Chronic Pain and Depression: Your FAQs Answered
It probably goes without saying that living with pain can be challenging, even depressing, at times. When pain starts to consume your thoughts and limit your ability to do the things you once loved and enjoyed (or even things you took for granted), it’s bound to have a negative impact on your mood. However, even though it makes sense that chronic pain can lead to changes in your mood or mental health, there are a lot of misunderstandings about pain and depression.
Here are answers to some of the most frequently asked questions about pain and depression.
1. What’s the difference between feeling depressed and depression?
Everyone feels depressed from time to time; it’s part of being human. That said, you may not call it “feeling depressed”. You may think of it as “being in a funk”, “having a down day”, or “feeling low/blue”. No matter what you call the experience, it’s a common experience. More importantly, it is normal to feel down on occasion, particularly if you’re having a bad pain day. However, if you find yourself having many challenging days back-to-back, or two weeks go by and you have had more bad days than good, then you might be experiencing more than just the feeling of depression.
Clinical psychologists and the DSM5 (American Psychiatric Association, 2013), affectionately referred to by myself as “the big book of psychological diagnoses”, state that you must have two key experiences to consider a diagnosis of a major depressive episode (commonly known by the public as clinical depression). These two experiences are:
1) feeling depressed most of the day, more days than not, for a two-week period, AND
2) you are experiencing a loss of interest or pleasure in activities you used to enjoy.
If you can say “yes” to each of these experiences, you might be experiencing a depressive episode. Keep reading to learn more.
2. What are the symptoms of depression?
According to the DSM5 (American Psychiatric Association, 2013), the symptoms of depression are*:
· Depressed mood most of the day, nearly every day.
· Markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day.
This is more than just not wanting to do something because you are concerned that it will cause you pain or aggravate your existing pain (which is common). Furthermore, this type of lack of interest can be thought of as an overarching lack of motivation or general sense of “blah” when it comes to things that used to bring you joy.
· Significant weight loss (when not dieting) or weight gain or decrease or increase in appetite nearly every day.
This can be tricky to determine for many people who have pain. Many people with chronic pain note that they have put on weight because of not being as physically active as they used to be (or would like to be). For people with chronic pain, it can sometimes be more helpful to think about appetite rather than actual weight changes; although for some people intense pain can actually cause loss of appetite.
· A slowing down of thought and a reduction of physical movement (observable by others, not merely subjective feelings of restlessness or being slowed down).
Once again, this type of physical slowing down can be easily misunderstood in people with pain. The diagnostic criteria refer to a general slowing down of most movements, not slowing down or moving differently due to worries about making pain worse or pain itself. In other words, someone who has started walking slower than before due to pain, but otherwise is moving and talking at their normal pace may not meet this criterion. Additionally, it is important to note that some, but not all, pain medications can cause fatigue (Zlott & Byrne, 2010), which may look like slowed movement or speech.
· Insomnia or hypersomnia nearly every day.
(Sleeping noticeably more or less than usual). People with chronic pain are often familiar with the experience of disrupted sleep. Intense pain can make it challenging to find a comfortable position to sleep in and may result in frequently waking up or tossing and turning throughout the night. Additionally, people with certain types of pain such as diabetic neuropathic pain may notice that pain intensity increases at night, and research shows evidence for this phenomenon as well (Odrich et al, 2006). Those with chronic pain may also be more likely to try to make up for their poor night-time sleep during the day. Last but not least, it is important to consider that some medications, such as opioids, anticonvulsants, and even some antidepressants, may increase tiredness and fatigue (Dimsdale et al, 2007; Zlott & Byrne, 2010). Because the relationship between pain, sleep, and depression is so complex, it is important to evaluated by a trained professional who understands how these experiences are related to one another.
· Fatigue or loss of energy nearly every day.
Pain and fatigue often go hand in hand and research shows that these experiences tend to happen at the same time (van Dartel et al, 2013) and may fuel one another (Manning et al, 2020). Additionally, because pain can often interfere with your ability to achieve a good night’s sleep, people with chronic pain often experience fatigue due to lack of sleep as well. (Gebhart et al, 2017). Lastly, as mentioned before, certain medications can contribute to fatigue (Zlott & Byrne, 2010)
· Feelings of worthlessness or excessive or inappropriate guilt nearly every day.
