, unless absolutely necessary
• Over-committing to activities which are stressful or overwhelming
• Assuming that things are hopeless – they’re not!
• Engaging in “emotional reasoning” (e.g., “because I feel awful, my life is terrible”)
• Assuming responsibility for events which are outside of your control
• Avoiding treatment as a way of coping so you don’t have to change

The Role of Isolation and Enabling in Depression Management

Some people living with chronic pain and depression become isolated and believe they can handle life without any help; some may go to the other extreme and become increasingly dependent on others to take care of them. Either style can worsen their depression. This reinforce his or her role as a victim. They may need to have treatment for depression. An effective depression management treatment plan should include cognitive behavioral therapy and possibly an antidepressant medication.

Suggestions for Helping a Depressed Friend

• Be empathic and understanding
• Don’t try to cheer up a depressed person
• Avoid critical or shaming statements
• Challenge expressions of hopelessness
• Empathize with feelings of sadness, grief, anger and frustration
• Don’t argue about how bad things are
• Don’t insist that depression or sadness are the wrong feelings to be experiencing
• Don’t become angry even though your efforts may be resisted or rejected
• Advocate for their recovery from depression
• Emphasize that depression is treatable
• Seek consultation if a depressed friend refuses necessary treatment

The important thing to remember is that people need to be able to recognize and admit that they have a problem before they can work on an effective solution. Typically, they are going to need help through a support network that includes a pain management specialist, physician, therapist and family members to help them work through any denial or depression issues in order to develop an effective recovery and pain management program.

So if you or someone you care about is suffering with chronic pain and possible depression, please reach out to a licensed healthcare professional with training and experience with both conditions. Freedom from suffering from chronic pain and depression is a right and it’s also a responsibility – it takes authentic action!