By Diana Mahoney, New England bureau. Share your thoughts and suggestions at clinicalpsychiatrynews@elsevier.com
Chronic pain cuts wide. One out of every five people lives with some sort of chronic pain. Of that 20%, one-third are not able or are only minimally able to maintain an independent lifestyle because of it, according to the International Association for the Study of Pain.
And chronic pain cuts deep. Beneath the veneer of the physical symptoms lies the social, emotional, and psychological havoc caused by the associated disability, isolation, fear, and helplessness, which leads to a substantially diminished quality of life.
Unfortunately, chronic pain is also invisible. There's no gash to suture, no broken leg to set. Instead, there exists an amorphous condition that is difficult to measure and even more difficult to manage, particularly in a health care culture that values cut-and-dry diagnoses and magic pills. Adding to the complexity is the fact that chronic pain often coexists with a range of psychological disorders, including depression, anxiety, personality disorders, cognitive problems, and substance abuse.
In one study designed to assess the prevalence of chronic pain conditions and their relationship with major depressive disorder (MDD), investigators from Stanford (Calif.) University conducted a cross-sectional telephone survey of a random sample of nearly 19,000 subjects from the general population.
About 4% of the survey participants met the diagnostic criteria for MDD, and of those, 43.5% reported having at least one chronic pain condition–a number four times greater than reported by individuals in the study who did not have depression (Arch. Gen. Psychiatry 2003;60:39–47).
More recently, another Stanford study sought to evaluate the strength of the association between major depression and chronic pain and to examine the clinical burden associated with the two conditions. Of nearly 6,000 randomly sampled primary care patients who responded to a questionnaire, about 7% met criteria for MDD, and two-thirds of those with depression reported chronic pain. Among all of the subjects in the sample who reported chronic pain, the prevalence of MDD was significantly higher than in those without pain (Psychosom. Med. 2006;68:262–8).
The direction of the pain/depression connection has yet to be fully understood, but the degree of disability appears to play an important role, according to lead investigator Bruce A. Arnow, Ph.D. Among those respondents with chronic pain, the prevalence of MDD was 23% in people with disabling pain, compared with 5% in those who were not disabled by their pain. “It's possible that those who are disabled by pain become depressed, and it is possible that those who are depressed are more likely to become disabled,” he said.
Regardless of initial direction, the likelihood that one will coexist with the other warrants that both be addressed. Numerous studies have shown that depressed chronic pain patients report greater pain intensity, more malignant disease course, and poorer response to pain treatments. Additionally, depression can impede rehabilitation efforts because of low motivation, poor morale, low energy, and hopelessness.
In contrast, considering the physical and mental health components of chronic pain as symptoms of a single pain syndrome can improve patient outcome. A large, multisite investigation of depression care from the University of Washington, Seattle, showed that older adults with chronic arthritis pain who were screened and treated for depression had significant improvements in pain severity and functioning, compared with those patients who received standard arthritis care. The treatment group benefited from a multidisciplinary program that included medication, psychotherapy, and in-person and telephone follow-up (JAMA 2003;290:2428–9).
The multidisciplinary intervention “not only helped patients with arthritis feel less depressed but also helped them cope better with their pain, to be more active, and to have a higher quality of life,” according to lead investigator Dr. Elizabeth H.B. Lin of the Group Health Cooperative in Seattle. Treating patients' depression isn't going to take the pain away, she said, but treatment can change the experience of pain, which can lead to improved outcomes.
In addition to antidepressant medications when warranted, various nonpharmacologic strategies, including patient psychoeducation, and cognitive-behavioral interventions, can give chronic pain patients a sense of control over their pain and the tools needed to modify behaviors that contribute to emotional and physical distress.
The bottom line, according to chronic pain expert Robert D. Kerns, Ph.D., associate professor in the departments of psychiatry, neurology, and psychology at Yale University, New Haven, Conn., is that patients with chronic pain have to be viewed from a broad biopsychosocial perspective.
“For greatest effectiveness [in managing chronic pain], we should be treating the whole person, not fixing a 'broken' body part,” Dr. Kerns said.