When pain gets in the way of being able to work, fulfill your obligations, or do the things you love; it is completely understandable to feel worthless or experience a lack of purpose. However, even when we can understand these feelings, that does not mean that they are healthy for you as a whole person. Research shows that worthlessness or feelings of inadequacy (not “measuring up”) predict depression (Zahn et al, 2015) and risk for suicide (Wakefield & Schmitz, 2015). So even if these types of feelings are spurred by the pain, it’s important to seek help and address these feelings.
· Diminished ability to think or concentrate, or indecisiveness, nearly every day.
This is another complex experience for people with chronic pain. Pain can impact your ability to focus (Moriarty, McGuire, & Finn, 2011); in fact, some chronic pain conditions, such as fibromyalgia, include memory or thought problems in their list of symptoms (American College of Rheumatology, 2021). Because lack of sleep and fatigue also contribute to difficulty thinking, it can be hard to know what is causing the problem. The most important thing to know is that all of these experiences (i.e., pain, depression, lack of sleep, fatigue, and even some medications), can contribute to this issues with memory and concentration, and it is more likely than not that several of these factors are playing a role for people in chronic pain.
· Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide. Chronic pain is associated with an increased risk of suicide (Racine, 2018). If you are experiencing thoughts of suicide, I urge you to seek help immediately. You can reach the national Suicide Prevention Lifeline at 800-273-8255, or https://suicidepreventionlifeline.org/; they provide services in both English and Spanish, as well as services for those who are hearing impaired.
3. Do Pain and Depression Fuel Each Other?
Yes!. Of course, being in pain and not being able to do the things that make you who you are can lead to depression…but did you know that depression can actually increase pain? It’s true!
When you are experiencing any strong, uncomfortable emotion (such as depression, anger, or anxiety) it can cause a chemical reaction in your brain which results in several neurochemicals being released. These neurochemicals and neurotransmitters travel from the brain, down the spinal cord, and to your nervous system, where they cause many physical reactions in your body. Some of these reactions can help us to deal with the stressful situation; however, they also have an unfortunate side effect: they amplify pain. You may have heard of several of these neurotransmitters including serotonin and norepinephrine. Both serotonin and norepinephrine are involved in mood, but serotonin is especially interesting because it also impacts sleep, appetite, and you guessed it…pain (Sanchez-Salcedo et al, 2021; Wise et al, 2007).
So, imagine that you are already having several bad pain days, you may start to experience the feeling of depression. But just having that feeling could potentially cause a chemical cascade that results in even more pain, so then you feel even more depressed. You’re stuck in the pain cycle, where both pain and depression just make each other worse.
4. Which came first, the pain or the depression?
The short answer- it’s complicated.
Research is somewhat unclear about which came first. Physical pain can be both a symptom and a contributor to depression, and some studies suggest that pain is common in 65% of people with depression (Williams et al, 2014). In the opposite direction, people with chronic pain are at increased risk for depression compared to people who are pain-free (Ohayon & Schatzberg, 2010). Most of the scientific studies show that pain and depression often occur together and contribute to each other.
However, research has also shown that for people with chronic pain, the most common course of events is first pain, then depression naturally follows due in part to pain, lack of sleep, and changes in day to day life (Ohayon & Schatzberg, 2010).
Regardless of where it started for you, if you are stuck in the pain cycle of pain and depression, it can feel overwhelming. It can be hard to break out of the cycle on your own. That’s where a pain psychologist or clinical health psychologist can be helpful.
5. Do I have to live with pain and depression forever?
NO!
Just because you are currently stuck in the pain cycle, it doesn’t mean that you must live in the cycle forever. In fact, quite the opposite- realizing that you are in the pain cycle is the first step to getting out.
While it’s true that it may not be possible to eliminate pain forever, there are ways that you can reduce the pain intensity for periods of time. These options may include a combination of medications, physical therapy, exercise, relaxation training, or complementary and alternative treatments such as acupuncture (make sure you talk with your physician or the medical provider managing your pain condition before pursuing any of these options). You can also learn strategies to help you do more of the things you need to do/want to do without over-doing-it and causing more pain.
Even though the pain likely will not disappear forever, you CAN treat the depression. Chronic pain therapy or pain-focused therapy can be especially helpful for depression related to chronic pain. One type of therapy, Cognitive Behavioral Therapy for Chronic Pain (CBT-CP) can help teach you new ways of responding when you experience thoughts about pain that ultimately lead to depression. This is more than just “thinking positive”; it’s a scientifically supported way to change your thinking so that your thoughts are more helpful to you, leading to less depression. CBT-CP can also help you learn new ways to do more and regain control over your life. Check out my Therapy Services page to learn more here.
