Psychiatry and Chronic Pain

Pain affects nearly 100 million people and is one of the most common complaints made to primary care providers by their patients. More than 20% of all medical visits are pain-related.

Consistent with a biopsychosocial model of illness, individuals with chronic pain often report that the pain interferes with their ability to engage in occupational and recreational activities. Their inability to engage in these activities can contribute to increased isolation, feelings of worthlessness and hopelessness, sleep disturbance, and depressed mood. It is estimated that ¼ of patients with chronic pain meet criteria for major depression. In addition, conditions such as anxiety, substance abuse and personality disorders occur at a greater rate in individuals who have a chronic pain condition than individuals who do not.

Depression and pain strongly reinforce each other. Therefore it is important to treat both concurrently in order to have the greatest chance for success.  Both antidepressants and anticonvulsants can be used 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.  Combined use may be appropriate for some patients.

In terms of antidepressant medications, tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors (SNRIs) have been found to be particularly helpful. The SSRIs have not been found to be particularly helpful on their own for pain specifically but definitely are helpful for the co-morbid depression frequently seen in patients with chronic pain. Alternatively, a combination of SSRI and low dose tricyclic medication can be helpful more specifically for the pain symptoms of a chronic pain syndrome which include sleep disturbance as a significant symptom.

In terms of anticonvulsant medications, carbamazepine, depakote, lamotrigine and gabapentin 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.

One of the most effective psychological approaches for pain management is based on a cognitive-behavioral therapy (CBT) approach. Its aim is to change maladaptive thoughts and behaviors that serve to maintain and exacerbate the experience of pain, to introduce relaxation training, and to promote increased activity and functioning. Alternative pain treatments like physical therapy and acupuncture/acupressure can also be considered.

In summary, when treating a patient with chronic pain, it is important to assess how the pain is affecting their quality of life and try to concurrently treat their chronic pain, their emotional discomfort and their overall functional capacity whenever possible.

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