Co-Morbid Depression and Pain 3/22/2018

It is worth spending some time reviewing the complicated relationship between depression and pain. It is easy to see how depression can worsen the experience of pain and pain can worsen the experience of depression. Depression can occur as a result of a poorly treated pain syndrome, especially if a patient’s level of functioning deteriorates as a result of the pain. Patients who experience difficulties engaging in occupational and social activities as a result of their pain can experience depressed mood, isolation, hopelessness and helplessness. It is estimated that ¼ of patients with a chronic pain syndrome meet criteria for a major depressive episode.

It therefore goes without saying that there are some pearls when it comes to treatment for a patient experiencing both depression and pain.

Pearl 1: “Killing two birds with one stone”.

Some medications can be used to treat co-morbid depression and pain. Antidepressants and anticonvulsants can be a useful approach for treating chronic pain. The types of pain that are most responsive to these medications are neuropathic syndromes, such as diabetic neuropathy, trigeminal neuropathy, and post-herpetic neuralgia. Chronic headaches, migraines, fibromyalgia, arthritis pain, and chronic low back pain may also be treated successfully with these medications.

In terms of antidepressant medications, tricyclic antidepressants, such as amitriptyline, doxepin, and imipramine and serotonin norepinephrine reuptake inhibitors (SNRIs) such as, venlafaxine, bupropion, and duloxetine have been found to be particularly helpful. In terms of anticonvulsant medications, carbamazepine (Tegretol), valproic acid (Depakote), lamotrigine (Lamictal) and gabapentin (Neurontin) have the most evidence for being helpful for chronic pain syndromes. Lamotrigine and gabapentin have fewer drug interactions and don’t require blood monitoring, making them easier to use in general.

Pearl 2: Treating depression can reduce reliance on pain medication

Many patients have the subjective feeling that opioid pain medication relieves their depressive symptoms or emotional pain as well as their physical pain. In fact, many patients seek to stay on long term opioid medication to treat their depression even after their physical pain is better. A recent study has shown that if a patient’s co-morbid depression is being adequately treated, the patient is more likely to be able to stop using opioid pain medication for pain management. The researchers calculated that antidepressant adherence was associated with a 24% great likelihood of opioid cessation.

Pearl 3: Long-term opioid use for pain increases the risk for developing depression.

Several studies have shown this risk (among others) for long term opioid use, related to the neurotransmitter effects in the brain. Other studies have also shown that a large percentage of prescriptions for opioid medication go to patients with undiagnosed mood or anxiety disorders who present with pain as their chief complaint.

In the study discussed above, the authors found that patients who stopped using opioid medications for pain had clinically significant improvement in their depression symptoms, whether or not they were adherent to their antidepressant medication. This finding implicates that the opioid use had some influence on the depressive symptoms.

As stated at the beginning of this article, the relationship between depression and pain is complicated. But as we learn more about the intricacies of the relationship, we are better able to tailor the treatment options to help with both debilitating conditions.

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