The Role Of Clinical Depression In Pain Management

Posted on Friday, December the 28th at 7:29pm

By: Dr. Stephen F. Grinstead, LMFT, ACRPS, CADC-II

Clinical 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 under-diagnosed and/or under-treated.  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.

Hitting The Wall Called Depression

There are several types of clinical depression that involve 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.  The following information is intended to provide you with a brief overview of the symptoms, causes, and treatment of clinical depression and offers you tools to assess the severity of any symptoms that patients may be experiencing to determine whether you should consider developing a depression treatment plan at this time.

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 necessarily a cause for concern.  Although these feelings are often referred to as depression, they typically do not constitute a 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.

A person experiencing a clinical depression, however, experiences substantial changes in their mood, thinking, behaviors, activities and self-perceptions.  A depressed person often has difficulty making decisions, for example, and the day-to-day tasks of paying bills, attending classes, reading assignments, and returning phone calls may seem overwhelming.

A depressed person may also dwell on negative thoughts, focus on unpleasant experiences, describe themselves as a failure, report that things are hopeless, and feel as though 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 even lead to thoughts of suicide. 

There are also different types of depression, including Bipolar Disorder, in which depressive episodes alternate with manic or hypomanic 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 of suicide. 

Please review the following information on a depression rating scale for patients.  The assessment and ratings are from the work of Terence T. Gorski (2006), and his book, Depression and Relapse: A Guide to Recovery, and is used here with his generous permission.  If you have clients with an addictive disorder and co-occurring depression you may want to consider obtaining Mr. Gorki’s depression book for a more in depth process that is beyond the scope of this article.

Gorski’s Depression Rating Instrument

Directions: Please Be Honest With Yourself As You Complete The Following

·        How Depressed Are You?
Please rate 0-10 _______, where:

1    =    When I get depressed, my depression is a nuisance but I can always function normally with extra effort.

5    =    When I get depressed, at times I can function normally with extra effort and at other times I can’t

10   = When I get depressed, I usually cannot function normally even with extra effort.

·        How often do you feel depressed?
Please rate 0-10 _______, where:

1    =    Almost Never

5    =    About half of the time

10  =   Almost all of the time

·        How long does each episode of depression last?
Please rate 0-10 _______, where:

1    =    Less than an hour

5    =    Several days

10  =   I’m depressed all of the time with no break between episodes

·        How severe are the negative consequences caused by your depression?
Please rate 0-10 _______, where:

1    =    Mild: I feel bad but there are no negative consequences

5    =    Moderate: My depression causes some serious problems in my life

10  =   Severe: My depression causes serious damage to my health, emotional well-being, and lifestyle

Gorski’s Suicide Check-List

·        I sometimes feel that life isn’t worth living

£ Yes £ No   £ Unsure

·        I sometimes think I would be better off dead

£ Yes £ No   £ Unsure

·        I sometimes think about killing myself

£ Yes £ No   £ Unsure

I sometimes think about ways to kill myself.

£ Yes £ No   £ Unsure

·        I have a plan to kill myself

£ Yes £ No   £ Unsure

·        I have recently tried to kill myself

£ Yes £ No   £ Unsure

·        I will probably try to kill myself some time in the future

£ Yes £ No   £ Unsure

Note: If you answered “yes” or “unsure” to any of the last six questions you may be so seriously depressed that you need professional help immediately.

Below you will see a symptoms checklist that includes many of the symptoms typical for clinical depression.  It’s important to note, however, that only some of these symptoms are necessary for a diagnosis of depression.  Some patients will be more comfortable with the depression rating instrument above while others may benefit more from the following symptom list.  Sometimes I use both.

Symptoms of Depression

·         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 loose 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. 

Treating Depression

One of the biggest problems in treating depression in people with chronic pain is missing the diagnosis.  This occurs for two reasons: (1) the person in chronic pain often does not realize he or she is also suffering from a major depression; and (2) the healthcare provider is not looking for it.  People living with chronic pain will often define their problem as strictly medical and related to the pain.  Therefore, being alert to explore if depression is present and being willing to develop a treatment strategy becomes 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.  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.