Lastly, there are medications that can be helpful for some people. Antidepressants such as Tricyclic Antidepressants, Serotonin Reuptake Inhibitors (SSRIs) and Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) have shown effectiveness in treating both depression and pain (Sanchez-Salcedo et al, 2021). Generally, psychologists do not prescribe medication, but if you think you might benefit from an antidepressant, talk to your Primary Care Physician or the medical specialist who manages your pain condition.
Additional Resources
If you or someone you know are experiencing thoughts of suicide, I urge you to seek help immediately. You can reach the national Suicide Prevention Lifeline at 800-273-8255, or https://suicidepreventionlifeline.org/; they provide services in both English and Spanish, as well as services for those who are hearing impaired.
The American Chronic Pain Association
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.
American College of Rhematology. (2021, August 24). Fibromyalgia. https://www.rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Conditions/Fibromyalgia
Dimsdale, J. E., Norman, D., DeJardin 1, D., & Wallace, M. S. (2007). The effect of opioids on sleep architecture. Journal of clinical sleep medicine, 3(01), 33-36.
Gerhart, J. I., Burns, J. W., Post, K. M., Smith, D. A., Porter, L. S., Burgess, H. J., Schuster, E., Buvanendran, A., Fras, AM., & Keefe, F. J. (2017). Relationships between sleep quality and pain-related factors for people with chronic low back pain: tests of reciprocal and time of day effects. Annals of Behavioral Medicine, 51(3), 365-375.
Manning, K., Kauffman, B. Y., Rogers, A. H., Garey, L., & Zvolensky, M. J. (2020). Fatigue severity and fatigue sensitivity: relations to anxiety, depression, pain catastrophizing, and pain severity among adults with severe fatigue and chronic low back pain. Behavioral Medicine, 1-9.
Moriarty, O., McGuire, B. E., & Finn, D. P. (2011). The effect of pain on cognitive function: a review of clinical and preclinical research. Progress in neurobiology, 93(3), 385-404.
Odrcich, M., Bailey, J. M., Cahill, C. M., & Gilron, I. (2006). Chronobiological characteristics of painful diabetic neuropathy and postherpetic neuralgia: diurnal pain variation and effects of analgesic therapy. Pain, 120(1-2), 207-212.
Ohayon, M. M., & Schatzberg, A. F. (2010). Chronic pain and major depressive disorder in the general population. Journal of psychiatric research, 44(7), 454-461.
Racine, M. (2018). Chronic pain and suicide risk: A comprehensive review. Progress in Neuro-Psychopharmacology and Biological Psychiatry, 87, 269-280.
Sánchez-Salcedo, J. A., Cabrera, M. M. E., Molina-Jiménez, T., Cortes-Altamirano, J. L., Alfaro-Rodríguez, A., & Bonilla-Jaime, H. (2021). Depression and Pain: use of antidepressant. Current Neuropharmacology.
Van Dartel, S. A. A., Repping‐Wuts, J. W. J., Van Hoogmoed, D., Bleijenberg, G., Van Riel, P. L. C. M., & Fransen, J. (2013). Association between fatigue and pain in rheumatoid arthritis: does pain precede fatigue or does fatigue precede pain?. Arthritis care & research, 65(6), 862-869.
Wakefield, J. C., & Schmitz, M. F. (2016). Feelings of worthlessness during a single complicated major depressive episode predict postremission suicide attempt. Acta Psychiatrica Scandinavica, 133(4), 257-265.
Williams, L. J., Jacka, F. N., Pasco, J. A., Dodd, S., & Berk, M. (2006). Depression and pain: an overview. Acta Neuropsychiatrica, 18(2), 79-87.
Wise, T. N., Fishbain, D. A., & Holder-Perkins, V. (2007). Painful physical symptoms in depression: a clinical challenge. Pain Medicine, 8(suppl_2), S75-S82.
Zahn, R., Lythe, K. E., Gethin, J. A., Green, S., Deakin, J. F. W., Young, A. H., & Moll, J. (2015). The role of self-blame and worthlessness in the psychopathology of major depressive disorder. Journal of affective disorders, 186, 337-341.
Zlott, D. A., & Byrne, M. (2010). Mechanisms by which pharmacologic agents may contribute to fatigue. PM&R, 2(5), 451-455.
*Symptoms listed in bold are directly from the DSM5, additional information that is not bolded is written by Dr. Jennifer Steiner.
